FUNDA REVIEWER

• It is a series of planned actions or operations directed towards a particular result or goa

  Process
• It is a systematic, rational method of planning and providing individualized nursing

  Nursing process
• Gather information about the patient condition

  Assess
• Identify the patient problem

  Diagnose
• Set goals of care and desired outcome and identify appropriate nursing action

  Plan
• Perform the nursing action identified in nursing planning

  Implement
• Determine if goals and expected outcome are achieved

  Evaluate
• the gathering and analysis of information about the patient’s health status.
• clinical judgments from the assessment to identify the patient’s response to health problems in the form of

  Nursing Diagnoses
• performing the planned interventions.


  Implement
• the patient’s response and whether the interventions were effective

  Evaluate
• critical thinking process that professional nurses use to apply the best available evidence to caregiving and promoting human functions and responses to health and illness (American Nurses Association, 2010).

  Nursing process
• the fundamental blueprint for how to care for patients

  Nursing process
• standard of practice, which, when followed correctly, protects nurses against legal problems related to nursing care (Austin, 2008)

  Nursing Process
• A series of steps that lead to accomplishing some goal or purpose.

  Nursing process
• Provides individualized, holistic, effective and efficient client care.

  Nursing Process
• • Cyclic and dynamic rather than static • Client-centered rather than task-centered • Problem-solving and systems theory • Decision making • Interpersonal (“How are you today?”) • Collaborative • Universally applicable • Can focus on problems or strengths


  Characteristics of the Nursing Process
• It is a systematic and continuous collection, validation, and communication of patient data

  Assessment
• These data reflect how health functioning is enhanced by health promotion or compromised by illness and injury

  Assessment
• The first step in the nursing process

  Assessment
• the deliberate and systematic collection of information about a patient to determine his or her current and past health and functional status and his or her present and past coping patterns

  Assessment
• Collection of information from a primary source

  Patient
• Collection of information from a secondary source

  Family members, health professionals, medical records
• To establish baseline information on the client • To determine the client’s normal function • To determine the client’s risk for diagnosis function • To provide data for the diagnostic phase • To organize a database regarding a client’s physical, psychosocial, and emotional health. • To identify health-promoting behaviors and actual and/or potential health problems.

  Purpose of Assessment
• performed within specified time after admission to a health care agency

  Initial Assessment
• The purpose is to establish complete database for problem identification and care planning


  Initial assessment
• ongoing process integrated with nursing care to determine specific problem identified in an earlier assessment and to identify new or overlooked problems

  Problem-Focused Assessment
• Assessment of client’s ability to perform self-care while assisting client to bathe.

  Problem-Focused Assessment
• Done during psychiatric or physiological crisis of the client to identify life threatening problems

  Emergency Assessment
• done several months (scheduled) after initial assessment to compare the client’s status to baseline data previously obtained

  Time-Lapsed Assessment
• Data from client’s point of view

  Subjective data
• Includes sensations, feelings, values, beliefs, attitudes, and perception of personal health status and life situations


  Subjective data
• referred to as SYMPTOMS or COVERT data, apparent only to the person affected, can be verified only by that person

  Subjective data
• observable and measurable, obtained through both physical examination and the results of lab and diagnostic testing


  Objective data
• referred to as SIGNS or OVERT data


  Objective data
• • Gathering information about a client’s health status • It must be both systematic and continuous • Should include past history and current problem

  • Can be subjective or objective

  • From primary or secondary source

  DATA COLLECTION
• To gather data using senses

  Observation
• Used to obtain Skin color (visions)

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


  Observation
• An interview is a planned communication or a conversation with a purpose

  Interviewing
• Nurse collects background info from previous charts

  Preparatory Phase