The document outlines the nursing process, which consists of assessment, planning, implementation, and evaluation. It describes the assessment phase in detail. Assessment involves collecting both subjective and objective data through various methods like observation, interview, and examination. The nurse organizes, validates, and documents the collected data to identify the patient's health status, problems, and needs in order to develop an appropriate care plan.
The document discusses the evaluation phase of the nursing process. It defines evaluation as comparing a patient's responses to predetermined goals and outcomes. The nurse evaluates whether expected outcomes were met, not just if interventions were done. Key aspects of evaluation include collecting and interpreting data, comparing outcomes to goals, documenting findings, and revising the care plan if needed. The evaluation determines if care was effective and ensures continuous good patient outcomes.
Nurses must provide effective reporting both orally and in writing to ensure continuity of patient care. Common types of reports include change-of-shift reports to pass on important patient information when nurses change shifts, transfer reports which provide details on a patient's condition and treatment when moved between units, incident reports for documenting any unexpected medical events, and telephone reports to communicate time-sensitive patient information. Effective reporting involves concisely relaying objective and relevant details about a patient's status, treatment, and care needs to keep all healthcare providers well-informed.
Nursing assessment involves collecting data to understand a patient's health status. It includes gathering subjective information from the patient and objective data through examination. The nurse organizes, validates, and documents the assessment data to identify health problems, strengths, and needs to develop an appropriate plan of care. Common assessment techniques are inspection, palpation, percussion, and auscultation to examine each body system.
The nursing process is a systematic method for planning and providing nursing care to patients. It involves five interrelated phases: assessment, diagnosis, planning, implementation, and evaluation. Assessment is the first phase and involves collecting subjective and objective data about the patient's health status through various techniques like inspection, palpation, percussion, and auscultation. The data is then organized, validated, and documented to form the patient's database which provides the basis for determining the patient's diagnoses, developing a care plan, and evaluating outcomes.
Nursing assessment involves collecting and analyzing clinical information about a client's health status. It includes observation, interviews, examinations, and medical record reviews. The purposes of assessment are to gather information, determine normal functioning, organize data, confirm hypotheses, enhance investigation of problems, frame nursing diagnoses, and identify health issues and strengths. There are several types of assessments including initial, focus, emergency, and time-lapsed assessments. Data is collected through various methods and sources, organized using frameworks like Gordon's functional health patterns, validated, and recorded for documentation. Proper assessment provides a basis for care, communication, reimbursement, and future reference.
The nursing process provides a framework for delivering nursing care. It involves assessment, nursing diagnosis, planning, implementation, and evaluation. Assessment involves collecting subjective and objective data about a patient's health status and history through various methods like observation, interviews, physical exams, and record reviews. This collected data is then organized, validated, and recorded to identify nursing diagnoses and develop a care plan to address any issues. The nursing process aims to improve the quality of patient care through a systematic, individualized approach.
This document discusses critical thinking in nursing. It defines critical thinking as an organized cognitive process used to carefully examine one's own thinking and the thinking of others based on evidence rather than assumptions. Critical thinking is needed for nurses to make accurate clinical decisions, solve problems, plan individualized care, and think creatively. It involves reflection, language skills, and intuition. Critical thinking progresses from basic to complex levels and involves commitment to decisions. Key competencies include using the scientific method, problem solving, decision making, diagnostic reasoning, and clinical decision making. A critical thinking model incorporates knowledge, experience, competencies, attitudes like curiosity and integrity, and standards.
This document discusses evidence-based practice (EBP) in nursing. It defines EBP as making clinical decisions based on evidence from scientific research combined with clinical experience and patient preferences. The history of EBP in nursing began in the 1970s with projects that developed research-based clinical protocols and demonstrated improved patient outcomes. EBP requires nurses to critically assess scientific evidence and implement high-quality interventions. It can help standardize care, reduce delays, and increase confidence in decision-making while maintaining professional standards and guiding further research. Factors that facilitate EBP include knowledge, skills, beliefs, capabilities, tools, and mentors while barriers include lack of value for research and lack of time, resources, and administrative support.
The document discusses the evaluation phase of the nursing process. It defines evaluation as comparing a patient's responses to predetermined goals and outcomes. The nurse evaluates whether expected outcomes were met, not just if interventions were done. Key aspects of evaluation include collecting and interpreting data, comparing outcomes to goals, documenting findings, and revising the care plan if needed. The evaluation determines if care was effective and ensures continuous good patient outcomes.
Nurses must provide effective reporting both orally and in writing to ensure continuity of patient care. Common types of reports include change-of-shift reports to pass on important patient information when nurses change shifts, transfer reports which provide details on a patient's condition and treatment when moved between units, incident reports for documenting any unexpected medical events, and telephone reports to communicate time-sensitive patient information. Effective reporting involves concisely relaying objective and relevant details about a patient's status, treatment, and care needs to keep all healthcare providers well-informed.
Nursing assessment involves collecting data to understand a patient's health status. It includes gathering subjective information from the patient and objective data through examination. The nurse organizes, validates, and documents the assessment data to identify health problems, strengths, and needs to develop an appropriate plan of care. Common assessment techniques are inspection, palpation, percussion, and auscultation to examine each body system.
The nursing process is a systematic method for planning and providing nursing care to patients. It involves five interrelated phases: assessment, diagnosis, planning, implementation, and evaluation. Assessment is the first phase and involves collecting subjective and objective data about the patient's health status through various techniques like inspection, palpation, percussion, and auscultation. The data is then organized, validated, and documented to form the patient's database which provides the basis for determining the patient's diagnoses, developing a care plan, and evaluating outcomes.
Nursing assessment involves collecting and analyzing clinical information about a client's health status. It includes observation, interviews, examinations, and medical record reviews. The purposes of assessment are to gather information, determine normal functioning, organize data, confirm hypotheses, enhance investigation of problems, frame nursing diagnoses, and identify health issues and strengths. There are several types of assessments including initial, focus, emergency, and time-lapsed assessments. Data is collected through various methods and sources, organized using frameworks like Gordon's functional health patterns, validated, and recorded for documentation. Proper assessment provides a basis for care, communication, reimbursement, and future reference.
The nursing process provides a framework for delivering nursing care. It involves assessment, nursing diagnosis, planning, implementation, and evaluation. Assessment involves collecting subjective and objective data about a patient's health status and history through various methods like observation, interviews, physical exams, and record reviews. This collected data is then organized, validated, and recorded to identify nursing diagnoses and develop a care plan to address any issues. The nursing process aims to improve the quality of patient care through a systematic, individualized approach.
