Nursing process assessing


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Nursing process assessing

  2. 2. NURSING PROCESS - INTRODUCTION The term NURSING PROCESS originated in 1955 by Haul. Johnson (1959), Orlando (1961), and Wiedenbach (1963) were the first users of the term nursing process. The Nursing Process enables the nurse to organize and deliver nursing care.
  3. 3. NURSING PROCESS -INTRODUCTION For the successful application of Nursing Process, ◦ the nurse integrates elements of critical thinking to make judgments ◦ and take actions based on reason. The nursing process is used to ◦ identify, diagnose and treat human responses to health and illness.
  5. 5. NURSING PROCESS -INTRODUCTION It is a dynamic continuous process as the clients need change. The use of Nursing Process promotes individualized nursing care And assists the nurse in responding to client needs in a timely and reasonable manner to improve or maintain the client’s level of health.
  6. 6. 1. Definition It is a systematic, rational method of planning and providing nursing care. Its goal is to identify a client’s health care status and actual or potential health problems, to establish plans to meet the identified needs, and to deliver specific nursing interventions to address those needs.
  7. 7. The Nursing Process is:A systematic, rational method of planning andproviding individualized nursing care.
  8. 8. Definition  The nursing process is cyclical, that is, 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 cycle may continue with reassessment or plan of care may be modified.
  9. 9.  It is synonymous with the PROBLEM SOLVING APPROACH that directs the nurse and the client to determine the need for nursing care, to plan and implement the care and evaluate the result. It is a G O S H approach (goal-oriented, organized, systematic and humanistic care) for efficient and effective provision of nursing care.
  10. 10. 2. PURPOSE OF THE NURSING PROCESS1. Identify a client’s health status and actual orPotential health problems or needs.2. To establish plans to meet the identified needs.3. Deliver specific nursing interventions to meetthose needs.
  11. 11. PURPOSE OF THE NURSING PROCESS 4. To Achieve Scientifically- Based, Holistic, Individualized Care For The Client. 5. To Achieve The Opportunity To Work Collaboratively With Clients, Others. 6. To Achieve Continuity Of Care.
  12. 12. 3. Benefits of Nursing Process1. Provides an orderly & systematic method for planning & providing care2. Enhances nursing efficiency by standardizing nursing practice3. Facilitates documentation of care4. Provides a unity of language for the nursing profession5. Is economical6. Stresses the independent function of nurses7. Increases care quality through the use of deliberate
  13. 13. 3. Benefits of Nursing Process1. Continuity of care2. Prevention of duplication3. Individualized care4. Standards of care5. Increased client participation6. Collaboration of care
  14. 14. 4. Characteristics of the Nursing Process1] Cyclic & dynamic in nature2] Client centered3] Focus on problem solving & Decision making4] Interpersonal & Collaborative style5] Universal applicability6] Use of critical thinking.7] Data from each phase provide input into the next phase.8]Decision making involved in every phase of nursing process.
  15. 15. CHARACTERISTICS:a. Systematic: The nursing process has an ordered sequence of activities and each activity depends on the accuracy of the activity that precedes it and influences the activity following it.
  16. 16. b.Dynamic: The nursing process has great interaction and overlapping among the activities and each activity is fluid and flows into the next activity
  17. 17. c. Interpersonal: The nursing process ensures thatnurses are client-centered rather than task-centeredand encourages them to work to enhance client’sstrengths and meet human needs.
  18. 18.  d. Goal-directed: The nursing process is a means for nurses and clients to work together to identify specific goals (wellness promotion, disease and illness prevention, health restoration, coping and altered functioning) that are most important to the client, and to match them with the appropriate nursing actions
  19. 19. e. Universally applicable: The nursing process allows nurses to practice nursing with well or ill people, young or old, in any type of practice setting
  20. 20. 5. Phases/Steps nursingprocessa. Assessingb. Diagnosingc. Planningd. Implementinge. Evaluating
  21. 21. 1. ASSESSING a. Collect data b. Organize data c. Validate data d. Analyze dataO e. Document data 2. DIAGNOSING a. Analyze dataV b. Identify health problems, risk, and strengths c. Formulate diagnostic statementsE 3. PLANNINGR a. Prioritize problems/diagnoses b. Formulate goals/desired outcome c. Select nursing interventionsV d. Write nursing ordersI 4. IMPLEMENTATION a. Reassess the client b. Determine the nurse’s need forE assistance c. Implement the nursing interventions d. Supervise delegated caseW 5. EVALUATION e. Document nursing activities a. Collect data related to outcomes b. Compare data with outcomes c. Relate nursing actions to client goals/outcomes d. Draw conclusions about problem status e. Continue, modify, or terminate the client’s care plan
  22. 22. 5. a. Assessing - Definition It is the systematic and continuous collection, organization, validation, and documentation of data (information) as compared to what is standard / norm . It is continuous process carried out during all phases of the nursing process. For Eg. In evaluation phase assessment is done to determine the outcomes of the nursing strategies and to evaluate goal achievement. All phases of nursing process depend on the accurate and complete collection of data.
