The document outlines the nursing process which includes assessment, diagnosis, planning, implementation, and evaluation. Assessment involves collecting subjective and objective data on the patient's physical, psychological, social, and medical history. Nursing diagnoses are developed based on the assessment findings and describe the patient's actual or potential health problems. Goals are then set and a care plan is developed which outlines nursing interventions. Implementation involves performing the interventions and reassessing the patient. Evaluation assesses if goals were met and determines if changes need to be made to the care plan. The nursing process is circular and ongoing to meet the changing needs of the patient.
The course deals with concepts, principles and techniques of health assessment, including history taking, physical examination, psychosocial assessment and interpreting laboratory findings to determine nursing diagnoses across the lifespan. The course outline covers the nursing process, data collection, documentation, assessment techniques, vital signs, physical exams and diagnostic procedures. Students will learn to analyze health assessments, utilize the nursing process, demonstrate critical thinking and accurately collect, classify and document subjective and objective data.
This document provides guidance on performing a physical assessment examination. It discusses the nursing process and how physical assessments are used to gather subjective and objective data to identify issues and evaluate care. It outlines the typical order of assessment techniques, including inspection, palpation, percussion, and auscultation. The document provides details on performing a general survey, health history, physical examination, and measurements of patients. It emphasizes a comprehensive assessment of all body areas and organ systems according to age-specific guidelines.
Medical audit is a systematic evaluation of medical care to improve patient outcomes. It involves reviewing medical records against criteria to identify areas for improvement. The key aspects that can be audited include structure, processes, and outcomes of care. Medical audit aims to ensure best possible care, evidence-based practice, and implementation of initiatives. It benefits patients through reduced suffering and ensures safety. Hospitals should establish medical audit committees and collect data to facilitate the audit process. Audits help practitioners identify weaknesses and make corrections to enhance quality of care.
Nursing Process (ADPIE) recopied from the original author of this ppt jeena.aejyJack Frost
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.
- Fundamentals of Nursing: history of nursing
- Florence Nightingale
- Nursing & Midwifery Council. (2015). the code: Professional standards of practice and behaviour for nurses and midwives.
- What is Critical Thinking?
- Why is Critical Thinking Important to Nurses?
- Complex thinking
- Important concepts in nursing
- The nursing process: Assessment
o Data collection: Objective & Subjective data
o Methods of Data Collection
Observation
Vital signs
BMI
• How to calculate
• Classification of BMI according to WHO
MAUC
Homeostasis
The interview
Samples
Information from the patient
Glascow scale
Physical examination
• Inspection
• Palpation
• Percussion
• Auscultation
Patient record
o The aims of assessment/rational for conducting a nursing assessment
o Holistic assessment
o Pressure sores
The Water low scale
o Medical history & Nursing history
o The environment during patient assessment
o Asking questions
The document provides guidance on understanding multiple choice questions for exams. It discusses the components of a multiple choice question including the case/scenario, stem, distractors, and correct response. It emphasizes reading the full question carefully, identifying keywords and time frames, eliminating implausible options, and applying knowledge to arrive at the answer. The document also reviews cognitive levels for exam preparation and provides examples of how to study and apply different levels of thinking.
This document provides an overview of the nursing process. It begins by outlining the objectives of understanding the nursing process, its characteristics, benefits, and phases. It then defines the nursing process as a modified scientific method used to assess client needs and develop a care plan. The key phases are described as assessment, nursing diagnosis, planning, implementation, and evaluation. Assessment involves collecting client data, nursing diagnosis identifies responses to health issues, planning develops the care approach, implementation provides care, and evaluation assesses effectiveness. The document explains each phase in further detail.
The nursing process involves 6 sequential steps: assessment, diagnosis, outcome identification, planning, implementation, and evaluation. It originated as a 3-step process and has evolved over time based on contributions from various nursing theorists. The nursing process provides organized, systematic, and individualized care. It is the foundation of nursing practice and ensures quality care delivery that meets professional standards.