This document discusses critical thinking in nursing. It defines critical thinking as an organized cognitive process used to carefully examine one's own thinking and the thinking of others based on evidence rather than assumptions. Critical thinking is needed for nurses to make accurate clinical decisions, solve problems, plan individualized care, and think creatively. It involves reflection, language skills, and intuition. Critical thinking progresses from basic to complex levels and involves commitment to decisions. Key competencies include using the scientific method, problem solving, decision making, diagnostic reasoning, and clinical decision making. A critical thinking model incorporates knowledge, experience, competencies, attitudes like curiosity and integrity, and standards.
This document discusses evidence-based practice (EBP) in nursing. It defines EBP as making clinical decisions based on evidence from scientific research combined with clinical experience and patient preferences. The history of EBP in nursing began in the 1970s with projects that developed research-based clinical protocols and demonstrated improved patient outcomes. EBP requires nurses to critically assess scientific evidence and implement high-quality interventions. It can help standardize care, reduce delays, and increase confidence in decision-making while maintaining professional standards and guiding further research. Factors that facilitate EBP include knowledge, skills, beliefs, capabilities, tools, and mentors while barriers include lack of value for research and lack of time, resources, and administrative support.
The document discusses the definition, history, and characteristics of nursing as a profession. It provides definitions of nursing from major nursing organizations and scholars. Nursing is defined as promoting health, preventing illness, and caring for those who are ill, disabled, or dying. The document also outlines the criteria for a profession, including specialized education, a theoretical body of knowledge, autonomy, ethics, and professional organizations. It discusses the pathway to nursing professionalism over time based on various frameworks. Key aspects of professional nursing practice and roles are also summarized.
Nursing planning involves determining what needs to be done, when, where, who will do it, and how to evaluate results. It is a purposeful, critical thinking activity that requires interaction with clients, families, and healthcare teams. The planning process consists of 4 phases: setting priorities, establishing goals, selecting interventions, and writing the care plan. Goals should be specific, measurable, and focus on expected outcomes. Interventions are chosen based on factors like the nursing diagnosis and research evidence. Care plans are used to guide care in various healthcare settings and for discharge planning.
The document provides information and guidance to nursing students on how to write a care plan, including defining the different components such as nursing diagnosis, goals, interventions, and evaluation. It explains each section in detail and provides examples. Resources are also included to help students understand and complete their care plan assignments.
The document provides an overview of the nursing process, which is defined as a systematic, organized method of planning and providing quality, individualized nursing care. It discusses the evolution of the nursing process from a 3-step model to the currently used 6-step model of assessment, diagnosis, outcome identification, planning, implementation, and evaluation. Each step is then described in more detail, with assessment discussed as the first step of collecting both subjective and objective data on the client. Diagnosis is defined as identifying the client's health problems based on the assessment data. Outcome identification involves formulating measurable goals for the client.
This document discusses the nursing diagnosis process. It begins by introducing nursing diagnosis as the second phase of the nursing process and a pivotal step. It then discusses NANDA's role in developing standardized nursing diagnoses and taxonomy. The document outlines the 13 domains of nursing diagnosis and characteristics such as being clear, evidence-based, and amenable to nursing intervention. It describes different types of diagnoses and provides examples. Finally, it discusses formulating diagnostic statements, including one, two and three part statements, and qualities of accurate diagnostic statements.
History of development of Nursing ProfessionsAnamika Ramawat
History of development of Nursing Professions, Characteristics, Criteria of the Nursing Profession, Perspective of Nursing Profession- National and Global Level
The document discusses the components of a nursing health assessment, including taking a health history, performing a physical examination, and reviewing laboratory and diagnostic test results. It provides details on collecting data through the health history, the various sections of a health history, and techniques for physical examination including inspection, auscultation, palpation, and percussion.
This document discusses discharge planning from the hospital. It defines discharge as when a patient leaves the hospital either after completing treatment, leaving against medical advice, or expiring. The key aspects of discharge planning are coordinating care, exchanging information between present and future caregivers, and initiating the process early. The goals of discharge planning are to provide continuity of care and ensure the patient's and family's understanding of the treatment plan and safe return home. The document outlines the steps of the discharge process, including assessment, diagnosis, planning, implementation, and evaluation.
Critical thinking in nursing involves recognizing issues, analyzing clinical data, evaluating information, and making conclusions. It is a continuous process of open-minded inquiry to determine which assumptions are true and relevant for each unique patient situation. Critical thinking skills for nurses include interpretation, analysis, inference, evaluation, explanation, and self-regulation. There are three levels of critical thinking - basic, complex, and commitment. Critical thinking competencies for nurses encompass general skills like scientific method and problem solving, as well as specific skills like diagnostic reasoning, clinical inference, and clinical decision making. Attitudes that are important for critical thinking include confidence, independent thinking, fairness, responsibility, risk taking, discipline, perseverance, creativity, curiosity, integrity, and
The document discusses the extended and expanded roles of nurses. It describes 22 different nursing roles including care giver, manager, advocate, counselor, communicator, rehabilitator, collaborator, school health nurse, occupational health nurse, parish nurse, public health nurse, home care nurse, rehabilitation nurse, office nurse, nurse epidemiologist, critical care nurse, nurse administrator, nurse practitioner, nurse midwife, community health nurse, and occupational health nurse. For each role, the document outlines the definition and key functions and responsibilities of nurses working in that specialty.
The document discusses various patterns of nursing care delivery systems used in India. It defines nursing care delivery as combining nursing services to meet patient needs across care settings. The key elements include clinical decision making, work allocation, communication, and management. Traditional methods like case method, functional method, and team method are explained along with their advantages and disadvantages. Advanced methods like case management, critical pathways, and primary nursing are also summarized. Factors influencing nursing care delivery systems are organizational policies, staffing, education, budgets, and patient needs.
nursing process:Implementation and evaluationArifa T N
The document outlines the steps of implementing the nursing process. It discusses that implementing is the action phase where the nurse performs nursing interventions using cognitive, interpersonal, and technical skills like problem solving, communication, and procedures. The process of implementing involves reassessing the client, determining if assistance is needed, performing interventions while ensuring privacy and client participation, supervising delegated care, and documenting activities. Guidelines for implementing include using evidence-based practice, clearly understanding and adapting interventions, providing safe care, teaching, support, and respecting client dignity.
The document discusses various methods of nursing documentation and recording. It describes the purposes of accurate nursing documentation as communication, legal documentation, nursing audits, education, financial billing, nursing research, and improving the quality of care. The principles of quality documentation include being factual, accurate, complete, current, organized and timely. Common documentation methods discussed are narrative notes, problem-oriented medical records (POMR), source records, charting by exception, and case management plans.
