The nursing process is a systematic problem-solving approach used by nurses to plan and provide care. It involves five steps: assessment, diagnosis, planning, implementation, and evaluation. Assessment involves continuously collecting subjective and objective data about a patient's health status through various methods like observation, interviews, and physical exams. This data is then organized, validated, and documented before moving to the diagnosis step. The nursing process ensures continuity of care and allows for individualized, collaborative, and outcome-focused care for patients.

1. NURSING PROCESS Presented by: Dave Jay S. Manriquez RN.

2. THE NURSING PROCESS A systematic problem-solving approach used to identify, prevent and treat actual or potential health problems and promote wellness.

3. Nursing process A systematic way to plan, implement and evaluate care for individuals, families, groups and communities.

4. Characteristics of the Nursing Process Dynamic Client-centered Planned Interpersonal and collaborative Universally applicable Can focus on problems or strengths

5. Open, flexible Humanistic and individualized Cyclical Outcome focused ( results oriented) Emphasizes feedback and validation

6. STEPS IN NURSING PROCESS Assessment Nursing Diagnosis Planning Implementation Evaluation

7. Nursing Process Assessment Nursing Diagnosis Planning Implementation Evaluation

8. Benefits of using the nursing process Continuity of care Prevention of duplication Individualized care Standards of care Increased client participation Collaboration of care

9. EVALUATION IMPLIMENTATION PLANNING ASSESSMENT DIAGNOSIS INTER RELATIONSHIP BETWEEN THE STEPS OF NURSING PROCESS

11. ASSESSMENT

12. Assessment 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. Assessing is the systematic and continuous collection, organization, validation and documentation of data. - Potter and Perry( 2006)

13. 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

14. Types of Assessment 1. Initial Assessment : Performed within specified time after admission to a health care agency Eg. Nursing Admission Assessment 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. E.g.. Assessment of clients ability to perform self-care while assisting client to bathe. 3. Emergency Assessment : Done during psychiatric or physiological crisis of the client to identify life threatening problems Eg. Rapid assessment of airway, breathing and circulation during cardiac arrest 4. Time lapsed-Reassessment : Done several months after initial assessment to compare the clients status to baseline data previously obtained.

15. Assessment ASESSMENT Collect data Organize data Validates Data Document data DIAGNOSIS PLANNING IMPLIMENTATION EVALUATION

16. 1.COLLECTION OF DATA Data Collection is the process of gathering information about a clients health status .

17. Collection of Data: 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.

18. Medical vs. Nursing Assessments Medical assessments Target data pointing to pathologic conditions Nursing assessments Focus on the patient’s response to health problems

19. Types of Data: 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 Eg. Itching, Pain, Feelings of worry 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. They can be seen, heard, felt or smelled and they are obtained by observation or physical examination Eg. A Blood Pressure Data Discolouration of the Skin

20. Objective Data vs. Subjective Data Objective data Observable and measurable data that can be seen, heard, or felt by someone other than the person experiencing them E.g., elevated temperature, skin moisture, vomiting Subjective data Information perceived only by the affected person E.g., pain experience, feeling dizzy, feeling anxious

21. Sources of Data: Primary Source (Direct Source client: Usually BEST source

22. Secondary Source (Indirect Source) Family Members Client’s records 1. Medical Records Eg. Medical History, Physical Examination, Operation notes, Progress notes, Consultation done by Physicians 2. Records of therapies done by other health professionals Eg. Social Workers, Dieticians, Physical Therapist 3. Laboratory Records Other health care professionals Verbal reports Literature

23. Data Collection Consider time needs of patient developmental stage physical surroundings past and present coping patterns

24. Data Characteristics Complete Factual Accurate Relevant

25. Data collection methods OBSERVATION INTERVIEWING PHYSICAL ASSESSMENT

26. Observation To gather data using senses Eg: laboured breathing, pallor or flushing,pain a lowered side rail ,functioning of an equipment , pt environment and people in it etc…

27. Interviewing An interview is a planned communication or a conversation with a purpose Types of questions and Setting Rapport are important Collection of Health History

28. Four Phases of a Nursing Interview Preparatory phase Introduction Working phase Termination

29. Interview Phases Preparatory Nurse collects background info from previous charts Ensure environment is conducive Arrange seating 3 – 4 ft apart Interviewer at 45° angle to patient Allow adequate time

30. Phases cont’d. Introduction Nurse introduces self Identifies purpose of interview Ensure confidentiality of information Provide for patient needs before starting

31. Phases cont’d. Working Nurse gathers info for sub jective data Excellent communication skills are needed Active listening Eye contact Open-ended questions

32. Phases cont’d. Termination Inform patient when nearing end of interview Ensure patient knows what will happen with info Offer patient chance to add anything

33. Physical assessment Appraisal of health status Usually by Review of Systems Overview of symptoms Observable, measurable data

34. Objective data Possible approaches—body systems, head to toe, or functional health patterns

35. Methods of physical assessment Inspection Percussion Palpation Auscultation

36. Problems Related to Data Collection Inappropriate organization of the database Omission of pertinent data Inclusion of irrelevant or duplicate data, erroneous or misinterpreted data Failure to establish rapport and partnership Recording an interpretation of data rather than observed behavior Failure to update the database

37. 2.ORGANISING DATA Nurses uses a written or computerized format for arranging he data systematically

38. 3.VALIDATING DATA VALIDATING -THE ACT OF DOUBLE CHECKING Verifies understanding of information Comparison with another source -patient or family member -record -health team member

39. 4. DOCUMENTING DATA Record in permanent record ASAP Use patient’s own words in subjective data – enclose in “ ___” (quotation marks) Avoid generalizations – be specific Don’t make summative statements

40. Thank you