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NURSING PROCESS
 

NURSING PROCESS

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nursing process assessment planning implementation evaluation data subjective objective documentation

nursing process assessment planning implementation evaluation data subjective objective documentation

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    NURSING PROCESS NURSING PROCESS Presentation Transcript

    • NURSING PROCESS
      • 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.
      • 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
      • Open, flexible
      • Humanistic and individualized
      • Cyclical
      • Outcome focused ( results oriented)
      • Emphasizes feedback and validation
    • STEPS IN NURSING PROCESS
      • 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
    • 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)
      • 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.
    • 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.
      •  
      •  
      •  
    • Medical vs. Nursing Assessments
      • 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
      •  
    • 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
    • Sources of Data:
      • 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
    • Data Collection
      • Consider
        • time
        • needs of patient
        • developmental stage
        • physical surroundings
        • past and present coping patterns
    • Data Characteristics
      • Complete
      • Factual
      • Accurate
      • Relevant
    • Data collection methods
      • 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…
    • 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
    • Four Phases of a Nursing Interview
      • 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
    • Phases cont’d.
      • 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
    • 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
    • Physical assessment
        • 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
    • Methods of physical asessment
      • 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
    • 2.ORGANISING DATA
      • 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
    • 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
    • Thank you