This document is a listing of qualifications and requirements for a professional nurse. It lists that a professional nurse must have the requisite diploma or degree, be licensed to practice, be physically and mentally fit, be confident in patient care decisions, be humble and honest to gain patient trust, fulfill duties impartially without prejudice, and have qualities like self-confidence, humility, honesty, loyalty, cooperation, observation skills, administration skills, supervision skills, and being responsible, competent, and having good human relations and communication skills. It concludes by stating the choice is yours and thanks the reader.
Home health nursing services allow individuals to receive healthcare in their homes, providing comfort and security. Services may include skilled nursing, physical therapy, occupational therapy, and more. Home health care has evolved from providing only physical care to incorporating medical services and highly technical procedures in the home. The typical home health process involves referral, admission involving assessment and care planning, and ongoing treatment and reassessment.
This document discusses health assessment in nursing. It describes the purpose and processes of health assessment, which includes obtaining a health history, performing a physical examination through various methods, and assessing each body system. The document outlines the types of assessments including initial, focused, emergency, and time-lapsed assessments. It also describes the main methods used in health assessment: observing, interviewing, and examining patients.
Nursing is defined as assisting individuals in activities contributing to health or its recovery. The document outlines the basic principles of nursing including safety, therapeutic effectiveness, and comfort. It discusses the objectives of nursing education which are to provide expert bedside care, integrate theory and practice, and develop skills and personality. The concepts of nursing include promoting health, preventing disease, assisting healing, and easing suffering. The qualities of a nurse include being caring, adaptable, hardworking, and having good communication skills and judgment. The document also discusses the functions and philosophy of nursing as both an art and a science.
The document discusses the code of ethics for nursing. It begins by defining what a code of ethics is and how it provides standards of behavior for a profession. It then discusses the specific nursing code of ethics, its purposes, and the evolution of the International Council of Nurses' code of ethics. The code has four main elements: nurses and people, nurses and practice, nurses and the profession, and nurses and co-workers. It outlines nurses' responsibilities and basic ethical principles like respect for persons, accountability, and confidentiality that nurses should uphold.
Definition
(Health, Assessment, evaluation and observation)
Health assessment steps
(Health History, Physical Examination & Documentation of Data)
Source of data
(primary or secondary)
Phases of the nursing process
(Assessment, Diagnosis, Planning, Implementation & evaluation)
Types of health assessment
(Comprehensive, Problem-based, Emergency, Episodic, Shift & Screening).
The document provides an introduction to health assessment concepts. It outlines the unit objectives which are to discuss the need for health assessment in nursing practice, explain key concepts, identify types of assessments, and document data using a problem-oriented approach. The document then defines terms like health, assessment, data collection, and diagnosis. It also describes the different types of assessments including initial, focused, emergency and time-lapsed assessments. Guidelines for collection, organization, validation and documentation of assessment data are provided.
The document discusses the definition, history, and characteristics of nursing as a profession. It provides definitions of nursing from major nursing organizations and scholars. Nursing is defined as promoting health, preventing illness, and caring for those who are ill, disabled, or dying. The document also outlines the criteria for a profession, including specialized education, a theoretical body of knowledge, autonomy, ethics, and professional organizations. It discusses the pathway to nursing professionalism over time based on various frameworks. Key aspects of professional nursing practice and roles are also summarized.
Nursing planning involves determining what needs to be done, when, where, who will do it, and how to evaluate results. It is a purposeful, critical thinking activity that requires interaction with clients, families, and healthcare teams. The planning process consists of 4 phases: setting priorities, establishing goals, selecting interventions, and writing the care plan. Goals should be specific, measurable, and focus on expected outcomes. Interventions are chosen based on factors like the nursing diagnosis and research evidence. Care plans are used to guide care in various healthcare settings and for discharge planning.
The document provides information and guidance to nursing students on how to write a care plan, including defining the different components such as nursing diagnosis, goals, interventions, and evaluation. It explains each section in detail and provides examples. Resources are also included to help students understand and complete their care plan assignments.
The document provides an overview of the nursing process, which is defined as a systematic, organized method of planning and providing quality, individualized nursing care. It discusses the evolution of the nursing process from a 3-step model to the currently used 6-step model of assessment, diagnosis, outcome identification, planning, implementation, and evaluation. Each step is then described in more detail, with assessment discussed as the first step of collecting both subjective and objective data on the client. Diagnosis is defined as identifying the client's health problems based on the assessment data. Outcome identification involves formulating measurable goals for the client.
This document discusses the nursing diagnosis process. It begins by introducing nursing diagnosis as the second phase of the nursing process and a pivotal step. It then discusses NANDA's role in developing standardized nursing diagnoses and taxonomy. The document outlines the 13 domains of nursing diagnosis and characteristics such as being clear, evidence-based, and amenable to nursing intervention. It describes different types of diagnoses and provides examples. Finally, it discusses formulating diagnostic statements, including one, two and three part statements, and qualities of accurate diagnostic statements.
History of development of Nursing ProfessionsAnamika Ramawat
History of development of Nursing Professions, Characteristics, Criteria of the Nursing Profession, Perspective of Nursing Profession- National and Global Level
The document discusses the components of a nursing health assessment, including taking a health history, performing a physical examination, and reviewing laboratory and diagnostic test results. It provides details on collecting data through the health history, the various sections of a health history, and techniques for physical examination including inspection, auscultation, palpation, and percussion.
This document discusses discharge planning from the hospital. It defines discharge as when a patient leaves the hospital either after completing treatment, leaving against medical advice, or expiring. The key aspects of discharge planning are coordinating care, exchanging information between present and future caregivers, and initiating the process early. The goals of discharge planning are to provide continuity of care and ensure the patient's and family's understanding of the treatment plan and safe return home. The document outlines the steps of the discharge process, including assessment, diagnosis, planning, implementation, and evaluation.
Critical thinking in nursing involves recognizing issues, analyzing clinical data, evaluating information, and making conclusions. It is a continuous process of open-minded inquiry to determine which assumptions are true and relevant for each unique patient situation. Critical thinking skills for nurses include interpretation, analysis, inference, evaluation, explanation, and self-regulation. There are three levels of critical thinking - basic, complex, and commitment. Critical thinking competencies for nurses encompass general skills like scientific method and problem solving, as well as specific skills like diagnostic reasoning, clinical inference, and clinical decision making. Attitudes that are important for critical thinking include confidence, independent thinking, fairness, responsibility, risk taking, discipline, perseverance, creativity, curiosity, integrity, and
The document discusses the extended and expanded roles of nurses. It describes 22 different nursing roles including care giver, manager, advocate, counselor, communicator, rehabilitator, collaborator, school health nurse, occupational health nurse, parish nurse, public health nurse, home care nurse, rehabilitation nurse, office nurse, nurse epidemiologist, critical care nurse, nurse administrator, nurse practitioner, nurse midwife, community health nurse, and occupational health nurse. For each role, the document outlines the definition and key functions and responsibilities of nurses working in that specialty.