The course deals with concepts, principles and techniques of health assessment, including history taking, physical examination, psychosocial assessment and interpreting laboratory findings to determine nursing diagnoses across the lifespan. The course outline covers the nursing process, data collection, documentation, assessment techniques, vital signs, physical exams and diagnostic procedures. Students will learn to analyze health assessments, utilize the nursing process, demonstrate critical thinking and accurately collect, classify and document subjective and objective data.
This document provides guidance on performing a physical assessment examination. It discusses the nursing process and how physical assessments are used to gather subjective and objective data to identify issues and evaluate care. It outlines the typical order of assessment techniques, including inspection, palpation, percussion, and auscultation. The document provides details on performing a general survey, health history, physical examination, and measurements of patients. It emphasizes a comprehensive assessment of all body areas and organ systems according to age-specific guidelines.
Medical audit is a systematic evaluation of medical care to improve patient outcomes. It involves reviewing medical records against criteria to identify areas for improvement. The key aspects that can be audited include structure, processes, and outcomes of care. Medical audit aims to ensure best possible care, evidence-based practice, and implementation of initiatives. It benefits patients through reduced suffering and ensures safety. Hospitals should establish medical audit committees and collect data to facilitate the audit process. Audits help practitioners identify weaknesses and make corrections to enhance quality of care.
Nursing Process (ADPIE) recopied from the original author of this ppt jeena.aejyJack Frost
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.
- Fundamentals of Nursing: history of nursing
- Florence Nightingale
- Nursing & Midwifery Council. (2015). the code: Professional standards of practice and behaviour for nurses and midwives.
- What is Critical Thinking?
- Why is Critical Thinking Important to Nurses?
- Complex thinking
- Important concepts in nursing
- The nursing process: Assessment
o Data collection: Objective & Subjective data
o Methods of Data Collection
Observation
Vital signs
BMI
• How to calculate
• Classification of BMI according to WHO
MAUC
Homeostasis
The interview
Samples
Information from the patient
Glascow scale
Physical examination
• Inspection
• Palpation
• Percussion
• Auscultation
Patient record
o The aims of assessment/rational for conducting a nursing assessment
o Holistic assessment
o Pressure sores
The Water low scale
o Medical history & Nursing history
o The environment during patient assessment
o Asking questions
The document provides guidance on understanding multiple choice questions for exams. It discusses the components of a multiple choice question including the case/scenario, stem, distractors, and correct response. It emphasizes reading the full question carefully, identifying keywords and time frames, eliminating implausible options, and applying knowledge to arrive at the answer. The document also reviews cognitive levels for exam preparation and provides examples of how to study and apply different levels of thinking.
This document provides an overview of the nursing process. It begins by outlining the objectives of understanding the nursing process, its characteristics, benefits, and phases. It then defines the nursing process as a modified scientific method used to assess client needs and develop a care plan. The key phases are described as assessment, nursing diagnosis, planning, implementation, and evaluation. Assessment involves collecting client data, nursing diagnosis identifies responses to health issues, planning develops the care approach, implementation provides care, and evaluation assesses effectiveness. The document explains each phase in further detail.
The nursing process involves 6 sequential steps: assessment, diagnosis, outcome identification, planning, implementation, and evaluation. It originated as a 3-step process and has evolved over time based on contributions from various nursing theorists. The nursing process provides organized, systematic, and individualized care. It is the foundation of nursing practice and ensures quality care delivery that meets professional standards.
The document discusses the nursing process and its characteristics, components, and applications. It compares the nursing process to the medical process. It describes the steps of the nursing process including assessment, nursing diagnosis, planning, implementation, and evaluation. It provides examples of nursing diagnoses statements and common errors to avoid when writing nursing diagnoses.
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.
A health assessment is a plan of care that identifies the specific needs of a person and how those needs will be addressed by the healthcare system or skilled nursing facility. Health assessment is the evaluation of the health status by performing a physical exam after taking a health history.
