FUNDA LEC

• Nursing Process


  A deliberate activity whereby the practice of nursing is performed in a systematic manner, the foundation, the essential, enduring skill that has characterized nursing from the beginning of the profession
• Nursing Process


  A SYSTEMATIC & OUTCOME ORIENTED method that nurses use to expedite diagnosis and treatment of actual and potential health problems
• Nursing Process


  1. Assessment

  2. Diagnosis

  3. Planning

  4. Implementation

  5. Evaluation
• Nursing Process


  Serves as a CRITICAL THINKING MODEL FOR NURSING
• Characteristics of the Nursing Process that Promote Critical Thinking

  • Purposeful & Deliberate
  • Humanistic
  • Systematic
  • Step-by-step, yet Dynamic
  • Outcome-focused & Cost Effective
  • Pro-active
  • Evidence-based
  • Intuitive & Logical
  • Reflective, Creative & Improvement-Oriented
• Steps of the Nursing Process

  1. Assessment: Collect & Record all information needed to be able to predict, detect, prevent, manage, or eliminate health problems, Clarify expected outcomes (results?), Develop a comprehensive plan

  2. Diagnosis: Analyze assessment data, draw conclusions, and determine actual and potential health problems and their cause(s), Presence of risk factors, Resources, strengths, use of healthy behaviors, Health states that are satisfactory but could be improved

  3. Planning: Clarify expected outcomes, set priorities, and determine interventions designed to detect, prevent, and manage health problems and risk factors, promote optimum function, independence, and sense of well-being, achieve the expected outcomes safely and efficiently

  4. Implementation: Put the plan into action by assessing appropriateness of (and readiness for) interventions, Performing interventions, then reassessing to determine initial responses, Making immediate changes as needed, Charting to monitor progress

  5. Evaluation: Assess the patient to decide whether expected outcomes have been met, Then decide whether to discharge the patient or modify the plan as appropriate, and plan for ongoing continuous assessment and improvement
• The Nursing Process


  1. Assessment
• Assessment


  • Systematic, deliberate process
  • Continuous data collection
  • Analyzes data about the patient, client's human response, health status, strengths and concerns
  • Finding all the "necessary puzzle pieces" to get a picture of your patient's health status
• Purpose of Assessment


  To establish data base about the client's response to health concerns or illness and the ability to manage health care needs
• Characteristics of an Assessment that promotes Critical Thinking

  • Purposeful - your aim is to gain all the information needed to ensure that your patients have individualized plans
  • Focused & Relevant - Must be focused to gain relevant information, depending on purpose and context
  • Systematic - Helps pay attention to what's important, learn how to prioritize, be comprehensive, and avoid omission errors
  • Comprehensive & Accurate - factual & complete
  • Recorded in a Standardized Way - value the importance of completing a standardized tool designed to promote an assessment that's purposeful, relevant, systematic and complete
• Main Types of Assessment

  • Data Base Assessment - "start of care" assessment, Comprehensive information gathered on initial contact with the person to assess all aspects of health status
  • Focus Assessment - Data gathered to determine the status of a specific condition
• Assessment Activities


  1. Collecting Data

  2. Identifying Cues & Making Inferences

  3. Validating / Verifying Data

  4. Organizing / Clustering Data

  5. Identifying Patterns / Testing First Impressions

  6. Reporting and Recording Data
• Data Gathering Resources


  • Primary Source - Client / patient
  • Secondary Sources - Significant others, Nursing & Medical Records, Verbal & Written Consultations, Diagnostic / Laboratory Studies
• The most up-to-date information comes from your direct assessment of the patient
• Data Collection Skills


  • Observation of patient
  • Interview of patient, family & other nurses
  • Examination of Patient
  • Medical Record Review
• Observation


  Noting pieces of information or cues through the use of senses (sight, touch, hearing, smell and taste)
• Interview


  A structured form of communication that the nurse uses to collect data face to face
• Key Points for an Interview


  • Ability to establish rapport
  • Ability to ask questions
  • Ability to listen is essential to successful interviews
  • Ability to observe
• Types of Interviews


  • Highly structured and elicit specific information by asking closed questions that call for a specific amount of data (Direct Interview)
  • The nurse allows the client to control the purpose, subject matter and pacing (Indirect Interview)
• Kinds of Interview Questions

