NURSING PROCESS

50 %
50 %
Information about NURSING PROCESS
Health & Medicine

Published on October 19, 2008

Author: jeena.aejy

Source: slideshare.net

Description

nursing process assessment planning implementation evaluation data subjective objective documentation

NURSING PROCESS Ms.JEENA AEJY

Ms.JEENA AEJY

THE NURSING PROCESS A systematic problem-solving approach used to identify, prevent and treat actual or potential health problems and promote wellness.

A systematic problem-solving approach used to identify, prevent and treat actual or potential health problems and promote wellness.

Nursing process A systematic way to plan, implement and evaluate care for individuals, families, groups and communities.

Nursing process

A systematic way to plan, implement and evaluate care for individuals, families, groups and communities.

Characteristics of the Nursing Process Dynamic Client-centered Planned Interpersonal and collaborative Universally applicable Can focus on problems or strengths

Dynamic

Client-centered

Planned

Interpersonal and collaborative

Universally applicable

Can focus on problems or strengths

Open, flexible Humanistic and individualized Cyclical Outcome focused ( results oriented) Emphasizes feedback and validation

Open, flexible

Humanistic and individualized

Cyclical

Outcome focused ( results oriented)

Emphasizes feedback and validation

STEPS IN NURSING PROCESS Assessment Nursing Diagnosis Planning Implementation Evaluation

Assessment

Nursing Diagnosis

Planning

Implementation

Evaluation

Nursing Process Assessment Nursing Diagnosis Planning Implementation Evaluation

Benefits of using the nursing process Continuity of care Prevention of duplication Individualized care Standards of care Increased client participation Collaboration of care

Continuity of care

Prevention of duplication

Individualized care

Standards of care

Increased client participation

Collaboration of care

EVALUATION IMPLIMENTATION PLANNING ASSESSMENT DIAGNOSIS INTER RELATIONSHIP BETWEEN THE STEPS OF NURSING PROCESS

 

Assessment Assessing is a continuous process carried out during all phases of nursing process. All phases of the nursing process depend on the accurate and complete collection of data. Assessing is the systematic and continuous collection, organization, validation and documentation of data. - Potter and Perry( 2006)

Assessing is a continuous process carried out during all phases of nursing process. All phases of the nursing process depend on the accurate and complete collection of data.

Assessing is the systematic and continuous collection, organization, validation and documentation of data.

- Potter and Perry( 2006)

Assessment is the deliberate and systematic collection of data to determine a clients current and past health status and to determine the clients present and past coping patterns - Carpenito 2000   Assessment is the systematic and continuous collection, validation and communication of patient data. - Carol Taylor  

Assessment is the deliberate and systematic collection of data to determine a clients current and past health status and to determine the clients present and past coping patterns

- Carpenito 2000

 

Assessment is the systematic and continuous collection, validation and communication of patient data.

- Carol Taylor

 

Types of Assessment 1. Initial Assessment : Performed within specified time after admission to a health care agency   Eg. Nursing Admission Assessment   2. Problem Focused Assessment : Ongoing process integrated with nursing care to determine specific problem identified in an earlier assessment and to identify new or overlooked problems.   E.g.. Assessment of clients ability to perform self-care while assisting client to bathe.     3. Emergency Assessment : Done during psychiatric or physiological crisis of the client to identify life threatening problems   Eg. Rapid assessment of airway, breathing and circulation during cardiac arrest   4. Time lapsed-Reassessment : Done several months after initial assessment to compare the clients status to baseline data previously obtained.

1. Initial Assessment : Performed within specified time after admission to a health care agency

 

Eg. Nursing Admission Assessment

 

2. Problem Focused Assessment : Ongoing process integrated with nursing care to determine specific problem identified in an earlier assessment and to identify new or overlooked problems.

 

E.g.. Assessment of clients ability to perform self-care while assisting client to bathe.

 

 

3. Emergency Assessment : Done during psychiatric or physiological crisis of the client to identify life threatening problems

 

Eg. Rapid assessment of airway, breathing and circulation during cardiac arrest

 

4. Time lapsed-Reassessment : Done several months after initial assessment to compare the clients status to baseline data previously obtained.

Assessment ASESSMENT Collect data Organize data Validates Data Document data DIAGNOSIS PLANNING IMPLIMENTATION EVALUATION

1.COLLECTION OF DATA Data Collection is the process of gathering information about a clients health status .