This document discusses the importance of proper medical documentation. It begins by defining medical documentation and outlining its key purposes, which include preserving patient information, justifying treatment, allowing for continuity of care, and satisfying regulatory requirements. The document emphasizes that documentation must be accurate, complete, legible, objective, and free of extraneous information. It differentiates between objective clinical findings and subjective patient-reported information. Proper documentation is presented as important for patient care, risk management, and legal protection for medical professionals.
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.
This document is a checklist used to assess standards and measurable elements for inpatient care at a healthcare facility. It covers areas like scope of service, patient safety goals, assessment of patients, patient and family education, and patient and family rights. For each standard, staff are asked questions to determine if the element is met, not met, not applicable, or not tested. Remarks can also be included. The goal is to evaluate areas like patient identification, communication, safety of medications, infection control, fall risk reduction, documentation, consent processes, privacy and more.
1. Medical documentation refers to written or electronic information about a patient's history, examinations, tests, treatments, and outcomes used for evaluation, treatment, communication between providers, research, and legal purposes.
2. The SOAP note format is commonly used and includes subjective information provided by the patient, objective exam findings, an assessment or diagnosis, and a treatment plan.
3. High quality medical documentation is accurate, relevant, complete, timely, and confidential to properly evaluate and care for patients over time.
1. The document discusses the nursing process and its various steps including assessment, nursing diagnosis, planning, implementation, and evaluation.
2. It explains the different types of assessments including initial, focused, emergency, and time-lapsed assessments. It also discusses the different types of nursing diagnoses such as actual, risk, wellness, possible, and syndrome diagnoses.
3. The document emphasizes the importance of the nursing process as a systematic method to plan and provide nursing care by establishing goals and interventions to address patients' health problems and needs.
This document discusses nursing assessment, which is defined as a systematic method of planning and providing individualized nursing care. It describes the characteristics of nursing assessment, which include being cyclic, problem-solving oriented, client-centered, and focused on decision making and critical thinking. The document outlines the process of nursing assessment, which involves collecting, organizing, validating, and documenting data from a variety of sources. It discusses different types of assessments and provides details on collecting data through observation, interviewing, and examination. The document also covers organizing, validating, and documenting the assessment data.
The nursing process is a systematic method for planning and providing nursing care. It consists of five interrelated phases: assessment, diagnosis, planning, implementation, and evaluation. Assessment involves the collection of subjective and objective data about a patient's health status and is the first phase of the nursing process. It provides the basis for determining a nursing diagnosis, planning care, and later evaluating outcomes. The key components of assessment include data collection techniques like inspection, palpation, percussion, and auscultation to gather a comprehensive health history and evaluate the patient holistically.
1. Define and identify the purposes of a nursing diagnosis.
2. Know what NANDA means and where to find more information.
3. Differentiate between the types of nursing diagnosis and be able to provide an example of each.
4. Differentiate a nursing diagnosis from a medical diagnosis.
5. Identify the three segments of a diagnostic statement and give examples of a comprehensive diagnostic statement.
- What is the nursing diagnosis?
- What is NANDA?
- Types of nursing diagnosis and examples of each.
- Criteria of nursing diagnosis.
- What is the difference(s) between a medical diagnosis and nursing diagnosis?
- Example: Pneumonia
- Possible nursing diagnosis:
o Altered gas exchange,
o Ineffective airway clearance,
o Activity intolerance,
o Risk for imbalanced nutrition,
o Risk for infection transmission,
o Discomfort.
- Refer to Maslow’s needs again
- Exercise
o Nursing diagnosis for Bronchitis
o Nursing diagnosis for Hypertension
The document outlines the nursing process and provides details on each step: assessment, nursing diagnosis, planning, implementation, and evaluation. It describes how nurses analyze patient data to formulate nursing diagnoses and identify goals and interventions. The planning stage involves prioritizing issues and developing individualized care plans. Implementation entails performing or delegating interventions. Evaluation assesses progress towards goals and the effectiveness of the care plan.
The nursing process is a systematic problem-solving approach used by nurses to provide care. It involves five steps: assessment, diagnosis, planning, implementation, and evaluation. Assessment involves continuously collecting and organizing data through various methods like observation, interviews, and physical exams. This data is then validated and documented before moving to the diagnosis step to identify any health problems or needs.
