1 data analysis

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1 data analysis

  1. 1. Nursing ProcessMaria Carmela L. Domocmat, RN, MSN
  2. 2. Nursing Process• Is the framework for professional nursing practice.• Nursing Process and Maslow are the main frameworks for the local board and the NCLEX Exams. Maria Carmela L. Domocmat, RN, MSN
  3. 3. • Remember ONLY the RN can assess, develop a plan of care, evaluate and educate clients.• Promotes humanistic, outcome-focused, cost-effective care Maria Carmela L. Domocmat, RN, MSN
  4. 4. • Pushes nurses to continually examine what they are doing and to study how it can be done better. Maria Carmela L. Domocmat, RN, MSN
  5. 5. • Nursing Process consists of five interrelated steps – Assessment – Diagnosis – Planning – Implementing – Evaluating Maria Carmela L. Domocmat, RN, MSN
  6. 6. Maria Carmela L. Domocmat, RN, MSN
  7. 7. Why learn about it?• The nursing process provides the basis for the board exams –you need to be thoroughly familiar with it to think your way to through the questions.• It helps you think critically in the clinical setting—you must master the principles behind the nursing process. Maria Carmela L. Domocmat, RN, MSN
  8. 8. • Using the nursing process complements what other health care professionals do by focusing on both the medical problems and human response –how the person responds to medical problems, treatment plans, and changes in activities of daily life. Maria Carmela L. Domocmat, RN, MSN
  9. 9. • Advantages to the nurse who becomes skilled in the use of the nursing process: Maria Carmela L. Domocmat, RN, MSN
  10. 10. COMPARISON OFPHYSICIAN’S DATA &NURSE’S DATA Maria Carmela L. Domocmat, RN, MSN
  11. 11. Physician’s data• Disease focus• Mrs. Garcia has pain and swelling in all joints. Diagnostic studies indicate that she has rheumatoid arthritis. We will start her in a course of anti-inflammatories to treat the rheumatoid arthritis.• (Focus is on treating the arthritis) Maria Carmela L. Domocmat, RN, MSN
  12. 12. Nurse’s data• Wholistic focus –considering their problems and their effect on the person’s ability to function independently.• Mrs. Garcia has pain and swelling in all joints, making it difficult to dress herself. She has voiced that it’s difficult to feel worthwhile when she can’t even feed herself. She states that she is depressed because she misses seeing her two small grandchildren. Carmela L. Domocmat, RN, MSN Maria
  13. 13. • We need to develop a plan to help her pain, to assist with her feeding and dressing, to work through feelings of low self-esteem, and for special visitations with the grandchildren.• (Focus is on Mrs. Garcia) Maria Carmela L. Domocmat, RN, MSN
  14. 14. • Meet the standards of nursing clinical practice• Graduation from an accredited school of nursing• Confidence• Job satisfaction• Professional growth• Aid in staff assignments• Employment in a nationally accredited hospital Maria Carmela L. Domocmat, RN, MSN
  15. 15. WHAT IS CRITICALTHINKING IN NURSING? Maria Carmela L. Domocmat, RN, MSN
  16. 16. Critical thinking in nursing:• Entails purposeful, outcome-oriented (results-oriented) thinking.• Is driven by patient, family, and community needs.• Is based on principles of nursing process and scientific method Maria Carmela L. Domocmat, RN, MSN
  17. 17. • Requires knowledge, skills and experience• Is guided by professional standards and ethics codes. Maria Carmela L. Domocmat, RN, MSN
  18. 18. • Requires strategies that maximize human potential (e.g., using individual strengths) and compensate for problems created by human nature (e.g., the powerful influence of personal perspectives, values and beliefs.)• Is constantly re-evaluating, self-correcting, and striving to improve. Maria Carmela L. Domocmat, RN, MSN
  19. 19. Critical Thinkers are:• Aware of their strengths and capabilities• Sensitive to their own limitations and predispositions• Open minded• Humble• Creative Maria Carmela L. Domocmat, RN, MSN
  20. 20. Critical Thinkers are:• Proactive• Flexible• Aware that errors are stepping- stones to new ideas• Willing to persevere• Cognizant to the fact that we don’t live in a perfect world• Introspective Maria Carmela L. Domocmat, RN, MSN
  21. 21. Maria Carmela L. Domocmat, RN, MSN
  22. 22. DATA COLLECTION,ANALYSIS, ANDDOCUMENTATION Maria Carmela L. Domocmat, RN, MSN
  23. 23. Maria Carmela L. Domocmat, RN, MSN
  24. 24. Assessment• the collection of data about an individual’s health state• first and most critical phase of the nursing process Maria Carmela L. Domocmat, RN, MSN
  25. 25. Assessment• ongoing and continuous throughout all the phases of the nursing process• is systematic and continuous collection, validation and communication of client data as compared to what is standard/norm Maria Carmela L. Domocmat, RN, MSN
  26. 26. Purpose:To establish a data base (all the informationabout the client) to determine the client’soverall level of functioning in order to make aprofessional clinical judgmentTo supplement, confirm, or question dataobtained in the nursing historyTo obtain data that will help the nurseestablish nursing diagnoses and plan patientcare Maria Carmela L. Domocmat, RN, MSN
  27. 27. To evaluate the appropriateness of thenursing interventions in resolving the patientsidentified pathophysiology problemscollect data of patient’s health status, toidentify deviations from normal, to discoverthe patient’s strengths and coping resources,to point actual problems, and factors thatplace the patient at risk for health problems Maria Carmela L. Domocmat, RN, MSN