Collection of Data:   Data base : A data base is all information about a client. It includes the nursing health history, physical assessment, the physician’s history, physical examination, results of laboratory and diagnostic tests and material contributed by other health personnel.      

Collection of Data:

 

Data base : A data base is all information about a client. It includes the nursing health history, physical assessment, the physician’s history, physical examination, results of laboratory and diagnostic tests and material contributed by other health personnel.

 

 

 

Medical vs. Nursing Assessments Medical assessments Target data pointing to pathologic conditions Nursing assessments Focus on the patient’s response to health problems

Medical assessments

Target data pointing to pathologic conditions

Nursing assessments

Focus on the patient’s response to health problems

Types of Data:   SUBJECTIVE DATA : Also referred to as symptoms or covert data are apparent only to the person affected and can be described or verified only by that person   Eg. Itching, Pain, Feelings of worry OBJECTIVE DATA : Also referred to as signs or overt data. These are detectable by an observer or can be measured or tested against an accepted standard.   They can be seen, heard, felt or smelled and they are obtained by observation or physical examination   Eg. A Blood Pressure Data Discolouration of the Skin  

SUBJECTIVE DATA : Also referred to as symptoms or covert data are apparent only to the person affected and can be described or verified only by that person

 

Eg. Itching, Pain, Feelings of worry

OBJECTIVE DATA : Also referred to as signs or overt data. These are detectable by an observer or can be measured or tested against an accepted standard.

 

They can be seen, heard, felt or smelled and they are obtained by observation or physical examination

 

Eg. A Blood Pressure Data

Discolouration of the Skin

 

Objective Data vs. Subjective Data Objective data Observable and measurable data that can be seen, heard, or felt by someone other than the person experiencing them E.g., elevated temperature, skin moisture, vomiting Subjective data Information perceived only by the affected person E.g., pain experience, feeling dizzy, feeling anxious

Objective data

Observable and measurable data that can be seen, heard, or felt by someone other than the person experiencing them

E.g., elevated temperature, skin moisture, vomiting

Subjective data

Information perceived only by the affected person

E.g., pain experience, feeling dizzy, feeling anxious

Sources of Data: Primary Source (Direct Source client: Usually BEST source

Primary Source (Direct Source

client: Usually BEST source

Secondary Source (Indirect Source) Family Members Client’s records 1. Medical Records Eg. Medical History, Physical Examination, Operation notes, Progress notes, Consultation done by Physicians 2. Records of therapies done by other health professionals Eg. Social Workers, Dieticians, Physical Therapist 3. Laboratory Records Other health care professionals Verbal reports Literature

Family Members

Client’s records

1. Medical Records

Eg. Medical History, Physical Examination,

Operation notes, Progress notes,

Consultation done by Physicians

2. Records of therapies done by other health professionals

Eg. Social Workers, Dieticians, Physical Therapist

3. Laboratory Records

Other health care professionals Verbal reports

Literature

Data Collection Consider time needs of patient developmental stage physical surroundings past and present coping patterns

Consider

time

needs of patient

developmental stage

physical surroundings

past and present coping patterns

Data Characteristics Complete Factual Accurate Relevant

Complete

Factual

Accurate

Relevant

Data collection methods OBSERVATION INTERVIEWING PHYSICAL ASSESSMENT

OBSERVATION

INTERVIEWING

PHYSICAL ASSESSMENT

Observation To gather data using senses Eg: laboured breathing, pallor or flushing,pain a lowered side rail ,functioning of an equipment , pt environment and people in it etc…

To gather data using senses

Eg: laboured breathing, pallor or flushing,pain

a lowered side rail ,functioning of an equipment , pt environment and people in it etc…

Interviewing An interview is a planned communication or a conversation with a purpose Types of questions and Setting Rapport are important Collection of Health History

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

Types of questions and

Setting

Rapport are important

Four Phases of a Nursing Interview Preparatory phase Introduction Working phase Termination

Preparatory phase

Introduction

Working phase

Termination

Interview Phases Preparatory Nurse collects background info from previous charts Ensure environment is conducive Arrange seating 3 – 4 ft apart Interviewer at 45° angle to patient Allow adequate time

Preparatory

Nurse collects background info from previous charts

Ensure environment is conducive

Arrange seating

3 – 4 ft apart

Interviewer at 45° angle to patient

Allow adequate time

Phases cont’d. Introduction Nurse introduces self Identifies purpose of interview Ensure confidentiality of information Provide for patient needs before starting

