Nursing process assessing 1


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Nursing process assessing 1

  2. 2. Introduction  The Nursing Process enables the nurse to organize and deliver nursing care.  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.  It is a dynamic continuous process as the clients need change.
  3. 3.  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. The term Nursing process originated in 1955 by Hall and Johnson (1959), Orlando (1961) & Wiedenbach (1963) were the first user with a series of phases
  4. 4. 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.
  5. 5. 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.
  6. 6. Purposes1] Identify a client’s health status & actual or potential health problems or Needs.2] To establish plans to meet the identified needs3] Deliver specific nursing interventions to meet those needs.
  7. 7. Phases/Steps nursing process 1] Assessing 2] Diagnosing 3] Planning 4] Implementing 5] Evaluating
  8. 8. Characteristics of the NursingProcess1] 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
  9. 9. Assessing It is the systematic and continuous collection, organization, validation, and documentation of data (information). 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.
  10. 10. Types of assessmentThere are 4 different types of assessment:- 1] Initial assessment 2] Problem focused assessment 3] Emergency assessment 4] Time lapsed reassessment
  11. 11. Type Time performed Purpose ExampleInitial Performed To establish a Nursingassessment within complete admission specified time database for assessment after problem admission to a identification, health care reference, and agency. future comparison
  12. 12. Type Time performed Purpose ExampleProblem- Ongoing To determine Hourly assessment offocused process the status of a client’s fluidassessment integrated with specific intake and urinary output nursing care problem in an ICU identified in Assessment of an earlier client’s ability assessment to perform self care while assisting a client to bathe.
  13. 13. Type Time performed Purpose ExampleEmergency During any To identify life- Rapid assessment ofassessment physiologic or threatening a person’s psychologic problems airway, breathing crisis of the status, and client circulation during a cardiac arrest Assessment of suicidal tendencies or potential for violence.
  14. 14. Type Time performed Purpose ExampleTime-lapsed Several To compare the Reassessment of a client’sreassessment months after client’s current functional initial status to health patterns in a home care assessment baseline data or outpatient previously setting or, in a hospital, at obtained. shift change.
  15. 15.  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.
  17. 17. Description of the assessment phase Description Phase Purpose ActivitiesAssessment Collecting, Establish a database To establish  Obtain a nursing health history Organizing, database about the  Conduct a physical assessment Validating & client’s response  Review client records  Review Nursing Documentin to health concerns literature  Consult support g client data. or illness and the persons ability to manage  Consult health professionals update health care needs. data as needed organize data validate data communicate / document data.
  18. 18. Collecting Data 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.
  19. 19.  A data base is all the information about a client; it includes ◦ Nursing health history, ◦ Physical assessment, ◦ The history & physical examination, ◦ Results of laboratory & diagnostic tests, ◦ And material contributed by other health personnel. To collect data clearly both the client & nurse must actively participate.
  20. 20. • Client data includes past history as wellas current problems. Eg of Past history  Eg of Current ◦ History of allergic Problems to penicillin ◦ pain, nausea, sleep ◦ Past surgical patterns & religious procedures practices. ◦ Folk healing practices ◦ Chronic disease
  21. 21. 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,
  22. 22.  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
  23. 23. 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.
  24. 24. 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.
  25. 25. 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.
  26. 26. 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.
  27. 27. 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,
  28. 28. Laboratory records andHealth care professionals.
  29. 29. Data Collection Methods The primary methods of data collection are ◦ Observing – Occurs whenever the nursing is in contact with the client or support persons. ◦ Interviewing – is used while taking the nursing health History ◦ Examining – Major method used in the physical health assessment.
  30. 30.  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.
  31. 31. Observing 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.
  32. 32. ◦ 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, muscle strength (Hand grip)
  33. 33. Two 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.
  34. 34.  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.
  35. 35. 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
  36. 36. 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
  37. 37. Types of interview questionsThere are 4 types of interview questions Closed question Open ended question Neutral questions Leading question
  38. 38. Closed question Open ended Neutral Leading question questions question Used in direct Associated with Is a question the Used in directiveinterview, nondirective client can answer interview &Are restrictive interview with out direction or Thus directs client pressure from the Invite clients to nurse. answer.Generally requiresyes of No or short discover & explore,factual answers elaborate, clarify or Eg. illustrate their Used in nonOften begin with thoughts or feelings. directive that You’re stressed question.when, where, who, It specifies only the about surgerywhat, do, did or broad topic to be Eg. tomorrow, aren’tdoes, or is, are, was. discussed & invites How do you feel you? longer that one or about that?Eg. two words. You’ll take medicineAre you having pain won’t you?now? An open ended Why do you thinkWhat medication did question begins with you had the what or how? operation?you take? Eg. What brought you to hospital?
  39. 39. 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.
  40. 40.  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:-
  41. 41. Stages of an interview Opening or introduction 2 steps 1] establish rapport 2] orientation Body or development – closing
  42. 42. 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.
  43. 43.  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
  44. 44.  The physical examination is carried our systematically. It may be organized according to the examiner’s preference, Head to toe approach System wise approach
  45. 45. 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
  46. 46.  Validating data helps nurse in following tasks.1] Ensure that assessment information is complete.2] Ensure that objective data & related subjective data agree.3] Obtain additional information that may have been overlooked.4] Differentiate between cues &
  47. 47.  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 cues(Eg. cues nurse observes incision is red, hot & swollen. nurse makes the inference that the incision is infected
  48. 48. 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)