This document discusses medical audit, including its definition, history, types, stages, principles, and limitations. Some key points:
- Medical audit objectively monitors and evaluates clinical performance to identify opportunities for improvement.
- It began in ancient times but modern clinical audit aims to improve patient outcomes and safety.
- Types of medical audit include statistical, morbidity, postoperative, obstetrics, random case, mortality, and nursing audits.
- Stages include preparing, selecting criteria, measuring performance, making improvements, and sustaining them.
- Principles are defining responsibilities, organizing participation, agreeing programs, and documenting processes/outcomes.
- Limitations include lack of commitment, low participation, imperfect techniques
This document discusses nursing diagnosis, which is the second phase of the nursing process where nurses use critical thinking to interpret assessment data and identify client problems. There are four main types of nursing diagnoses: actual, wellness, risk, and syndrome. An example of an actual diagnosis is inadequate airway clearance. A risk diagnosis identifies potential problems, like infection risk. Nursing diagnoses are developed based on assessment data and help provide more effective patient care.
This document discusses medical audits and provides information on various types of audits including internal and external audits, managerial/organizational audits, medical/clinical audits, and financial audits. It explains the need for audits to maintain safety, quality, reputation and funding. The document outlines the six stages of clinical audits including preparing, selecting criteria, measuring performance, making improvements, sustaining improvements, and re-auditing. Methods used in audits like direct observation, checklists, documentation reviews, questionnaires and interviews are also mentioned.
The document outlines the nursing process, which includes 5 phases - assessment, nursing diagnosis, planning, implementation, and evaluation.
The assessment phase involves collecting client data through various methods like observation, interview, and examination. In the nursing diagnosis phase, the nurse analyzes the assessment data to identify client problems/needs and prioritize them.
The planning phase involves setting goals to address the problems and selecting nursing interventions. Implementation involves applying the planned care. Finally, in the evaluation phase the nurse determines if the goals were met by collecting additional client data. The nursing process provides a systematic framework to plan and deliver individualized nursing care.
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 guidelines for accurately recording health assessments. It states that the assessment should include all collected information about the client's health status and be documented in their medical or nursing records, whether on paper or electronically. The main purposes of recording are to facilitate safe care and treatment, communicate with healthcare professionals, establish diagnoses, identify new problems, and determine educational needs, while also serving as a legal record and for research. Guidelines include recording the patient's own words, being specific, maintaining privacy, and including complete details.
This document provides an overview of medical audit, including:
- Definitions of medical audit as the retrospective evaluation and analysis of medical records to monitor clinical performance.
- The history of medical audit from ancient codes to its modern establishment in India in 2007 through the National Accreditation Board for Hospitals.
- The purposes of medical audit which include planning improvements, ensuring regulatory standards, and assessing health program effectiveness.
The document discusses the nursing process, which is a systematic, critical thinking process that nurses use to provide individualized care. It includes five main steps: assessment, nursing diagnosis, planning, implementation, and evaluation. Assessment involves collecting client data through various methods. Nursing diagnosis involves analyzing the data to identify actual or potential health problems. Planning involves establishing goals and selecting interventions. Implementation is providing the planned care. Evaluation assesses client progress and care plan effectiveness. The nursing process helps nurses apply evidence-based care and problem-solve to promote client health and well-being.
This document outlines 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. The 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 performing the interventions. Evaluation assesses client progress and intervention effectiveness.
The document discusses the nursing process and its characteristics, components, and applications. It compares the nursing process to the medical process. It describes the steps of the nursing process including assessment, nursing diagnosis, planning, implementation, and evaluation. It provides examples of nursing diagnoses statements and common errors to avoid when writing nursing diagnoses.
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.
A health assessment is a plan of care that identifies the specific needs of a person and how those needs will be addressed by the healthcare system or skilled nursing facility. Health assessment is the evaluation of the health status by performing a physical exam after taking a health history.