The document discusses various patterns of nursing care delivery systems used in India. It defines nursing care delivery as combining nursing services to meet patient needs across care settings. The key elements include clinical decision making, work allocation, communication, and management. Traditional methods like case method, functional method, and team method are explained along with their advantages and disadvantages. Advanced methods like case management, critical pathways, and primary nursing are also summarized. Factors influencing nursing care delivery systems are organizational policies, staffing, education, budgets, and patient needs.
nursing process:Implementation and evaluationArifa T N
The document outlines the steps of implementing the nursing process. It discusses that implementing is the action phase where the nurse performs nursing interventions using cognitive, interpersonal, and technical skills like problem solving, communication, and procedures. The process of implementing involves reassessing the client, determining if assistance is needed, performing interventions while ensuring privacy and client participation, supervising delegated care, and documenting activities. Guidelines for implementing include using evidence-based practice, clearly understanding and adapting interventions, providing safe care, teaching, support, and respecting client dignity.
The document discusses various methods of nursing documentation and recording. It describes the purposes of accurate nursing documentation as communication, legal documentation, nursing audits, education, financial billing, nursing research, and improving the quality of care. The principles of quality documentation include being factual, accurate, complete, current, organized and timely. Common documentation methods discussed are narrative notes, problem-oriented medical records (POMR), source records, charting by exception, and case management plans.
This document is a listing of qualifications and requirements for a professional nurse. It lists that a professional nurse must have the requisite diploma or degree, be licensed to practice, be physically and mentally fit, be confident in patient care decisions, be humble and honest to gain patient trust, fulfill duties impartially without prejudice, and have qualities like self-confidence, humility, honesty, loyalty, cooperation, observation skills, administration skills, supervision skills, and being responsible, competent, and having good human relations and communication skills. It concludes by stating the choice is yours and thanks the reader.
Home health nursing services allow individuals to receive healthcare in their homes, providing comfort and security. Services may include skilled nursing, physical therapy, occupational therapy, and more. Home health care has evolved from providing only physical care to incorporating medical services and highly technical procedures in the home. The typical home health process involves referral, admission involving assessment and care planning, and ongoing treatment and reassessment.
This document discusses health assessment in nursing. It describes the purpose and processes of health assessment, which includes obtaining a health history, performing a physical examination through various methods, and assessing each body system. The document outlines the types of assessments including initial, focused, emergency, and time-lapsed assessments. It also describes the main methods used in health assessment: observing, interviewing, and examining patients.
Nursing is defined as assisting individuals in activities contributing to health or its recovery. The document outlines the basic principles of nursing including safety, therapeutic effectiveness, and comfort. It discusses the objectives of nursing education which are to provide expert bedside care, integrate theory and practice, and develop skills and personality. The concepts of nursing include promoting health, preventing disease, assisting healing, and easing suffering. The qualities of a nurse include being caring, adaptable, hardworking, and having good communication skills and judgment. The document also discusses the functions and philosophy of nursing as both an art and a science.
The document discusses the code of ethics for nursing. It begins by defining what a code of ethics is and how it provides standards of behavior for a profession. It then discusses the specific nursing code of ethics, its purposes, and the evolution of the International Council of Nurses' code of ethics. The code has four main elements: nurses and people, nurses and practice, nurses and the profession, and nurses and co-workers. It outlines nurses' responsibilities and basic ethical principles like respect for persons, accountability, and confidentiality that nurses should uphold.
Definition
(Health, Assessment, evaluation and observation)
Health assessment steps
(Health History, Physical Examination & Documentation of Data)
Source of data
(primary or secondary)
Phases of the nursing process
(Assessment, Diagnosis, Planning, Implementation & evaluation)
Types of health assessment
(Comprehensive, Problem-based, Emergency, Episodic, Shift & Screening).
The document provides an introduction to health assessment concepts. It outlines the unit objectives which are to discuss the need for health assessment in nursing practice, explain key concepts, identify types of assessments, and document data using a problem-oriented approach. The document then defines terms like health, assessment, data collection, and diagnosis. It also describes the different types of assessments including initial, focused, emergency and time-lapsed assessments. Guidelines for collection, organization, validation and documentation of assessment data are provided.
This document provides an overview of concepts related to health assessment. It defines key terms like health, assessment, data collection and diagnosis. It discusses the need for health assessment in general nursing practice and identifies different types of health assessments like initial, problem-focused, emergency and time-lapsed assessments. The document also provides examples of documenting a health assessment using a problem-oriented approach.
The series of questions provided would likely occur during the "Gathering information about the patient's chief concerns" phase of a patient-centered interview. The questions are gathering specific details about the patient's diet and weight, which are important concerns to assess. Setting the stage would involve introducing oneself and explaining the purpose of the interview. Collecting the assessment involves gathering additional assessment data through physical exam or tests. Termination involves concluding the interview.
nursing process is the base or heart of complete nursing and nursing process gives the framework for the nurses in giving care to the patient the knowledge of nursing process is must to become a licensed nurse or to practice nursing this ppt give nurses a brief idea what all thing are including in nursing process and to determine efficiency, knowledge, skills and attitude of personnel and can make best use of their skills into clinical practice.
The document discusses health assessment and the nursing process. It defines health using the WHO definition and describes the health triangle consisting of physical, social, and mental health. It then explains the nursing process as a 5 step problem-solving approach and notes that assessment is the first step where nurses collect data through observation, interviewing, and examination to identify client needs and problems. Finally, it outlines the importance of health assessment for establishing a baseline, identifying issues, planning care, and evaluating outcomes.
NURSING PROCESS AND CRITHICAL THINKING
Purposes of nursing process
To identify a client’s health status and actual or potential health care problems or needs.
To establish plans to meet the identified needs.
To deliver specific nursing interventions to meet those needs
The nursing process document describes the steps of the nursing process which includes assessment, nursing diagnosis, planning, implementation, and evaluation. It defines assessment as the systematic collection of data and identifies the main components and purposes of assessment. The key types of assessment are also outlined which include initial, problem-focused, emergency, and time-lapsed assessments.
The nursing process involves 5 steps: assessment, diagnosis, planning, implementation, and evaluation. It is a systematic, critical thinking process that nurses use to provide individualized care. During assessment, nurses collect both subjective and objective client data to identify health problems. They then make nursing diagnoses to label each problem. Next, they plan care by setting goals and selecting interventions. Nurses then implement the planned care and document their actions. Finally, they evaluate if the goals were achieved and the care plan was effective.
The document defines and describes the nursing process, which includes assessment, nursing diagnosis, planning, implementation, and evaluation. It is a systematic, critical thinking process used by nurses to provide individualized care. Assessment involves collecting client data through various methods. Nursing diagnosis involves analyzing the data to identify actual or potential health problems. Planning establishes goals and selects interventions. Implementation involves applying the interventions. Evaluation assesses client progress and intervention effectiveness.