  28. 28. • Wholistic data collection.• Nurse collects physiologic, psychological, sociocultural, developmental, and spiritual data about the client Maria Carmela L. Domocmat, RN, MSN
  29. 29. nurse focuses on how client’s healthstatus affects his activities of daily living(ADL) and how the client’s ADL affect ishealth Ex: client with asthma Maria Carmela L. Domocmat, RN, MSN
  30. 30. assess how client interact within theirfamily, cultures, and community and howthe client’s health status affects the familyand community Ex: client with DM who has amputation; single parent mother of a 6 year-old child Maria Carmela L. Domocmat, RN, MSN
  31. 31. • Data from nursing assessment can be classified as subjective and objective. Maria Carmela L. Domocmat, RN, MSN
  32. 32. Data include:nursing health historyphysical assessmentthe physician’s history & physicalexaminationresults of laboratory & diagnostictestsmaterial from other health personnel Maria Carmela L. Domocmat, RN, MSN
  33. 33. Maria Carmela L. Domocmat, RN, MSN
  34. 34. Assessment– The first step in determining the health status of the client– Because the entire plan of care is based on the data collected during this phase, you need to make every effort to ensure that your information is correct, complete, and organized in a way that helps you begin to get a sense of patterns of health or illness. Maria Carmela L. Domocmat, RN, MSN
  35. 35. Types of Assessment Maria Carmela L. Domocmat, RN, MSN
  36. 36. Types of Assessment• Initial comprehensive assessment• Ongoing or partial assessment• Focused or problem-oriented assessment• Emergency assessment• Time-lapsed assessment Maria Carmela L. Domocmat, RN, MSN
  37. 37. Initial comprehensive assessment• assessment performed within a specified time on admission Maria Carmela L. Domocmat, RN, MSN
  38. 38. Initial comprehensive assessment• Involves collection of subjective data about the – client’s perception of his/her health of all body parts or systems, – past health history, – family history, and – lifestyle and health practices (which includes information related to the client’s overall function) as well as objective data gathered during a step-by-step physical examination Maria Carmela L. Domocmat, RN, MSN
  39. 39. Initial comprehensive assessmentWhen performed?• On the initial contact with the client• where: hospital, community, clinic or home setting• purpose: to have a baseline comprehensive data about the client• Ex: nursing admission assessment Maria Carmela L. Domocmat, RN, MSN
  40. 40. Ongoing or partial assessment Maria Carmela L. Domocmat, RN, MSN
  41. 41. Ongoing or partial assessment• consists of data collection that occurs after the comprehensive database is established• consists of mini-overview of the client’s body systems and holistic health patterns as a follow-up on his health status Maria Carmela L. Domocmat, RN, MSN
  42. 42. Ongoing or partial assessment• When performed?• usually performed whenever the nurse or another health care professional has an encounter with the client Maria Carmela L. Domocmat, RN, MSN
  43. 43. Ongoing or partial assessment • purposes: • Any problems that were initially detected in the client’s body system or holistic health patterns are reassessed in less depth to determine any major changes (deterioration or improvement) from the baseline data. • Brief reassessment of the client’s normal body system or wholistic health patterns is performed to detect new problems Maria Carmela L. Domocmat, RN, MSN
  44. 44. Focused or problem-oriented assessment• consists of a thorough assessment of a particular health problem and does not cover areas not related to the problem• purpose: to have a thorough assessment on the special health concern of the client identified in an earlier assessment Maria Carmela L. Domocmat, RN, MSN
  45. 45. Focused or problem-oriented assessment• When performed?• performed when a comprehensive database exists for a client and he/she comes to the health care agency with a special health concern Maria Carmela L. Domocmat, RN, MSN
  46. 46. Emergency assessment• a very rapid assessment performed in a life-threatening situations• rapid assessment done during any physiologic/physiologic crisis of the client to identify life threatening problems Maria Carmela L. Domocmat, RN, MSN
  47. 47. Emergency assessment• purpose: to determine the status of the client’s life-sustaining physical functions Maria Carmela L. Domocmat, RN, MSN
  48. 48. Time-lapsed assessment• reassessment of client’s functional health pattern done several months after initial assessment to compare the client’s current status to baseline data previously obtained. Maria Carmela L. Domocmat, RN, MSN
  49. 49. Sources of Data Maria Carmela L. Domocmat, RN, MSN
  50. 50. Sources of Data• Primary source: – data directly gathered from the client using interview and physical examination.• Secondary source: – data gathered from client’s family members, significant others, client’s medical records/chart, other members of health team, and related care literature/journals. Maria Carmela L. Domocmat, RN, MSN
  51. 51. Maria Carmela L. Domocmat, RN, MSN
  52. 52. Maria Carmela L. Domocmat, RN, MSN

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