This document discusses the importance of proper medical documentation. It begins by defining medical documentation and outlining its key purposes, which include preserving patient information, justifying treatment, allowing for continuity of care, and satisfying regulatory requirements. The document emphasizes that documentation must be accurate, complete, legible, objective, and free of extraneous information. It differentiates between objective clinical findings and subjective patient-reported information. Proper documentation is presented as important for patient care, risk management, and legal protection for medical professionals.
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.
This document is a checklist used to assess standards and measurable elements for inpatient care at a healthcare facility. It covers areas like scope of service, patient safety goals, assessment of patients, patient and family education, and patient and family rights. For each standard, staff are asked questions to determine if the element is met, not met, not applicable, or not tested. Remarks can also be included. The goal is to evaluate areas like patient identification, communication, safety of medications, infection control, fall risk reduction, documentation, consent processes, privacy and more.
1. Medical documentation refers to written or electronic information about a patient's history, examinations, tests, treatments, and outcomes used for evaluation, treatment, communication between providers, research, and legal purposes.
2. The SOAP note format is commonly used and includes subjective information provided by the patient, objective exam findings, an assessment or diagnosis, and a treatment plan.
3. High quality medical documentation is accurate, relevant, complete, timely, and confidential to properly evaluate and care for patients over time.
1. The document discusses the nursing process and its various steps including assessment, nursing diagnosis, planning, implementation, and evaluation.
2. It explains the different types of assessments including initial, focused, emergency, and time-lapsed assessments. It also discusses the different types of nursing diagnoses such as actual, risk, wellness, possible, and syndrome diagnoses.
3. The document emphasizes the importance of the nursing process as a systematic method to plan and provide nursing care by establishing goals and interventions to address patients' health problems and needs.
This document discusses nursing assessment, which is defined as a systematic method of planning and providing individualized nursing care. It describes the characteristics of nursing assessment, which include being cyclic, problem-solving oriented, client-centered, and focused on decision making and critical thinking. The document outlines the process of nursing assessment, which involves collecting, organizing, validating, and documenting data from a variety of sources. It discusses different types of assessments and provides details on collecting data through observation, interviewing, and examination. The document also covers organizing, validating, and documenting the assessment data.
The nursing process is a systematic method for planning and providing nursing care. It consists of five interrelated phases: assessment, diagnosis, planning, implementation, and evaluation. Assessment involves the collection of subjective and objective data about a patient's health status and is the first phase of the nursing process. It provides the basis for determining a nursing diagnosis, planning care, and later evaluating outcomes. The key components of assessment include data collection techniques like inspection, palpation, percussion, and auscultation to gather a comprehensive health history and evaluate the patient holistically.
1. Define and identify the purposes of a nursing diagnosis.
2. Know what NANDA means and where to find more information.
3. Differentiate between the types of nursing diagnosis and be able to provide an example of each.
4. Differentiate a nursing diagnosis from a medical diagnosis.
5. Identify the three segments of a diagnostic statement and give examples of a comprehensive diagnostic statement.
- What is the nursing diagnosis?
- What is NANDA?
- Types of nursing diagnosis and examples of each.
- Criteria of nursing diagnosis.
- What is the difference(s) between a medical diagnosis and nursing diagnosis?
- Example: Pneumonia
- Possible nursing diagnosis:
o Altered gas exchange,
o Ineffective airway clearance,
o Activity intolerance,
o Risk for imbalanced nutrition,
o Risk for infection transmission,
o Discomfort.
- Refer to Maslow’s needs again
- Exercise
o Nursing diagnosis for Bronchitis
o Nursing diagnosis for Hypertension
The document outlines the nursing process and provides details on each step: assessment, nursing diagnosis, planning, implementation, and evaluation. It describes how nurses analyze patient data to formulate nursing diagnoses and identify goals and interventions. The planning stage involves prioritizing issues and developing individualized care plans. Implementation entails performing or delegating interventions. Evaluation assesses progress towards goals and the effectiveness of the care plan.