  23. 23. 5. b. Purpose of Assessment1. To establish a data base (all the information about the client):2. Nursing health history3. Physical assessment4. The physician’s history & physical examination5. Results of laboratory & diagnostic tests6. Material from other health personnel
  24. 24. 5. c. Types of assessmentThere are 4 different types of assessment:- 1] Initial assessment 2] Problem focused assessment 3] Emergency assessment 4] Time lapsed reassessment
  25. 25. Type Time performed Purpose Example1.Initial Performed To establish a Nursingassessment within complete admission specified time database for assessment after problem admission to identification, a health care reference, and agency. future comparison
  26. 26. Type Time performed Purpose Example2.Problem- Ongoing To determine Hourlyfocused process the status of a assessment ofassessment integrated with specific client’s fluid nursing care problem intake and identified in an urinary output earlier in an ICU assessment Assessment of client’s ability to perform self care while assisting a client to bathe.
  27. 27. Type Time performed Purpose Example3.Emergenc During any To identify life- Rapidy assessment physiologic or threatening assessment of a psychologic problems person’s crisis of the airway, client breathing status, and circulation during a cardiac arrest Assessment of suicidal tendencies or potential for violence.
  28. 28. Type Time Purpose Example performed4.Time- Several To compare the Reassessmentlapsed months after client’s current of a client’sreassessment initial status to functional assessment baseline data health patterns previously in a home care obtained. or outpatient setting or, in a hospital, at shift change.
  29. 29.  Assessment varies according to ◦ purpose, ◦ timing, ◦ time available & ◦ client status. Nursing assessments focus on a client response to a health problem. A Nursing assessment include the clients perceived needs, health problems, related experience , health practices, values and life styles. Data should be relevant to a particular health problem.
  30. 30. Activities in Assessing phase Activities: a. Collection of data b. Validation of data c. Organization of data d. Analyzing of data e. Recording/documentation of data Assessment = Observation of the patient + Interview of patient, family & Significant Others + examination of the patient + Review of medical record
  31. 31. 5. d. Description of the assessment phase Phase Description Purpose Activitiesi. Assessment Collecting, To establish Establish a database Organizing, database about  Obtain a nursing health history Validating , the client’s  Conduct a physical Analyzing & response to assessment Documenting health concerns  Review client client data. or illness and the records ability to  Review Nursing literature manage health  Consult support care needs. persons  Consult health professionals update data as needed organize data validate data communicate / document data.
  32. 32. 5. d) a. Collecting Data – i. Meaning Is the process of gathering information about a client’s health status. It must be both systematic & continuous To prevent the omission of significant data & reflect a client’s changing health status. To collect data clearly both the client & nurse must actively participate.
  33. 33. • Client data includes past history as well as current problems. Eg of Past history  Eg of Current Problems ◦ History of allergic to ◦ pain, nausea, sleep penicillin patterns & religious ◦ Past surgical practices. procedures ◦ Folk healing practices ◦ Chronic disease
  34. 34. 5. d) a. ii.Types of data Subjective Data Objective data Also referred to as  Also referred to as signs or symptoms or covert data overt data, Can be verified described by  Are detectable by an observer only the person who or affected.  Can be measured or tested Eg. Itching, pain, feelings of against an accepted standard. worry.  They can be seen, heard felt It includes the client’s or smelled and sensations, feelings values,  They are obtained by beliefs, attitudes and observation or physical perception of personal examination health status and life  For eg. Discoloration of skin,
  35. 35.  During Physical Examination, the nurse obtains objective data to validate subjective data. Information supplied by family members, significant others or health professionals are considered subjective if it is not based on fact. A complete data base of both subjective & objective data provides a base line for comparing the client’s responses to nursing & medical intervention.