Introduction

Nurse introduces self

Identifies purpose of interview

Ensure confidentiality of information

Provide for patient needs before starting

Phases cont’d. Working Nurse gathers info for sub jective data Excellent communication skills are needed Active listening Eye contact Open-ended questions

Working

Nurse gathers info for sub jective data

Excellent communication skills are needed

Active listening

Eye contact

Open-ended questions

Phases cont’d. Termination Inform patient when nearing end of interview Ensure patient knows what will happen with info Offer patient chance to add anything

Termination

Inform patient when nearing end of interview

Ensure patient knows what will happen with info

Offer patient chance to add anything

Physical assessment Appraisal of health status Usually by Review of Systems Overview of symptoms Observable, measurable data

Appraisal of health status

Usually by Review of Systems

Overview of symptoms

Observable, measurable data

Objective data Possible approaches—body systems, head to toe, or functional health patterns

Objective data

Possible approaches—body systems, head to toe, or functional health patterns

Methods of physical asessment Inspection Percussion Palpation Auscultation

Inspection

Percussion

Palpation

Auscultation

Problems Related to Data Collection Inappropriate organization of the database Omission of pertinent data Inclusion of irrelevant or duplicate data, erroneous or misinterpreted data Failure to establish rapport and partnership Recording an interpretation of data rather than observed behavior Failure to update the database

Inappropriate organization of the database

Omission of pertinent data

Inclusion of irrelevant or duplicate data, erroneous or misinterpreted data

Failure to establish rapport and partnership

Recording an interpretation of data rather than observed behavior

Failure to update the database

2.ORGANISING DATA Nurses uses a written or computerized format for arranging he data systematically

Nurses uses a written or computerized format for arranging he data systematically

3.VALIDATING DATA VALIDATING -THE ACT OF DOUBLE CHECKING Verifies understanding of information Comparison with another source -patient or family member -record -health team member

VALIDATING -THE ACT OF DOUBLE CHECKING

Verifies understanding of information

Comparison with another source

-patient or family member

-record

-health team member

4. DOCUMENTING DATA Record in permanent record ASAP Use patient’s own words in subjective data – enclose in “ ___” (quotation marks) Avoid generalizations – be specific Don’t make summative statements

Record in permanent record ASAP

Use patient’s own words in subjective data – enclose in “ ___” (quotation marks)

Avoid generalizations – be specific

Don’t make summative statements

Thank you

Add a comment

Related presentations

Related pages

Nursing process - Wikipedia, the free encyclopedia

The nursing process is a modified scientific method. [1] Nursing practise was first described as a four stage nursing process by Ida Jean Orlando in 1958. [2]
Read more

Nursing Process Steps

The nursing process is a scientific method used by nurses to ensure the quality of patient care. This approach can be broken down into five separate steps.
Read more

The Nursing Process - American Nurses Association

The common thread uniting different types of nurses who work in varied areas is the nursing process—the essential core of practice for the registered ...
Read more

Nursing Process

We provide an In-Depth look into the nursing process. ... Contrary to popular belief, nurses do more than simply draw blood and take bandages.
Read more

Nursing process | definition of nursing process by Medical ...

process [pros´es] 1. a prominence or projection, as from a bone. 2. a series of operations or events leading to achievement of a specific result. 3. to ...
Read more

Nursing Process: Purpose and Steps - Video & Lesson ...

The nursing process is a series of organized steps designed for nurses to provide excellent care. Learn the five phases, including assessing,...
Read more

Nursing Process and Critical Thinking: Amazon.de: Judith M ...

Judith M. - Nursing Process and Critical Thinking jetzt kaufen. ISBN: 9780132242868, Fremdsprachige Bücher - Grundlagen & Fähigkeiten
Read more

The Nursing Process - MJC - Modesto Junior College

1 11/26/12 kwb: NP overview - Transfer students The Nursing Process The common thread uniting different types of nurses who work in varied areas is the ...
Read more

The Nursing Process - Rnspeakcom - Nursing Journal

Nursing process is a scientific process which is a foundation, the essential tool, and the enduring skill that has characterized nursing.The 6 steps of ...
Read more

Nursing Process : TheNursingProcess.com

Nursing Process. The nursing process is used by nurses every day to help patients improve their health and assist doctors in treating patients. Nursing ...
Read more