The document provides information on health assessment in nursing. It defines health assessment as a systematic process by which a nurse collects and analyzes subjective and objective data on a client's health status through interaction with the client and other providers. The data collection involves observation, interviews, physical exams, and intuition. The purposes of assessment include establishing a health baseline, identifying health issues and needed care/treatments, and developing a holistic understanding of the client. The nursing process framework is also described, which involves assessment, nursing diagnosis, planning, implementation, and evaluation steps to provide individualized client care.
Health
THREE ASPECTS OF HEALTH
Nursing Assessment
Objectives of health assessment
Reasons for doing assessment:-
Reasons for doing assessment:-
Importance of health assessment
Conti…
Types of Assessment
Initial assessment
Problem focused assessment
Emergency assessment
Time lapsed assessment
Initial assessment
Problem Focused Assessment
Emergency assessment
Time – lapsed reassessment
Setting and environment
Data collection
Data collection is the process of gathering information about a client’s health status. It includes the health history, physical examination, results of laboratory and diagnostic tests, and material contributed by other health personnel.
Types of data collection
Two types:
subjective data and
objective data.
1. Subjective data, also referred to as symptoms or covert data, are clear only to the person affected and can be described only by that person. Itching, pain, and feelings of worry are examples of subjective data.
Conti….
2. Objective data, also referred to as signs or overt data, 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. For example, a discoloration of the skin or a blood pressure reading is objective data
Sources of data collection
Sources of data are primary or secondary.
Primary : It is the direct source of information. The client is the primary source of data.
Secondary: It is the indirect source of information. All sources other than the client are considered secondary sources. Family members, health professionals, records and reports, laboratory and diagnostic results are secondary sources.
Methods of data collection
Conti….
Observation includes looking, watching, examining. Observation begins the moment the nurse meets the client. It is a conscious, deliberate skill that is developed through efforts and with an organized approach.
Observation has two aspects:
Noticing the data and
Selecting, organizing, and interpreting the data.
2- Interviewing
STAGES OF AN INTERVIEW
An interview has three major stages:
The opening or introduction
The body or development
The closing
3- Examination
Inspection
Auscultation
Palpation
Types of palpation
Light palpation
Deep palpation
Bimanual palpation
Percussion
4- Intuition
Data Validation
3- Organization of data
4- Documenting Data
The nursing process is a systematic, 5-step method for planning and providing individualized nursing care: 1) assessment, 2) diagnosis, 3) planning, 4) implementation, and 5) evaluation. It involves collecting client data, identifying issues, setting goals and interventions, executing the care plan, and determining its effectiveness. The nursing process focuses on the client's response to health issues and promotes holistic, evidence-based, and collaborative care.
The document discusses the nursing process, which includes assessment, nursing diagnosis, planning, implementation, and evaluation. It describes each component in detail. Assessment involves collecting client data through various methods. Nursing diagnosis identifies client problems based on the assessment. Planning establishes goals and interventions. Implementation carries out the planned interventions. Evaluation assesses client progress and intervention effectiveness. The nursing process is a systematic approach to providing individualized care.
The nursing process functions as a systematic guide to client-centered care with 5 sequential steps. These are assessment, diagnosis, planning, implementation, and evaluation. Assessment is the first step and involves critical thinking skills and data collection; subjective and objective
The document defines and explains the nursing process, which includes assessment, nursing diagnosis, planning, implementation, and evaluation. It is a systematic, critical thinking process used by nurses to provide individualized, evidence-based care. Assessment involves collecting client data through various methods. Nursing diagnosis identifies actual or potential health problems based on assessment findings. Planning establishes goals and interventions. Implementation involves applying the interventions. Evaluation assesses progress towards goals and effectiveness of the care plan.
The document discusses the nursing process, which includes assessment, nursing diagnosis, planning, implementation, and evaluation. It provides details on each step:
Assessment involves collecting subjective and objective data through various methods like observation, interviews, and examinations. Nursing diagnosis identifies client problems based on the assessment data. Planning establishes goals and chooses nursing interventions. Implementation puts the care plan into action. Evaluation assesses client progress and nursing effectiveness. The nursing process is cyclic and ensures individualized, evidence-based care centered on the client.
The document defines and describes the nursing process, which includes assessment, nursing diagnosis, planning, implementation, and evaluation. It is a systematic, critical thinking process used by nurses to provide individualized, evidence-based care. Assessment involves collecting client data through various methods. Nursing diagnosis identifies actual or potential health problems based on assessment findings. Planning establishes goals and selects interventions. Implementation involves performing interventions. Evaluation assesses progress towards goals and effectiveness of the care plan.
The document discusses the nursing process, which is a systematic, cyclic framework for providing quality nursing care. It consists of 5 steps: assessment, diagnosis, planning, implementation, and evaluation. Assessment involves collecting client data from various sources. Diagnosis identifies actual or potential nursing problems. Planning establishes goals and interventions. Implementation carries out planned interventions. Evaluation determines if goals were met and identifies need for re-planning. The nursing process framework guides nursing practice across all settings and specialties.
Mechanical ventilation uses endotracheal intubation and a ventilator to replace spontaneous respiration and ventilation.
The ventilator provides the function of the respiratory muscles, endotracheal tube establishes a patent and unobstructed airway and the exogenous oxygen source gives a patient a therapeutic concentration of the gas.
Pulmonary edema can be defined as an abnormal accumulation of extravascular fluid in the lung parenchyma.
This process leads to diminished gas exchange at the alveolar level, progressing to potentially causing respiratory failure.
Endotracheal (ET) intubation involves the oral or nasal insertion of a flexible tube through the larynx into the trachea for the purposes of controlling the airway & mechanically ventilating the patient and is Performed by doctors, anesthetist, respiratory therapist or nurse practitioner in the procedure . it is emergency procedure.
A drug is a substance used in the diagnosis, treatment, or prevention of health problems.
A drug is a chemical substance derived from different sources –living or non living , which alter or change the function of cells, by reacting with them.
A route of administration is the path by which a drug, fluid, poison or other substance is brought into contact with the body.
Nurses must administer numerous drugs daily in a safe and efficient manner. The nurse should administer drugs in accord with nursing standards of practice and agency policy. The safe storage and maintenance of an adequate supply of drugs are other responsibilities of the nurse.
The nurse documents the actual administration of medications on the medication administration record. The MAR is a medical record form that contains the drug’s name, dose, route, and frequency of administration
A health history is a collection of data that provides a detailed profile of the patient's health status.
Nurses use therapeutic communication skills and interviewing techniques during the health history to establish an effective nurse-patient relationship. Physical examination is an important tool in assessing the client’s health status.