  36. 36. Eg. Of subjective & objective data. Sl. Subjective Data Objective Data No.1 I have fever Body tem – 1000F Tachycardia – 100 bt/mt Dull & tired Dried lips2 I feel sick to my stomach Vomited 100ml of green tinged fluid Abdomen firm Slightly distended Active bowel sounds in all 4 quadrants3 I am short of breath RR – 28br/mt Tachypnoea Lung sound diminished in ® lower lobe.
  37. 37. 5. d) a. iii.Sources of Data Sources of data are primary or secondary. The client is the primary source of data. Secondary or indirect sources are family members or other support persons, other health professionals, records & reports laboratory and diagnostic analyses, and relevant literature. All sources other than the client are considered secondary sources.
  38. 38. Client The best source of data unless the client is to ill, young or confused to communicate clearly. The client can provide subjective data that no one else can offer.
  39. 39. Support people Family members, friends and care givers who know the client well often can supplement or verify information provided by the client. ◦ They might convey information about the client’s response to illness ◦ the stresses client was experiencing before the illness, ◦ family attitudes on illness and health, ◦ and the clients home environment. Support people data are very important in case of a client who is very young unconscious or confused.
  40. 40. Client Records It includes information documented by various health care professionals. Client records also contain data regarding the client’s occupation, religion, and marital status. By reviewing the records the nurse can avoid asking questions for which answers have already been supplied. Medical records (Medical history, physical examination, operative report, progress notes & consultations by Physicians.) Records of therapies – Social workers, nutritionists, dietitians or physical therapists
  41. 41. Laboratory records andHealth care professionals.
  42. 42. 5. d) a. iv. Data Collection Methods The primary methods of data collection are ◦ I. Observing – Occurs whenever the nurse is in contact with the client or support persons. ◦ II. Interviewing – is used while taking the nursing health History ◦ III. Examining – Major method used in the physical health assessment.
  43. 43.  In reality, the nurse uses all three methods simultaneously when assessing clients. for Eg. During the client interview the nurse observes, listens, asks questions, and mentally retains information to explore in the physical examination.
  44. 44. 5. d) a. iv. I. Observing - Meaning is to gather data by using the senses. Observation is a conscious, deliberate skill that is developed through effort & with an organized approach.Eg. Using the senses to observe client data.
  45. 45. i. b. Methods of Observation◦ Vision :- overall appearance (body size , general weight, signs of distress or posture & grooming) discomfort, facial & body gestures, skin colour & lesions◦ Smell: - Body or Breath odors.◦ Hearing: - lung, heart sounds, bowel sounds, ability to communicate, language spoken.◦ Touch :- Skin temperature, moisture,
  46. 46. i. c.Aspects of Observation 1] Noticing the data 2] Selecting, organizing & interpreting the data Eg : - A nurse who observes that a client’s face is flushed, must relate that observation to body temperature, activity, environmental temperature, and blood pressure. Errors can occur in selecting, organizing & interpreting data.
  47. 47.  Nursing observations must be organized so that nothing significant is missed. Most nurses develop a particular sequence for observing events, usually focusing on the client first. For Eg. A nurse walks into a client’s room and observes, in the following order. 1]Clinical signs of client distress (Eg. pallor or flushing, labored breathing, and behavior indicating pain or emotional distress) 2] Threats to clients safety, real or anticipated (Eg. a lowered side rail) 3]The presence and functioning of associated equipment (Eg. Equipment & oxygen) 4] The immediate environment, including the people in it.