  • Open-ended - lead or invite clients to explore their thoughts or feelings
  • Close ended - restrictive and generally require only short answers giving specific information; often begin with when, where, who, what, do, does, did
• Planning the Interview and Setting

  • Time - need to be scheduled when the client is comfortable and free of pain
  • Place - must have adequate privacy to promote communication
  • Seating arrangement - most people feel comfortable 3 to 4 ft. apart during an interview
• Stages of an Interview

  1. Opening - sets the tone of the remainder of the interview, Establish rapport - process of creating good will and trust, Orientation - explaining the purpose and nature of the interview

  2. Body - client communicates what he or she thinks, feels, knows and perceives in response to questions from the nurse

  3. Closing - important in facilitating future interactions
• Examination of the Patient (Physical Assessment)

  It has to be: Thorough, Systematic, Skilled
• Approaches to Examination of the Patient

  • Head-to-toe Assessment/Cephalocaudal
  • Body System Approach
• Skills Used in Physical Exam

  • Inspection / Visualization
  • Palpation
  • Percussion
  • Auscultation
• Purposes of Medical Record Review

  • To relate the past health care history of the patient to the present episode
  • To identify what medication the patient is taking so that the assessment can include the effectiveness of the medication & the occurrence of any side effects
• Data Collection Formats


  • Maslow's Basic Need Frameworks
  • Henderson's Components of Nursing Care
  • Gordon's Functional Health Patterns
  • Nanda's Human Response Patterns
  • Nursing Theories
  • Human Growth & Development
• Subjective Data


  Information given verbally by the patient
• Objective Data


  Factual data that are observed by the nurse & could be noted by any other skilled observer
• Types of Subjective Data

  • Symptoms or covert data e.g. - itching pain, feelings of worry, includes client's sensations, feelings, values, beliefs, attitudes and perception of personal health status and life situations
• Types of Objective Data

  • Signs or overt data - detectable by an observer or can be tested against an accepted standard e.g. discoloration of the skin
• Assessment Activity: Identifying Cues & Making Inferences

  1. Cues - the subjective & objective data identified

  2. Inference - how one interprets or perceive a cue
• Advantages of Validating/Verifying Data

  • It helps one to avoid: Making assumptions, Missing key information, Misunderstanding situations, Jumping to conclusions or focusing in the wrong direction, Making errors in problem identification
• Guidelines in Validating/Verifying Data

  • Data that can be measured accurately can be accepted as factual
  • Data that someone else observes (indirect data) may or may not be true
  • Double check information that's extremely abnormal or inconsistent with patient cues
  • Double check that your equipment is working correctly
  • Recheck own data
  • Look for factors that may alter accuracy
  • Ask someone else, preferably an expert, to collect the same data
  • Compare subjective & objective data to see if what the person is stating is congruent with what you observe
  • Clarify statements and very your inferences with the patient
  • Compare your impressions with those of other key members of the health care team
• Assessment Activity: Organizing/Clustering Data


  1. Cluster your data according to your purpose - to identify nursing diagnoses and problems, to identify signs and symptoms of possible medical problems, to set priorities

  2. Clustering data one way, then clustering it another way helps you think critically
• Ways of Organizing/Clustering Data


  • Clustering of data according to a nursing model - helps to identify nursing diagnoses & problems
  • Clustering of data according to Body systems - helps to identify data that may indicate medical problems
  • Maslow's Hierarchy of Needs - used to set priorities
  • ABC (Airway Breathing Circulation) - used to set priorities
• Assessment Activity: Identifying Patterns / Testing First Impressions


  1. Involves deciding what's relevant & irrelevant, making tentative decisions about what the data suggests, focusing assessment to gain more information to better understand the situations at hand

  2. Remember cause & effect; find out why or how the pattern came to be
• Assessment Activity: Reporting & Recording


  1. Report abnormal findings as soon as possible

  2. Before reporting, take a moment to be sure you have all the necessary information readily at hand

  3. Jot down the facts in order of importance

  4. Give precise information, state the facts rather than how you interpret the facts
• Summary of Assessment Activities

  • Collecting Data
  • Identifying Cues & Making Inferences
  • Validating / Verifying Data
  • Organizing / Clustering Data
  • Identifying Patterns / Testing First Impressions
  • Reporting and Recording Data
• Nursing Process - DIAGNOSIS

  1. Diagnosis

  2. Diagnosing

  3. Diagnose

  4. Nursing Diagnosis