The nursing process is a systematic problem-solving approach used by nurses to provide care. It involves five steps: assessment, diagnosis, planning, implementation, and evaluation. Assessment involves continuously collecting and organizing data through various methods like observation, interviews, and physical exams. This data is then validated and documented before moving to the diagnosis step to identify any health problems or needs.
This document discusses medical audit, including its definition, history, types, stages, principles, and limitations. Some key points:
- Medical audit objectively monitors and evaluates clinical performance to identify opportunities for improvement.
- It began in ancient times but modern clinical audit aims to improve patient outcomes and safety.
- Types of medical audit include statistical, morbidity, postoperative, obstetrics, random case, mortality, and nursing audits.
- Stages include preparing, selecting criteria, measuring performance, making improvements, and sustaining them.
- Principles are defining responsibilities, organizing participation, agreeing programs, and documenting processes/outcomes.
- Limitations include lack of commitment, low participation, imperfect techniques
This document discusses nursing diagnosis, which is the second phase of the nursing process where nurses use critical thinking to interpret assessment data and identify client problems. There are four main types of nursing diagnoses: actual, wellness, risk, and syndrome. An example of an actual diagnosis is inadequate airway clearance. A risk diagnosis identifies potential problems, like infection risk. Nursing diagnoses are developed based on assessment data and help provide more effective patient care.
This document discusses medical audits and provides information on various types of audits including internal and external audits, managerial/organizational audits, medical/clinical audits, and financial audits. It explains the need for audits to maintain safety, quality, reputation and funding. The document outlines the six stages of clinical audits including preparing, selecting criteria, measuring performance, making improvements, sustaining improvements, and re-auditing. Methods used in audits like direct observation, checklists, documentation reviews, questionnaires and interviews are also mentioned.
The document outlines the nursing process, which includes 5 phases - assessment, nursing diagnosis, planning, implementation, and evaluation.
The assessment phase involves collecting client data through various methods like observation, interview, and examination. In the nursing diagnosis phase, the nurse analyzes the assessment data to identify client problems/needs and prioritize them.
The planning phase involves setting goals to address the problems and selecting nursing interventions. Implementation involves applying the planned care. Finally, in the evaluation phase the nurse determines if the goals were met by collecting additional client data. The nursing process provides a systematic framework to plan and deliver individualized nursing care.
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 guidelines for accurately recording health assessments. It states that the assessment should include all collected information about the client's health status and be documented in their medical or nursing records, whether on paper or electronically. The main purposes of recording are to facilitate safe care and treatment, communicate with healthcare professionals, establish diagnoses, identify new problems, and determine educational needs, while also serving as a legal record and for research. Guidelines include recording the patient's own words, being specific, maintaining privacy, and including complete details.
This document provides an overview of medical audit, including:
- Definitions of medical audit as the retrospective evaluation and analysis of medical records to monitor clinical performance.
- The history of medical audit from ancient codes to its modern establishment in India in 2007 through the National Accreditation Board for Hospitals.
- The purposes of medical audit which include planning improvements, ensuring regulatory standards, and assessing health program effectiveness.
The document discusses the nursing process, which is a systematic, critical thinking process that nurses use to provide individualized care. It includes five main steps: assessment, nursing diagnosis, planning, implementation, and evaluation. Assessment involves collecting client data through various methods. Nursing diagnosis involves analyzing the data to identify actual or potential health problems. Planning involves establishing goals and selecting interventions. Implementation is providing the planned care. Evaluation assesses client progress and care plan effectiveness. The nursing process helps nurses apply evidence-based care and problem-solve to promote client health and well-being.
This document outlines 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. The 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 performing the interventions. Evaluation assesses client progress and intervention effectiveness.
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 outlines the scientific process of nursing, which involves assessment, nursing diagnosis, planning, implementation, and evaluation. It describes these components in detail. The nursing process is a systematic method nurses use to provide individualized care by collecting data, identifying issues or problems, setting goals, implementing interventions, and evaluating outcomes. It is a cyclic and dynamic problem-solving approach that is client-centered.
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 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.