  48. 48. 5. d) a. iv. II. Interviewing An interview is a planned communication or a conversation with a purpose for Eg. to get or give information, identify problems of mutual concern, evaluate change, teach Eg. for an Interview is nursing Health history. There are 2 approaches in interview
  49. 49. Direct Indirect or nondirectiveHighly structured & elicits Rapport- building interviewspecific informations (understanding between two or more people)Nurse establishes purpose of Nurse allows the client tointerview and controls the control the purpose, subjectinterview matter and pacingClients who responds mayhave limited opportunity toask question or Discussconcerns
  50. 50. Types of interview questionsThere are 4 types of interview questions Closed question Open ended question Neutral questions Leading question
  51. 51. Closed question Open ended Neutral questions Leading question question1. Used in direct 1. Associated with 1. Is a question the 1. Used in directive interview, nondirective client can answer interview & interview without direction or2. Are restrictive 2. Invite clients to pressure from the 2. Thus directs client discover & nurse. answer.3. Generally requires explore, elaborate, yes of No or short clarify or illustrate Eg. factual answers their thoughts or 2. Used in non feelings. directive that question. a. You’re stressed4. Often begin with about surgery 3. It specifies only when, where, who, tomorrow, aren’t the broad topic to Eg. what, do, did or you? be discussed & a. How do you feel does, or is, are, invites longer that about that? was. b. You’ll take medicine one or two words.Eg. won’t you?a. Are you having pain 4. An open ended b. Why do you think now? question begins you had theb. What medication did with what or how? operation? you take? Eg. a. What brought you to hospital? b. How did you feel in that?
  52. 52. Planning the interview and setting Before beginning an interview, the nurse reviews available information.Eg. Operative report, information about the current illness. Each interview is influenced by time, place, seating arrangement or distance, and language.
  53. 53.  Time: -Nurse need to plan for an interview with hospitalized clients ◦ physically comfortable, ◦ free of pain, ◦ when interruptions by friends, family, and other health professionals are minimal.The client should be made to feel comfortable & unhurried. Place: - Well lighted, well ventilated, moderate sized room, free of nurse, movements, interruptions encourages the communication. Seating arrangements: - Distance:-
  54. 54. Stages of an interview Opening or introduction 2 steps 1] establish rapport 2] orientation Body or development – closing
  55. 55. 5. d) a. iv. III. Examining Physical examination or physical assessment is a systematic data collection method that uses observation to detect health problems. To conduct examination the nurse uses techniques of 1) Inspection 2) auscultation, 3) palpation, 4) percussion.
  56. 56. Inspection
  57. 57. Palpation
  58. 58. Auscultation
  59. 59. Percussion
  60. 60.  Inspection: - Process of checking that things are in the correct condition. Auscultation: - Examining the internal organs by listening to the sounds that they give out Palpation: - Examination of organ by touches or pressure of the hand over the part. Percussion: - Tapping with the fingers or
  61. 61.  The physical examination is carried our systematically. It may be organized according to the examiner’s preference, Head to toe approach (Cephalo caudal approach) System wise approach – examine all the body system Review of system approach – examine only particular area affected
  62. 62. b. Organization of data Uses a written or computerized format that organizes assessment data systematically. Maslow’s basic needs Body system model Gordon’s functional health patterns
  64. 64.  Gordon’s Functional Health Patterns: i. Health perception-health management pattern. ii. Nutritional-metabolic pattern iii. Elimination pattern iv. Activity-exercise pattern v. Sleep-rest pattern vi. Cognitive-perceptual pattern vii. Self-perception-concept pattern viii. Role-relationship pattern ix. Sexuality-reproductive pattern x. Coping-stress tolerance pattern xi. Value-belief pattern
  65. 65. c.Validating Data The information gathered during assessment phase must be complete, factual, and accurate because the nursing diagnoses and interventions are based on this information. Validation is double checking or verifying the data is accurate and
  66. 66. Purposes of data validation1. Ensure that data collection is complete2. Ensure that objective and subjective data agree3. Obtain additional data that may have been overlooked4. Avoid jumping to conclusion5. Differentiate cues and inferences
  67. 67.  Cues - subjective and objective data that can be directly observed by the nurse.(What client can say, what the nurse can see, hear, feel, smell or measure) Inferences - Nurses interpretation or conclusions made based on the cuesExample:1. Red, swollen wound = infected wound2. Dry skin = dehydrated
  68. 68. d. Analyze data Compare data against standard and identify significant cues. Standard/norm are generally accepted measurements, model, pattern:Ex:1. Normal vital signs,2. Standard weight and height,3. Normal laboratory/diagnostic values,4. Normal growth and development pattern
  69. 69. e. Documenting data To complete the assessment phase, the nurse records client data. record in a factual manner It includes all data collected about client status. Eg. Data in factual manner Wrong manner Slice of toast – I Appetite is good” Egg - I “normal appetite” Juice - 250ml. Coffee- 240ml.- Record subjective data in client’s own words (more accuracy)