FUNDA

• Nursing process


  Systematic, rational method of planning and providing individualized nursing care

  
• Purposes of nursing process

  • Identify client's health status and actual or potential health care problems of needs
  • Establish plans to meet needs
  • Deliver specific interventions

  
• Phases of the nursing process

  • Assessing (Assessment)
  • Diagnosing (Nursing Diagnosis)
  • Planning
  • Implementing
  • Evaluating

  
• Sometimes included in the nursing process: Identifying outcomes, in between diagnosing and planning (Outcome Criteria)

  
• Characteristics of the nursing process

  • Cyclic and dynamic rather than static
  • Client centered
  • Problem-solving and systems theory
  • Decision making
  • Interpersonal and collaborative
  • Universal applicability
  • Critical thinking skills
  • Clinical reasoning skills

  
• Assessing


  Systematic and continuous collection, organization, validation, and documentation of data (information)
• Types of assessment


  • Initial nursing assessment
  • Problem-focused assessment
  • Emergency assessment
  • Time-lapsed reassessment

  
• Data should be relevant to a particular health problem
• The Joint Commission requires an initial nursing assessment for each client, including history and physical examination, performed and documented within 24 hours of admission

  
• Subjective data


  Symptoms or covert data, apparent only to person affected, can be described only by person affected, includes sensations, feelings, values, beliefs, attitudes, and perception of personal health status and life situations
• Objective data


  Signs or overt data, detectable by an observer, can be measured or tested against an accepted standard, can be seen, heard, felt, or smelled, obtained through observation or physical examination
• Sources of data


  • Client
  • Client records
  • Health care professionals
  • Literature
• Observing


  Gathering data using the senses, used to obtain data on skin color, body or breath odors, lung or heart sounds, skin temperature
• Interviewing


  Planned communication or a conversation with a purpose, used to get or give information, identify problems of mutual concern, evaluate change, teach, provide support, provide counseling or therapy
• Focused interview is where the nurse asks the client specific questions to collect information related to the client's problem
• Types of data obtained

  • Skin color (vision)
  • Body or breath odors (smell)
  • Lung or heart sounds (hearing)
  • Skin temperature (touch)
• Interviewing


  Planned communication or a conversation with a purpose
• Focused interview


  Nurse asks the client specific questions to collect information related to the client's problem
• Uses of interviewing


  • Get or give information
  • Identify problems of mutual concern
  • Evaluate change
  • Teach
  • Provide support
  • Provide counseling or therapy
• Directive interview


  Nurse establishes purpose and controls the interview, used to gather and give information when time is limited, in an emergency
• Nondirective interview


  Rapport (understanding between two or more people), client controls the purpose, subject matter, and pacing
• Combination of directive and nondirective approaches is usually appropriate during information-gathering interview
• Types of interview questions

  • Closed questions (restrictive, yes/no, factual, less effort and information from client)
  • Open-ended questions (specify broad topic to discuss, invite longer answers, get more information from client, useful to change topics and elicit attitudes)
  • Neutral questions
  • Leading questions
• Planning the interview and setting

  • Time (client free of pain, limited interruptions)
  • Place (private, comfortable environment, limited distractions)
  • Seating arrangement (hospital, office or clinic, group, distance, comfortable)
  • Language (use easily understood terms, interpreter or translator)
• Stages of an interview

  • The opening (establish rapport, orient client)
  • The body (client communicates, nurse asks questions)
  • The closing (nurse ends interview when necessary information is collected)
• Examining


  Systematic data-collection method using observation and inspection, auscultation, palpation, and percussion
• What examining includes


  • Vital signs, height and weight
  • Cephalocaudal approach (head-to-toe progression)
  • Screening examination (review of systems)
• Conceptual models/frameworks


  • Gordon's functional health pattern framework
  • Orem's self-care model
  • Roy's adaptation model
• Wellness models


  • Assist clients to identify and explore lifestyle habits and health behaviors, beliefs, values, and attitudes
• Non-nursing models


  • Body systems model (integumentary, respiratory, cardiovascular, nervous, musculoskeletal, gastrointestinal, genitourinary, reproductive, and immune systems)
  • Maslow's Hierarchy of Needs (physiological, safety and security, love and belonging, self-esteem, self-actualization)
  • Developmental theories (Havighurst's age periods and developmental tasks, Freud's five stages of development, Erikson's eight stages of development, Piaget's phases of cognitive development, Kohlberg's stages of moral development)
• Validation


  The act of "double-checking," verifying data to confirm it is accurate and factual
• Validation ensures that assessment information is complete, that objective and related subjective data agree, and that additional information that may have been overlooked is obtained
• Cues


  Subjective, objective data that can be directly observed by the nurse
• Inferences


  Nurse's interpretation based on cues
• Avoid jumping to conclusions
• Record client data in a factual manner without stating interpretations, and record subjective data with quotes in client's own words
• Health assessment process


  • Data collection (interview, history taking, physical assessment, medical records)
  • Documentation (organized)
  • FOCUS (main problem)
  • DATA (supports main problem)
  • ACTION (dependent, independent, collaboration, health education)
  • DIAGNOSTIC REASONING (relevant data collection, organized data, conclusion on how to manage patient)