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).
nursing process philippine setting (pdf format)DanetteMaeMRoc
The nursing process involves 5 steps: assessment, diagnosis, planning, implementation, and evaluation. It is a systematic method used by nurses to identify issues, develop care plans, provide care, and evaluate outcomes. Assessment involves collecting client data through various methods. Diagnosis identifies actual or potential problems based on assessment findings. Planning establishes goals and selects interventions. Implementation carries out the care plan. Evaluation assesses progress towards goals and effectiveness of the plan. The nursing process is cyclic and ensures individualized, evidence-based care.
The nursing process is a systematic, critical thinking method used by nurses to plan and provide individualized care. It consists of five phases - assessment, diagnosis, planning, implementation, and evaluation. In assessment, nurses collect client data through various methods. They then use the data to establish nursing diagnoses, which are clinical judgments about actual or potential health problems. During planning, nurses prioritize problems, set goals, and select interventions. They implement the plan by providing care. Finally, evaluation determines if goals were met and the effectiveness of the plan.
The document discusses the nursing process, which is a systematic method for planning and providing nursing care. It outlines the key steps as assessment, diagnosis, planning, implementation, and evaluation. Assessment involves collecting both subjective and objective data from various sources like the client, family, and medical records. This data is then organized, interpreted, and documented. The nursing diagnosis phase further analyzes the collected data to identify any actual or potential health problems nurses can address. The overall nursing process provides structure to nursing care and allows for continuity and quality of care.
Assessment – first step in the nursing processNursing Path
The nursing process begins with assessment, which involves systematically collecting client data through observation, interviews, examinations, and medical record reviews. This data is then validated, organized according to standards like Gordon's Functional Health Patterns, analyzed by comparing to norms, and recorded to establish a comprehensive health history and baseline for the client. Assessment is ongoing and may be initial, focused on a specific problem, or time-lapsed to monitor changes over time.
Nursing assessment is the systematic collection of data to identify a patient's health status and needs. It involves gathering both subjective and objective information from various sources including patient interviews, medical records, and examination. This data is organized using frameworks like Gordon's Functional Health Patterns and analyzed to understand the patient's condition, identify problems, and form the basis for an effective nursing care plan. The overall goal of assessment is to obtain a holistic view of the patient.
The document outlines the nursing process, which includes 5 phases - assessment, nursing diagnosis, planning, implementation, and evaluation.
The assessment phase involves collecting client data through various methods like observation, interview, and examination. In the nursing diagnosis phase, the nurse analyzes the assessment data to identify client problems/needs and prioritize them.
The planning phase involves setting goals to address the problems and selecting nursing interventions. Implementation involves applying the planned care. Finally, in the evaluation phase the nurse determines if the goals were met by collecting additional client data. The nursing process provides a systematic framework to plan and deliver individualized nursing care.
Nursing Process presentation by Rebira .pptxRebiraWorkineh
The document provides an overview of the nursing process and nursing assessment. It discusses the historical perspective of the nursing process, defining it as a systematic problem-solving approach. The nursing process consists of six steps: assessment, diagnosis, planning, implementation, evaluation, and outcome identification. Nursing assessment is the first step and involves systematically collecting subjective and objective data from patients. There are various types and methods of assessment, with the goal being to establish a baseline and determine normal and abnormal functioning to provide data for diagnosis.
Nursing Process presentation in wallagga university by Rebira .pptxRebiraWorkineh
The document provides an overview of the nursing process and nursing assessment. It discusses the historical perspective of the nursing process, defining it as a systematic problem-solving approach. The nursing process consists of six steps: assessment, diagnosis, planning, implementation, evaluation, and outcome identification. Nursing assessment is the first step of the nursing process. It involves systematically collecting subjective and objective data from patients and others. There are various types and methods of assessment to gather comprehensive information.
The nursing process document describes the steps of the nursing process and how it is used to plan and provide individualized patient care. It outlines the 6 main steps as assessment, diagnosis, planning, implementation, evaluation, and reassessment. Assessment involves collecting both subjective and objective patient data to develop an understanding of their health status. This data is then analyzed during diagnosis to identify any health problems or needs. The following steps of planning, implementation, and evaluation are used to create a care plan and provide nursing interventions to address the identified needs and problems. The nursing process is cyclic and repeated to allow for continuous reassessment and adaptation of the care plan based on the patient's changing condition.
