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  1. 1. NURSING PROCESS <ul><li>Ms.JEENA AEJY </li></ul>
  2. 2. THE NURSING PROCESS <ul><li>A systematic problem-solving approach used to identify, prevent and treat actual or potential health problems and promote wellness. </li></ul>
  3. 3. <ul><li>Nursing process </li></ul><ul><li>A systematic way to plan, implement and evaluate care for individuals, families, groups and communities. </li></ul>
  4. 4. Characteristics of the Nursing Process <ul><li>Dynamic </li></ul><ul><li>Client-centered </li></ul><ul><li>Planned </li></ul><ul><li>Interpersonal and collaborative </li></ul><ul><li>Universally applicable </li></ul><ul><li>Can focus on problems or strengths </li></ul>
  5. 5. <ul><li>Open, flexible </li></ul><ul><li>Humanistic and individualized </li></ul><ul><li>Cyclical </li></ul><ul><li>Outcome focused ( results oriented) </li></ul><ul><li>Emphasizes feedback and validation </li></ul>
  6. 6. STEPS IN NURSING PROCESS <ul><li>Assessment </li></ul><ul><li>Nursing Diagnosis </li></ul><ul><li>Planning </li></ul><ul><li>Implementation </li></ul><ul><li>Evaluation </li></ul>
  7. 7. Nursing Process Assessment Nursing Diagnosis Planning Implementation Evaluation
  8. 8. Benefits of using the nursing process <ul><li>Continuity of care </li></ul><ul><li>Prevention of duplication </li></ul><ul><li>Individualized care </li></ul><ul><li>Standards of care </li></ul><ul><li>Increased client participation </li></ul><ul><li>Collaboration of care </li></ul>
  10. 11. Assessment <ul><li>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. </li></ul><ul><li>Assessing is the systematic and continuous collection, organization, validation and documentation of data. </li></ul><ul><li>- Potter and Perry( 2006) </li></ul>
  11. 12. <ul><li>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 </li></ul><ul><li>- Carpenito 2000 </li></ul><ul><li>  </li></ul><ul><li>Assessment is the systematic and continuous collection, validation and communication of patient data. </li></ul><ul><ul><li>- Carol Taylor </li></ul></ul><ul><li>  </li></ul>
  12. 13. Types of Assessment <ul><li>1. Initial Assessment : Performed within specified time after admission to a health care agency </li></ul><ul><li>  </li></ul><ul><li>Eg. Nursing Admission Assessment </li></ul><ul><li>  </li></ul><ul><li>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. </li></ul><ul><li>  </li></ul><ul><li>E.g.. Assessment of clients ability to perform self-care while assisting client to bathe. </li></ul><ul><li>  </li></ul><ul><li>  </li></ul><ul><li>3. Emergency Assessment : Done during psychiatric or physiological crisis of the client to identify life threatening problems </li></ul><ul><li>  </li></ul><ul><li>Eg. Rapid assessment of airway, breathing and circulation during cardiac arrest </li></ul><ul><li>  </li></ul><ul><li>4. Time lapsed-Reassessment : Done several months after initial assessment to compare the clients status to baseline data previously obtained. </li></ul>
  13. 14. Assessment ASESSMENT Collect data Organize data Validates Data Document data DIAGNOSIS PLANNING IMPLIMENTATION EVALUATION
  14. 15. 1.COLLECTION OF DATA Data Collection is the process of gathering information about a clients health status .
  15. 16. <ul><li>Collection of Data: </li></ul><ul><li>  </li></ul><ul><li>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. </li></ul><ul><li>  </li></ul><ul><li>  </li></ul><ul><li>  </li></ul>
  16. 17. Medical vs. Nursing Assessments <ul><li>Medical assessments </li></ul><ul><ul><li>Target data pointing to pathologic conditions </li></ul></ul><ul><li>Nursing assessments </li></ul><ul><ul><li>Focus on the patient’s response to health problems </li></ul></ul>
  17. 18. Types of Data:   <ul><li>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 </li></ul><ul><li>  </li></ul><ul><li>Eg. Itching, Pain, Feelings of worry </li></ul><ul><li>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. </li></ul><ul><li>  </li></ul><ul><li>They can be seen, heard, felt or smelled and they are obtained by observation or physical examination </li></ul><ul><li>  </li></ul><ul><li>Eg. A Blood Pressure Data </li></ul><ul><li>Discolouration of the Skin </li></ul><ul><li>  </li></ul>
  18. 19. Objective Data vs. Subjective Data <ul><li>Objective data </li></ul><ul><ul><li>Observable and measurable data that can be seen, heard, or felt by someone other than the person experiencing them </li></ul></ul><ul><ul><li>E.g., elevated temperature, skin moisture, vomiting </li></ul></ul><ul><li>Subjective data </li></ul><ul><ul><li>Information perceived only by the affected person </li></ul></ul><ul><ul><li>E.g., pain experience, feeling dizzy, feeling anxious </li></ul></ul>
  19. 20. Sources of Data: <ul><li>Primary Source (Direct Source </li></ul><ul><ul><ul><li>client: Usually BEST source </li></ul></ul></ul>
