HA

• Nursing process


  Systematic, rational method of planning and providing individualized nursing care
• Nursing process


  • Cyclical - its components follow a logical sequence, but more than one component may be involved at one time
  • At the end of the first cycle, care may be terminated if goals are achieved, or the cycle may continue with reassessment, or the plan of care may be modified
• Assessment


  1. Collecting, organizing, validating, and documenting client data

  2. Obtain a nursing health history

  3. Conduct a physical assessment

  4. Review client records

  5. Review nursing literature

  6. Consult support persons

  7. Consult health professionals

  8. Update data as needed

  9. Organize data

  10. Validate data

  11. Communicate/document data
• Diagnosing


  1. Analyzing and synthesizing data

  2. Compare data against standards

  3. Cluster or group data (generate tentative hypotheses)

  4. Identify gaps and inconsistencies

  5. Determine client's strengths, risks, and problems

  6. Formulate nursing diagnoses and collaborative problem statements

  7. Document nursing diagnoses on the care plan
• Planning


  1. Set priorities and goals/outcomes in collaboration with client

  2. Establish goals/desired outcomes

  3. Select nursing strategies/interventions

  4. Consult other health professionals

  5. Write nursing interventions and nursing care plan

  6. Communicate care plan to relevant health care providers
• Implementing


  1. Reassess the client to update the database

  2. Determine the nurse's need for assistance

  3. Perform planned nursing interventions

  4. Document care and client responses to care

  5. Give verbal reports as necessary
• Evaluating


  1. Collaborate with client and collect data related to desired outcomes

  2. Judge whether goals/outcomes have been achieved

  3. Relate nursing actions to client goals/outcomes

  4. Make decisions about problem status

  5. Review and modify the care plan as indicated or terminate nursing care

  6. Document achievement of outcomes and modification of the care plan
• Nursing


  The protection, promotion, and optimization of health and abilities, prevention of illness and injury, alleviation of suffering through the diagnosis and treatment of human responses and advocacy in the care of individuals, families, communities and populations
• Emphasis is placed on "diagnosis and treatment of human responses" based on "accurate client assessments," including how effective nursing interventions are "to promote health and prevent illness and injury"
• The registered nurse collects comprehensive data pertinent to the patient's health or situation
• Scope and standard of nursing practice

  • Collects data in a systematic and ongoing process
  • Involves the patient, family, other healthcare providers, and environment, as appropriate, in holistic data collection
  • Prioritizes data collection activities based on the patient's immediate condition, or anticipated needs of the patient or situation
  • Uses appropriate evidence-based assessment techniques and instruments in collecting pertinent data
  • Uses analytical models and problem-solving tools
  • Synthesizes available data, information, and knowledge relevant to the situation to identify patterns and variances
  • Documents relevant data in a retrievable format
• Health history


  • Consists of subjective data collected during an interview
  • Includes information about patients' current state of health, medications they take, previous illnesses and surgeries, and family history and a review of systems
  • Patients may report feelings or experiences associated with health problems, which are called symptoms and are considered subjective data
  • Subjective data acquired directly from the patient are considered primary source data
  • If data are acquired from another individual (such as a family member), they are referred to as secondary source data
• Subjective data


  • Can be elicited and verified only by the client
  • Provide clues to possible physiologic, psychological, and sociologic problems
  • Provide information that may reveal a client's risk for a problem as well as areas of strengths for the client
  • Information is obtained through interviewing
  • Consist of sensations or symptoms, feelings, perceptions, desires, preferences, beliefs, ideas, values, and personal information
• Directive interview


  • Highly structured and elicits specific information
  • The nurse establishes the purpose of the interview and controls the interview, at least at the outset
  • The client responds to questions but may have limited opportunity to ask questions or discuss concerns
  • Nurses frequently use directive interviews to gather and to give information when time is limited (e.g., in an emergency situation)
• Non-directive interview


  • Rapport-building interview
  • The nurse allows the client to control the purpose, subject matter, and pacing
  • Rapport is an understanding between two or more people
• A combination of directive and nondirective approaches is usually appropriate during the information-gathering interview
• Unregistered nurses can assist/help the registered nurses but with precaution. Unregistered nurses cannot be left alone with the patient and they should not be allowed to administer medication
• The focus of nursing diagnosis is the diagnosis and treatment of human responses
• Closed questions


