halec2

• Nursing Process


  A framework for critical thinking to diagnose and treat human responses to actual or potential health problems
• Nursing Process


  • Organized framework to guide practice
  • Problem solving method - client focused
  • Systematic- sequential steps
  • Goal oriented- outcome criteria
  • Dynamic-always changing, flexible
  • Involves looking at the whole patient at all times
  • Provides a "road map" that ensures good nursing care & improves patient outcomes
• Critical Thinking- nurses need to use Nursing process
• Critical Thinking


  Always thinking about your thinking, and your actions, and your decisions
• Basis in using Critical Thinking: Deal w/ complex problems on a daily basis, Work w/ patient that are unique, Provide holistic care
• Advantages of Nursing Process

  • Provides individualized care - Client is an active participant
  • Promotes continuity of care
  • Provides more effective communication among nurses and healthcare professionals
  • Develops a clear and efficient plan of care
  • Provides personal satisfaction as you see client achieve goals
  • Professional growth as you evaluate effectiveness of your interventions
• Phases of Nursing Process

  • Assessment
  • Diagnosis
  • Planning
  • Implementation
  • Evaluation
• Process of Systematic Assessment

  1. Collect data

  2. Verify data

  3. Organize data

  4. Identify Patterns

  5. Report & Record data
• Comprehensive data collection


  Begins before you actually see the patient, Continues with admission interview and physical assessment once you meet patient, Other information resources include: family, significant others, nursing records, old medical records, diagnostic studies, relevant nursing literature, Consider age, growth & development
• Types of Data


  • Objective Data – signs; those that can be observed and measured
  • Subjective Data – symptoms; those that described only by the person experiencing it
• Sources of Data


  • Primary – patient/client
  • Secondary – family members, patient's record, health team members, related literature
• Categories of Interview


  • Standardized/ Structured
  • Non-Standardized
  • Semi-Standardized
  • Focused
  • Non-Directive
• Interview Instruments


  • Interview Schedule
  • Interview Guide
• Types Of Questions


  • Open-Ended Questions
  • Close-Ended Questions
  • Biased Or Leading Questions
  • Neutral Questions
• Guidelines When Conducting An Interview

  • Initiation
  • Appropriate Use Of Non-Verbal Communication
  • Questioning
  • Focusing
  • Terminating The Interview
• Health History


  Taking a Patient's history is arguably the most important aspect of patient assessment, and is increasingly being undertaken by HCPs including midwives. The procedure allows patients to present their account of the problem and provides essential information for the practitioner.
• The History Taking Process

  1. The Presenting Complaint

  2. Past Medical History

  3. Medication History

  4. Family history

  5. Social History
• Gordon's 11 Functional Patterns


  • Health Perception and Health Management Pattern
  • Nutrition and Metabolism Pattern
  • Elimination Pattern
  • Activity and Exercise Pattern
  • Sleep and Rest Pattern
  • Cognitive-Perceptual Pattern
  • Self-Perception and Self-Concept Pattern
  • Role-Relationship Pattern
  • Sexuality-Reproductive Pattern
  • Coping-Stress Tolerance Pattern
  • Value-Belief Pattern
• What is your opinion about health?
• Nutrition and Metabolism Pattern

  Assessment is focused on the pattern of food and fluid consumption relative to metabolic need. The adequacy of local nutrient supplies is evaluated. Actual or potential problems related to fluid balance, tissue integrity, and host defenses may be identified as well as problems with the gastrointestinal system.
• Nutrition and Metabolism FHP Assessment Questions

  • Ask about their skin, scalp and nails?
  • What is your diet menu?
  • Any food restriction regarding disease point of view?
  • Any food restriction regarding religious point of view?
  • Any food like or dislike?
  • Any food allergy?
• Elimination Pattern


  Data collection is focused on excretory patterns (bowel, bladder, skin). Excretory problems such as incontinence, constipation, diarrhea, and urinary retention may be identified.
• Elimination FHP Assessment Questions

  • Color of urine, amount, frequency, odor and any discharge.
  • Any urinary problem, dysurea, Anurea, Oligourea, , polyuria.
  • Are you using any laxative? If yes which?
  • Any problem during passing defecation?
• Activity and Exercise Pattern

  Assessment is focused on the activities of daily living requiring energy expenditure, including self-care activities, exercise, and leisure activities. The status of major body systems involved with activity and exercise is evaluated, including the respiratory, cardiovascular, and musculo-skeletal systems.
• Activity and Exercise FHP Assessment Questions

  • Do you any breathing problem? (In which apnea, hypoxia, hypoxemia, hypercapnia.)
  • Do you have cough? (Productive or non-productive)
  • Any changes in heart beat during exercise?
  • Do you feel pale during exercise?
  • What type of exercise you do or any problem during exercise?
• Cognition and Perception Pattern


  Assessment is focused on the ability to comprehend and use information and on the sensory functions. Data pertaining to neurologic functions are collected to aid this process. Sensory experiences such as pain and altered sensory input may be identified and further evaluated.
• COGNITION AND PERCEPTION

  • Orientation about time place and person.
  • Any difficulty in sentence making?
  • Loss of memory.
• Sleep and Rest Pattern

  Assessment is focused on the person's sleep, rest, and relaxation practices. Dysfunctional sleep patterns, fatigue, and responses to sleep deprivation may be identified.
• Self-Perception and Self-Concept Pattern


  Assessment is focused on the person's attitudes toward self, including identity, body image, and sense of self-worth. The person's level of self-esteem and response to threats to his or her self-concept may be identified.
• Self-Perception and Self-Concept FHP Assessment Questions

  • What is your self-perception about yourself?
  • Are you satisfied with your self-body image?
  • Do you like grooming?
• Roles and Relationships Pattern


  Assessment is focused on the person's roles in the world and relationships with others. Satisfaction with roles, role strain, or dysfunctional relationships may be further evaluated.
• Roles and Relationships FHP Assessment Questions

  • What is your role in family?
  • If you are in hospital then who will perform your responsibilities?
  • All the family members are cooperative with you?
  • Who is decision maker in your family?
• Sexuality and Reproduction Pattern

  Assessment is focused on the person's satisfaction or dissatisfaction with sexuality patterns and reproductive functions. Concerns with sexuality may he identified.