Approximate 15 % of the information used in the assessment comes from the physical examination.
This document discusses fluid imbalances and their management. It defines fluid balance and types of fluid imbalances including fluid volume deficit and excess. Fluid volume deficit can result from loss of fluids and causes symptoms like weight loss and decreased skin turgor. Treatment involves replacing fluids intravenously with crystalloid or colloid fluids. Fluid volume excess, seen in conditions like heart failure, causes symptoms like respiratory distress. Treatment focuses on improving oxygenation through positioning and oxygen therapy, administering diuretic medications, and monitoring the patient's response.
Roy conceptualizes the human system in a holistic perspective, as holism stems from the underlying philosophic assumption of the model. Holism is the aspect of unified meaningfulness of human behaviour in which the human system is greater than the sum of individual parts.
This system model provides a comprehensive, flexible, holistic and system based perspective for nursing.
It deals with stress and stress reduction and is primarily concerned with the effects of stress on health.
This model provides a total approach to client problems by providing a multidimensional view of the person as an individual.
Lung cancer is the leading cause of cancer incidence and cancer death for both men and women.
Malignant chest tumor can be primary, arising within the lung, chest wall, or mediastinum, or it can be a metastasis from a primary tum or site elsewhere in the body.In approximately 70 percent of the patient with lung cancer disease has spread to regional lymphatic and other sites by the time of diagnosis
Comparison between qualitative and quantitative research design.pptxSapana Shrestha
The key difference between quantitative and qualitative research paradigm is related to methods is their flexibility. There is difference in research concept, sources of information, methodology, sampling technique, scope, findings and interpretation
Ensure that the right medications given to the right patient in the right dose through the right route at the right time for the right reason based on the right (appropriate) assessment data using the right documentation and monitoring for the right responses by the patient with right education, ensuring that patient receive accurate and through information about the mediation and considering the right to refuse, acknowledging that patients can and do refuse to take medication (Elliot&liu,2010; Macdonald, 2010; Kee et al.,2012).
Nurses and midwives are responsible to provide their clients/patients with the high-quality care. They are undoubtedly confronted with various
ethical challenges in their professional practice, so they should be familiar with ethical codes of conduct and the essentials of ethical decision making. The ethical tradition of nursing/midwives is self-reflective, enduring, and
distinctive. A code of ethics for the nursing/midwives profession makes
explicit the primary obligations, values, and ideals of the profession that inform every aspect of the nurse’s life.
Nursing theories provide a framework for nursing practice, education, research, and management. They describe concepts like person, health, environment, and nursing that are important to the nursing profession. A theory consists of concepts, definitions, assumptions, and propositions that explain relationships between concepts. Developing nursing theories helps nursing establish a unique body of knowledge and distinguishes its practice from other professions. Theories guide the assessment, intervention, and evaluation of nursing care.
Theory of self care includes of self-care, self-care agency, self-care requisites and therapeutic self-care demand. This theory promotes the goal of self-care
Self-Care: Activities performed independently by an individual to promote and maintain personal well-being throughout life.
The term diagnosis is a statement or conclusion regarding the nature of phenomenon.
A nursing diagnosis is a clinical judgment concerning a human response to health conditions/life processes, or a vulnerability for that response, by an individual, family, group or community. A nursing diagnosis provides the basis for selection of nursing interventions to achieve outcomes for which the nurse has accountability.
The nursing process is cyclical; that is, its component follows 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 the cycle may continue with reassessment, or the plan of care may be modified.
Hemodialysis: management of chronic kidney diseaseSapana Shrestha
Hemodialysis is a mechanical process of removing waste products (toxic nitrogenous substances) and replacing essential substances by the process of diffusion and removal of excess water from body by the process of osmosis by means of artificial kidney (made with modified cellulose or synthetic) through semi-permeable membranes.
peritoneal dialysis, management of chronic renal failureSapana Shrestha
Peritoneal dialysis is a technique of dialysis in which solute and fluid exchange occurs between peritoneal capillary blood and dialysis solution in the peritoneal cavity via peritoneal layer with the help of peritoneal catheter.
Policy on management of kidney disease in NepalSapana Shrestha
Government of Nepal provides primary health services free of cost at a district level through basic health care center, and district hospital. Secondary and tertiary level health care is provide at a reasonable cost by provincial and federal level hospitals and specialized tertiary care center.
Nano-gold for Cancer Therapy chemistry investigatory projectSIVAVINAYAKPK
chemistry investigatory project
The development of nanogold-based cancer therapy could revolutionize oncology by providing a more targeted, less invasive treatment option. This project contributes to the growing body of research aimed at harnessing nanotechnology for medical applications, paving the way for future clinical trials and potential commercial applications.
Cancer remains one of the leading causes of death worldwide, prompting the need for innovative treatment methods. Nanotechnology offers promising new approaches, including the use of gold nanoparticles (nanogold) for targeted cancer therapy. Nanogold particles possess unique physical and chemical properties that make them suitable for drug delivery, imaging, and photothermal therapy.
Giloy in Ayurveda - Classical Categorization and SynonymsPlanet Ayurveda
Giloy, also known as Guduchi or Amrita in classical Ayurvedic texts, is a revered herb renowned for its myriad health benefits. It is categorized as a Rasayana, meaning it has rejuvenating properties that enhance vitality and longevity. Giloy is celebrated for its ability to boost the immune system, detoxify the body, and promote overall wellness. Its anti-inflammatory, antipyretic, and antioxidant properties make it a staple in managing conditions like fever, diabetes, and stress. The versatility and efficacy of Giloy in supporting health naturally highlight its importance in Ayurveda. At Planet Ayurveda, we provide a comprehensive range of health services and 100% herbal supplements that harness the power of natural ingredients like Giloy. Our products are globally available and affordable, ensuring that everyone can benefit from the ancient wisdom of Ayurveda. If you or your loved ones are dealing with health issues, contact Planet Ayurveda at 01725214040 to book an online video consultation with our professional doctors. Let us help you achieve optimal health and wellness naturally.
The skin is the largest organ and its health plays a vital role among the other sense organs. The skin concerns like acne breakout, psoriasis, or anything similar along the lines, finding a qualified and experienced dermatologist becomes paramount.
The biomechanics of running involves the study of the mechanical principles underlying running movements. It includes the analysis of the running gait cycle, which consists of the stance phase (foot contact to push-off) and the swing phase (foot lift-off to next contact). Key aspects include kinematics (joint angles and movements, stride length and frequency) and kinetics (forces involved in running, including ground reaction and muscle forces). Understanding these factors helps in improving running performance, optimizing technique, and preventing injuries.