  20. 21. Secondary Source (Indirect Source) <ul><li>Family Members </li></ul><ul><li>Client’s records </li></ul><ul><li>1. Medical Records </li></ul><ul><li>Eg. Medical History, Physical Examination, </li></ul><ul><li>Operation notes, Progress notes, </li></ul><ul><li>Consultation done by Physicians </li></ul><ul><li>2. Records of therapies done by other health professionals </li></ul><ul><li>Eg. Social Workers, Dieticians, Physical Therapist </li></ul><ul><li>3. Laboratory Records </li></ul><ul><li>Other health care professionals Verbal reports </li></ul><ul><li>Literature </li></ul>
  21. 22. Data Collection <ul><li>Consider </li></ul><ul><ul><li>time </li></ul></ul><ul><ul><li>needs of patient </li></ul></ul><ul><ul><li>developmental stage </li></ul></ul><ul><ul><li>physical surroundings </li></ul></ul><ul><ul><li>past and present coping patterns </li></ul></ul>
  22. 23. Data Characteristics <ul><li>Complete </li></ul><ul><li>Factual </li></ul><ul><li>Accurate </li></ul><ul><li>Relevant </li></ul>
  23. 24. Data collection methods <ul><li>OBSERVATION </li></ul><ul><li>INTERVIEWING </li></ul><ul><li>PHYSICAL ASSESSMENT </li></ul>
  24. 25. Observation <ul><li>To gather data using senses </li></ul><ul><li>Eg: laboured breathing, pallor or flushing,pain </li></ul><ul><li>a lowered side rail ,functioning of an equipment , pt environment and people in it etc… </li></ul>
  25. 26. Interviewing <ul><li>An interview is a planned communication or a conversation with a purpose </li></ul><ul><ul><li>Types of questions and </li></ul></ul><ul><ul><li>Setting </li></ul></ul><ul><ul><li>Rapport are important </li></ul></ul>Collection of Health History
  26. 27. Four Phases of a Nursing Interview <ul><li>Preparatory phase </li></ul><ul><li>Introduction </li></ul><ul><li>Working phase </li></ul><ul><li>Termination </li></ul>
  27. 28. Interview Phases <ul><li>Preparatory </li></ul><ul><ul><li>Nurse collects background info from previous charts </li></ul></ul><ul><ul><li>Ensure environment is conducive </li></ul></ul><ul><ul><li>Arrange seating </li></ul></ul><ul><ul><ul><li>3 – 4 ft apart </li></ul></ul></ul><ul><ul><ul><li>Interviewer at 45° angle to patient </li></ul></ul></ul><ul><ul><li>Allow adequate time </li></ul></ul>
  28. 29. Phases cont’d. <ul><li>Introduction </li></ul><ul><ul><li>Nurse introduces self </li></ul></ul><ul><ul><li>Identifies purpose of interview </li></ul></ul><ul><ul><li>Ensure confidentiality of information </li></ul></ul><ul><ul><li>Provide for patient needs before starting </li></ul></ul>
  29. 30. Phases cont’d. <ul><li>Working </li></ul><ul><ul><li>Nurse gathers info for sub jective data </li></ul></ul><ul><ul><li>Excellent communication skills are needed </li></ul></ul><ul><ul><ul><li>Active listening </li></ul></ul></ul><ul><ul><ul><li>Eye contact </li></ul></ul></ul><ul><ul><ul><li>Open-ended questions </li></ul></ul></ul>
  30. 31. Phases cont’d. <ul><li>Termination </li></ul><ul><ul><li>Inform patient when nearing end of interview </li></ul></ul><ul><ul><li>Ensure patient knows what will happen with info </li></ul></ul><ul><ul><li>Offer patient chance to add anything </li></ul></ul>
  31. 32. Physical assessment <ul><ul><li>Appraisal of health status </li></ul></ul><ul><ul><li>Usually by Review of Systems </li></ul></ul><ul><ul><ul><li>Overview of symptoms </li></ul></ul></ul><ul><ul><ul><li>Observable, measurable data </li></ul></ul></ul>
  32. 33. <ul><li>Objective data </li></ul><ul><li>Possible approaches—body systems, head to toe, or functional health patterns </li></ul>
  33. 34. Methods of physical asessment <ul><li>Inspection </li></ul><ul><li>Percussion </li></ul><ul><li>Palpation </li></ul><ul><li>Auscultation </li></ul>
  34. 35. Problems Related to Data Collection <ul><li>Inappropriate organization of the database </li></ul><ul><li>Omission of pertinent data </li></ul><ul><li>Inclusion of irrelevant or duplicate data, erroneous or misinterpreted data </li></ul><ul><li>Failure to establish rapport and partnership </li></ul><ul><li>Recording an interpretation of data rather than observed behavior </li></ul><ul><li>Failure to update the database </li></ul>
  35. 36. 2.ORGANISING DATA <ul><li>Nurses uses a written or computerized format for arranging he data systematically </li></ul>
  36. 37. 3.VALIDATING DATA <ul><li>VALIDATING -THE ACT OF DOUBLE CHECKING </li></ul><ul><li>Verifies understanding of information </li></ul><ul><li>Comparison with another source </li></ul><ul><li>-patient or family member </li></ul><ul><li>-record </li></ul><ul><li>-health team member </li></ul>
  37. 38. 4. DOCUMENTING DATA <ul><li>Record in permanent record ASAP </li></ul><ul><li>Use patient’s own words in subjective data – enclose in “ ___” (quotation marks) </li></ul><ul><li>Avoid generalizations – be specific </li></ul><ul><li>Don’t make summative statements </li></ul>
  38. 39. Thank you