  • Used in the directive interview, are restrictive and generally require only "yes" or "no" or short factual answers that provide specific information
  • Often begin with "when," "where," "who," "what," "do (did, does)," or "is (are, was)"
  • Often used when information is needed quickly, such as in an emergency situation
  • The highly stressed person and the person who has difficulty communicating will find closed questions easier
• Advantages of closed questions

  • Questions and answers can be controlled more effectively
  • They require less more effort from the interviewee
  • They may be less threatening, since they do not require explanations or justifications
  • They take less time
  • Information can be asked for sooner that it would be volunteered
  • Responses are easily documented
  • Questions are easy to use and can be handled by unskilled interviewers
• Disadvantages of closed questions

  • They may provide too little information and require follow-up questions
  • They may not reveal how the interviewee feels
  • They do not allow the interviewee to volunteer possible valuable information
  • They may inhibit communication and convey lack of interest by the interviewer
  • The interviewer may dominate the interview with questions
• Open-ended questions


  • Associated with the nondirective interview
  • Invite clients to discover and explore, elaborate, clarify, or illustrate their thoughts or feelings
  • Specifies only the broad topic to be discussed and invites answers longer than one or two words
  • Give clients the freedom to divulge only the information that they are ready to disclose
  • Useful at the beginning of an interview or to change topics and to elicit attitudes
  • May begin with "what" or "how"
• Advantages of open-ended questions

  • They let the interviewee control the interview
  • They encourage the interviewee to provide more information
  • They allow the interviewee to express feelings and attitudes
  • They provide more in-depth information
  • They allow the interviewee to raise issues of importance to them
  • They are less threatening to the interviewee
• EY DO NOT ALLOW THE INTERVIEWEE TO VOLUNTEER POSSIBLE VALUABLE INFORMATION
• THEY MAY INHIBIT COMMUNICATION AND CONVEY LACK OF INTEREST BY THE INTERVIEWER
• THE INTERVIEWER MAY DOMINATE THE INTERVIEW WITH QUESTIONS
• Open-ended questions


  Associated with the nondirective interview, invite clients to discover and explore, elaborate, clarify, or illustrate their thoughts or feelings
• Open-ended questions


  Specifies only the broad topic to be discussed and invites answers longer than one or two words
• Open-ended questions


  Give clients the freedom to divulge only the information that they are ready to disclose
• Open-ended questions


  Useful at the beginning of an interview or to change topics and to elicit attitudes
• Open-ended questions


  • "How have you been feeling lately?"
  • "What brought you to the hospital?"
  • "How did you feel in that situation?"
  • "Would you describe more about how you relate to your child?"
  • "What would you like to talk about today?"
• Advantages of open-ended questions

  • They let the interviewee do the talking
  • The interviewer is able to listen and observe
  • They reveal what the interviewee's lack of information, misunderstanding of words, frame or rederende, prejudices, or streotypes
  • They can provide information the interviewer may not ask for
  • They can reveal the interviewee's degree of feeling about an issue
  • They can convey interest and trust because of the freedom they provide
• Disadvantages of open-ended questions

  • They take more time
  • Only brief answers may be given
  • Valuable information may be withheld
  • They often elicit more information than necessary
  • Responses are difficult to document and require skill in recording
  • Interviewer requires skill in controlling an open-ended interview
  • Responses require insight and sensitivity from the interviewer
• Neutral questions


  A question the client can answer without direction or pressure from the nurse, is open ended and is used in nondirective interviews
• Neutral questions


  • "How do you feel about that?"
  • "What do you think led to the operation?"
• Leading questions


  Usually closed, used in a directive interview, and thus directs the client's answer
• Leading questions give the client less opportunity to decide whether the answer is true or not
• Leading questions create problems if the client, in an effort to please the nurse, gives inaccurate responses. This can result in inaccurate data
• Leading questions


  • "You're stressed about surgery tomorrow, aren't you?"
  • "You will take your medicine, won't you?"
• Planning the interview and setting

  • Time
  • Place
  • Seating arrangement
  • Distance
  • Language