How to Control Your Asthma Tips by gokuldas hospital.Gokuldas Hospital
Respiratory issues like asthma are the most sensitive issue that is affecting millions worldwide. It hampers the daily activities leaving the body tired and breathless.
The key to a good grip on asthma is proper knowledge and management strategies. Understanding the patient-specific symptoms and carving out an effective treatment likewise is the best way to keep asthma under control.
5-hydroxytryptamine or 5-HT or Serotonin is a neurotransmitter that serves a range of roles in the human body. It is sometimes referred to as the happy chemical since it promotes overall well-being and happiness.
It is mostly found in the brain, intestines, and blood platelets.
5-HT is utilised to transport messages between nerve cells, is known to be involved in smooth muscle contraction, and adds to overall well-being and pleasure, among other benefits. 5-HT regulates the body's sleep-wake cycles and internal clock by acting as a precursor to melatonin.
It is hypothesised to regulate hunger, emotions, motor, cognitive, and autonomic processes.
- Video recording of this lecture in English language: https://youtu.be/Pt1nA32sdHQ
- Video recording of this lecture in Arabic language: https://youtu.be/uFdc9F0rlP0
- Link to download the book free: https://nephrotube.blogspot.com/p/nephrotube-nephrology-books.html
- Link to NephroTube website: www.NephroTube.com
- Link to NephroTube social media accounts: https://nephrotube.blogspot.com/p/join-nephrotube-on-social-media.html
Travel vaccination in Manchester offers comprehensive immunization services for individuals planning international trips. Expert healthcare providers administer vaccines tailored to your destination, ensuring you stay protected against various diseases. Conveniently located clinics and flexible appointment options make it easy to get the necessary shots before your journey. Stay healthy and travel with confidence by getting vaccinated in Manchester. Visit us: www.nxhealthcare.co.uk
The Children are very vulnerable to get affected with respiratory disease.
In our country, the respiratory Disease conditions are consider as major cause for mortality and Morbidity in Child.
Are you looking for a long-lasting solution to your missing tooth?
Dental implants are the most common type of method for replacing the missing tooth. Unlike dentures or bridges, implants are surgically placed in the jawbone. In layman’s terms, a dental implant is similar to the natural root of the tooth. It offers a stable foundation for the artificial tooth giving it the look, feel, and function similar to the natural tooth.
PGx Analysis in VarSeq: A User’s PerspectiveGolden Helix
Since our release of the PGx capabilities in VarSeq, we’ve had a few months to gather some insights from various use cases. Some users approach PGx workflows by means of array genotyping or what seems to be a growing trend of adding the star allele calling to the existing NGS pipeline for whole genome data. Luckily, both approaches are supported with the VarSeq software platform. The genotyping method being used will also dictate what the scope of the tertiary analysis will be. For example, are your PGx reports a standalone pipeline or would your lab’s goal be to handle a dual-purpose workflow and report on PGx + Diagnostic findings.
The purpose of this webcast is to:
Discuss and demonstrate the approaches with array and NGS genotyping methods for star allele calling to prep for downstream analysis.
Following genotyping, explore alternative tertiary workflow concepts in VarSeq to handle PGx reporting.
Moreover, we will include insights users will need to consider when validating their PGx workflow for all possible star alleles and options you have for automating your PGx analysis for large number of samples. Please join us for a session dedicated to the application of star allele genotyping and subsequent PGx workflows in our VarSeq software.
2. Nursing Assessment:
• Assessment is the first step of nursing process.
• Assessing is the systematic and continuous
collection, organization, validation and
documentation of data.
• This includes data about person’s physical and
psychological status or study of the patient as a
whole to identify his strengths and weakness and
his needs and problems
• Nursing assessment does not focus upon disease
as do medical assessment. It is based on a board
scientific knowledge, keen observation and
purposeful listening. 2
3. • 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
3
4. Contd…..
• It starts with the admission of the patient and
continues while the patient is under the care of the
nurse
• Continuous assessment helps to modify the nursing
care plan according to the changing needs of the
patient.
• There are four different types of assessment:
A) Initial / comprehensive assessment
B) Problem-Focused assessment
C) Emergency assessment
D) Time-lapsed reassessment
4
5. 1. Initial / comprehensive assessment: An initial
assessment, also called an admission assessment, is
performed when the client enters a health care
from a health care agency.
The purposes are to evaluate the client’s health status,
to identify functional health patterns that are
problematic, and to provide an in-depth,
comprehensive database, which is critical for
evaluating changes in the client’s health status in
subsequent assessments.
5
6. • 2. Problem-Focused assessment: A problem focus
assessment collects data about a problem that has
already been identified. This type of assessment has a
narrower scope and a shorter time frame than the
initial assessment. In focus assessments, nurse
determine whether the problems still exists and
whether the status of the problem has changed (i.e.
improved, worsened, or resolved).
6
7. 3. Emergency assessment: Emergency assessment
takes place in life-threatening situations in which the
preservation of life is the top priority. Time is of the
essence rapid identification of and intervention for
the client’s health problems. Often the client’s
difficulties involve airway, breathing and circulatory
problems (the ABCs).
Emergency assessment focuses on few essential health
patterns and is not comprehensive.
7
8. 4. Time-lapsed reassessment: Time lapsed
reassessment, another type of assessment, takes
place after the initial assessment to evaluate any
changes in the clients functional health. Nurses
perform time-lapsed reassessment when substantial
periods of time have elapsed between assessments
8
9. Purposes of Assessment
• To establish baseline information on the client
• To determine the client’s risk for dysfunction or to
identify the life-threatening problem
• To determine the client’s strength
• To provide data for diagnosis
• To identify the patient’s problems
• To compare the client’s current status to baseline data
previously obtained.
9
10. Methods of Assessment
• Interview (History taking)
• Physical examination
• Review of clinical records
• Consultation
10
11. Assessment consists of 4 separate
activities
• Data collection
• Data organization
• Data validation
• Documenting data
11
12. a. Data Collection
• Data collection is the process of gathering information
about a client’s health status.
• It must be both systematic and continuous to prevent
the omission of significant data and reflect a client’s
changing health status.
• A database is all the information about a client; it
includes the nursing health history, physical
assessment, and primary care providers’ history,
results of laboratory and diagnostic tests and
material contributed by other health personnel.
12
13. Types of data
• The information that is collected during assessment is
called data. There are two types of data.
• Subjective data
• Objective data
13
15. 1. Subjective data:
• Subjective data, also referred to as symptoms or
covert data
• It consists of information given by the patient or his
relatives to the nurse as in history taking
• It is given from the patient’s or relative’s own point of
view
• It is also gathered during daily contacts with the
persons
• The symptoms that the patients complains are the
examples of the subjective data. For e.g. “I have a
fever”, “I could not sleep at night”, “My legs are
swollen”, feeling of sadness, blurring vision, pain etc.
