NURSING PROCESS

• Nursing process


  A systematic method of providing care to clients
• Nursing process

  1. Assessment

  2. Diagnosis

  3. Planning

  4. Implementation

  5. Evaluation

  
• Nursing process


  • Allows nurses to communicate plan and activities to clients, other health care professionals and families
  • Decision-making is involved in every phase
  • Interpersonal and collaboration
  • Universally applicable
  • Use a variety of critical thinking skills
  • Data from each phase provide input into the next phase
  • Client centered
  • Adaptation of problem solving

  
• Assessment


  Collecting subjective and objective data
• Assessment

  1. Collection of data

  2. Organizing data

  3. Validating data

  4. Documenting data
• Diagnosis


  Analyzing subjective and objective data to make a professional nursing judgment
• Diagnosis


  1. Analysis of data

  2. Identifying health problems, risks and strengths

  3. Formulating the Diagnostic statements
• Planning


  1. Prioritizing problems/diagnoses

  2. Formulation of goals/desired outcomes

  3. Selecting nursing interventions

  4. Writing nursing interventions

  
• Implementation


  1. Reassessing the client

  2. Determining the nurse's need for assistance

  3. Implementing the nursing intervention

  4. Supervise delegated activities

  5. Documenting nursing activities

  
• Evaluation


  1. Collect data related to the outcomes

  2. Compare data with outcomes

  3. Relate nursing actions to client goals/outcomes

  4. Draw conclusions about problem status

  5. Continue, modify or terminate the client's care plan
• Critical thinking


  • Thinking that results in the development of new ideas and products
  • The ability to develop and implement new and better solutions
• Critical thinking


  • Nurses use knowledge from other subjects and fields
  • Nurses deal with change in stressful environment
  • Nurses make important decisions
• Creativity


  A major component of critical thinking
• Creativity


  • Generate many ideas rapidly
  • Generally flexible and natural
  • Create original solutions to problems
  • Tend to be independent and self-confident, even when under pressure
  • Demonstrate individuality
• Health assessment


  A systematic method of collecting and analyzing data for the purpose of planning patient-centered care
• Health assessment is the first and most critical phase of the nursing process

  
• Health assessment is ongoing and continuous throughout all the phases of the nursing process
• Types of assessment

  • Initial comprehensive assessment
  • Ongoing or partial assessment
  • Focused or problem-oriented assessment
  • Emergency assessment
• Initial comprehensive assessment


  • Involves collection of subjective data about the client's perception of her health of all body parts or systems, past health history, family history, lifestyle and health practices
  • Involves collection of objective data gathered during a step-by-step physical examination
• Ongoing or partial assessment


  • Data collection that occurs after the comprehensive assessment is established
  • Mini-overview of the client's body systems and holistic health patterns as a follow-up on his health status
  • Initial problems in the client's body system or holistic health patterns are reassessed in less depth to determine any major changes
• Focused or problem-oriented assessment


  • Does not take the place of the comprehensive health assessment
  • Consists of a thorough assessment of a particular client problem and does not cover areas not related to the problem
• Emergency assessment


  • Very rapid assessment performed in life-threatening situations
  • An immediate diagnosis is needed to provide prompt treatment
• Frameworks for health assessment

  • Functional health framework
  • Head to toe framework
  • Body Systems framework
• Functional health framework


  • Evaluates the effects of the mind, body, and environment in relation to a person's ability to perform the tasks of daily living
  • Organizes data collection in terms of Gordon's 11 functional health patterns
• Head-to-toe framework


  • A system for collecting data in an organized manner, starting from head and proceeding systematically downward to the toes
  • Used to improve efficiency and to expedite the actual physical examination
• Body systems framework


  • Focuses on the pathophysiology involved within specific body systems
  • Commonly used when the purpose of the examination is to determine function of a particular body system
• Steps of health assessment

  1. Collection of subjective data

  2. Collection of objective data

  3. Validation of data

  4. Documentation of data
• Subjective data


  Sensations or symptoms, feelings, perceptions, desires, preferences, beliefs, ideas, values, and personal information that can be elicited and verified only by the client
• Objective data


  Directly observed by the examiner, including physical characteristics, body functions, appearance, behavior, measurements, and results of laboratory testing
• Validation of data


  Ensures that the assessment process is not ended before all relevant data have been collected, and helps to prevent documentation of inaccurate data
• Diagnosis involves identifying problems or concerns based on assessment findings using the nursing diagnosis classification system.
• The nursing process is the systematic approach to planning, implementing, evaluating, and documenting patient care.
• Assessment involves gathering data about the client's health status through observation, interview, examination, and testing.