15
16. Contd…
2. Objective data:
• Objective data, also referred to as signs or overt
data
• The information about the person obtained by the
nurses through observation or physical
examination or various tests
• They can be seen, heard, felt, or smelled. For
example, a discoloration of the skin or a blood
pressure reading are objective data.
• These data are considered objective because the
data are found to be the same by any observer
• The signs which the examiner finds in the patient
are the objective data, e.g. temperature 39 ͦC,
bluish discoloration of nail-bed. Etc..
16
17. Sample application: types of data
Mrs. Shisu, age 47, has come to the clinic after“passing
out” twice in the last 2 days. She tells the nurse that
she becomes “light headed” after almost any type of
activity. She has experienced some nausea since
yesterday and vomited after eating breakfast this
morning. She also tells the nurse that she is very
nervous about these occurrences because she
remembers her mother having similar symptoms
when the mother suffered from a brain disorder. The
nurse observes that the client’s gait is unsteady and
her skin is pale. The client also has large bruises on
her right arm and the right side of her face, which she
states occurred when she fell.
17
18. Types of data
Subjective
• Report of fainting
• Complaint of dizziness
• Nausea
• Verbalization of anxiety
• Self-reported fall
Objectives
• Vomiting
• Unsteady gait
• Pale skin
• Bruises on right side of face
• and right arm
18
19. Sources of data:
Sources of data are primary or secondary. The client is
the primary source of data.
1. Primary sources-
• The information collected from the client is
considered to be the most reliable, unless the patient
is semi conscious, has physical and mental problems.
2. Secondary sources-
• Family members or other support persons, other
health professionals, record and reports, laboratory
and diagnostic analysis, and relevant literature are
secondary or indirect sources.
• Infact, all sources other than the client are considered
secondary sources.
19
21. Contd…
Data collection methods
The principle methods used to collect data are:
• Observing
• Interviewing
• Examining
• Diagnostic and laboratory test
21
22. Contd….
1. Observing:
• To observe is to gather data by using the senses.
• Observation is a conscious, deliberate skill that is
developed through effort and with an organized
approach.
• Although nurses observe mainly through sight, most
of the senses are engaged during careful
observations. By carefully watching the client, the
• nurse can detect nonverbal cues that indicate a
variety of feelings, including presence of pain, anxiety,
and anger. Observational skills are essential in
detecting the early warning signs of physical changes
(e.g., pallor and sweating).
22
23. • Observation has two aspects:
a) noticing the data and
b) selecting, organizing, and interpreting the data.
• A nurse who observes that a client’s face is flushed must relate that
observation to findings such as body temperature, activity,
environmental temperature, and blood pressure.
23
24. Contd…..
2. Interviewing:
• An interview is a planned communication or a
conversation with a purpose. For example, to get or
give information, identify problems of mutual
concern, evaluate change, teach, provide support, or
provide counseling or therapy.
• One example of the interview is the nursing health
history, which is a part of the nursing admission
history.
24
25. • An interview is a therapeutic interaction that has a
specific purpose.
• The purpose of the assessment interview is to collect
information about the client’s health history and
current status in order to make determinations about
the client’s health needs.
• Effective interviewing depends on the nurse’s
knowledge and ability to skillfully elicit information
from the client using appropriate techniques of
communication.
• Observation of nonverbal behavior during the
interview is also essential to effective data collection.
25
27. Contd…
3. Examining:
• Physical examination or physical assessment is a
systematic data collection method that uses
observation.
• To conduct the examination the nurse uses technique
of inspection, palpation, percussion and auscultation.
27
28. 4. diagnostic and laboratory test
• Results of laboratory and diagnostic tests can be
useful objective data as these values often serve as
defining characteristics for various altered health
states; these can also be helpful in ruling out certain
suspected problems.
• For example, diabetic clients who are poorly
controlled on diet and/or medication will usually have
an elevated blood glucose level.
• The pattern of these types of variations is useful in
determining a plan of care. In addition, the
effectiveness of nursing and medical interventions
and progress toward health restoration are often
monitored through laboratory and diagnostic test
data.
28
29. Analysis of Data
• Identify abnormal findings
• Cluster findings into logical groups
• Localize findings anatomically
• Localize findings into probable process:
• Pathological – such as inflammatory, metabolic,
degenerative…
• Pathophysiological – mal functioning, such as
congestive heart failure…
29
30. Analysis cont…
• Psychopathological – behavioral, mood disorder, thought
process disturbance
• Construct a working hypothesis from the central findings
• Match the findings with all causative conditions you know
could as associated
• Eliminate hypothesis that fail to explain the findings
• Weight the probabilities & select the most likely diagnosis
• Consider life-threatening & treatable situations
• Test the hypothesis or obtain further studies
• Establish a working definition of the problem
30
31. Documentation of Data
• Permanent medico legal record of the patient’s
health status & treatment
• Record pertinent/relevant positive findings –
abnormal findings
• Record pertinent negative findings – normal
findings, or absence of abnormal findings
31
32. b. Organizing Data:
• The nurse uses a written format that organizes the
assessment data systematically.
• The nurse organizes, or clusters, the information
together in order to identify areas of strengths and
weaknesses.
• This process is known as data clustering.
• The format may be modified according to the
client’s physical status such as one focused on
musculoskeletal data for orthopedic clients.
32
33. c. Validating Data:
• Data verification is the process through which data
are validated as being complete and accurate. Once
the nurse completes the initial data collection, the
data are reviewed for inconsistencies or omissions.
• The information gathered during the assessment
phase must be complete, factual and accurate
because the nursing diagnosis and interventions
are based on this information.
33
34. Contd……
Validating data helps the nurse complete these tasks:
• ensure that assessment information is complete,
• ensure that objective and related subjective data
agree,
• obtain additional information that may have been
overlooked and
• Differentiate between cues and inferences (cues are
subjective and objective date that can be directly
observed by the nurse; that is, what client says and
what the nurse can see, hear, smell or measure.
Inferences are the nurse’s interpretation or
conclusions made based on cues).
34
35. • For example, if a client is confused or unable to
communicate, or if two sources provide conflicting
data, it is necessary for the nurse to seek further
information or clarification.
• Data verification is done by examining the congruence
between subjective and objective data.
• For example, a client might exhibit nonverbal
expressions of pain (e.g., guarding a part of the body,
facial grimacing) but verbally deny feeling pain.
35
36. d. Documenting data:
• Assessed data should be recorded and some should
be reported immediatey.
• Accurate documentation is essential and should
include all data collected about the client health
status.
• Data are recorded in a factual manner and not
interpreted by the nurse.
• Documentation of data is essential to communicate
the information of the patient to the other related
health care team members and ensures for the
delivery of continuous quality of care.
36