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 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 carries out the planned 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 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.
How to Build a Module in Odoo 17 Using the Scaffold MethodCeline George
Odoo provides an option for creating a module by using a single line command. By using this command the user can make a whole structure of a module. It is very easy for a beginner to make a module. There is no need to make each file manually. This slide will show how to create a module using the scaffold method.
Exploiting Artificial Intelligence for Empowering Researchers and Faculty, In...Dr. Vinod Kumar Kanvaria
Exploiting Artificial Intelligence for Empowering Researchers and Faculty,
International FDP on Fundamentals of Research in Social Sciences
at Integral University, Lucknow, 06.06.2024
By Dr. Vinod Kumar Kanvaria
This slide is special for master students (MIBS & MIFB) in UUM. Also useful for readers who are interested in the topic of contemporary Islamic banking.
How to Fix the Import Error in the Odoo 17Celine George
An import error occurs when a program fails to import a module or library, disrupting its execution. In languages like Python, this issue arises when the specified module cannot be found or accessed, hindering the program's functionality. Resolving import errors is crucial for maintaining smooth software operation and uninterrupted development processes.
Macroeconomics- Movie Location
This will be used as part of your Personal Professional Portfolio once graded.
Objective:
Prepare a presentation or a paper using research, basic comparative analysis, data organization and application of economic information. You will make an informed assessment of an economic climate outside of the United States to accomplish an entertainment industry objective.
This presentation was provided by Steph Pollock of The American Psychological Association’s Journals Program, and Damita Snow, of The American Society of Civil Engineers (ASCE), for the initial session of NISO's 2024 Training Series "DEIA in the Scholarly Landscape." Session One: 'Setting Expectations: a DEIA Primer,' was held June 6, 2024.
বাংলাদেশের অর্থনৈতিক সমীক্ষা ২০২৪ [Bangladesh Economic Review 2024 Bangla.pdf] কম্পিউটার , ট্যাব ও স্মার্ট ফোন ভার্সন সহ সম্পূর্ণ বাংলা ই-বুক বা pdf বই " সুচিপত্র ...বুকমার্ক মেনু 🔖 ও হাইপার লিংক মেনু 📝👆 যুক্ত ..
আমাদের সবার জন্য খুব খুব গুরুত্বপূর্ণ একটি বই ..বিসিএস, ব্যাংক, ইউনিভার্সিটি ভর্তি ও যে কোন প্রতিযোগিতা মূলক পরীক্ষার জন্য এর খুব ইম্পরট্যান্ট একটি বিষয় ...তাছাড়া বাংলাদেশের সাম্প্রতিক যে কোন ডাটা বা তথ্য এই বইতে পাবেন ...
তাই একজন নাগরিক হিসাবে এই তথ্য গুলো আপনার জানা প্রয়োজন ...।
বিসিএস ও ব্যাংক এর লিখিত পরীক্ষা ...+এছাড়া মাধ্যমিক ও উচ্চমাধ্যমিকের স্টুডেন্টদের জন্য অনেক কাজে আসবে ...
A workshop hosted by the South African Journal of Science aimed at postgraduate students and early career researchers with little or no experience in writing and publishing journal articles.
This presentation includes basic of PCOS their pathology and treatment and also Ayurveda correlation of PCOS and Ayurvedic line of treatment mentioned in classics.
it describes the bony anatomy including the femoral head , acetabulum, labrum . also discusses the capsule , ligaments . muscle that act on the hip joint and the range of motion are outlined. factors affecting hip joint stability and weight transmission through the joint are summarized.
3. It is the framework for nursing practice in that it provides the
mechanism by which nurses use their belief, knowledge and skills to
diagnose and treat the patient’s response to actual or potential
health problems.
4. The major purpose is to provide framework
within which the individualized needs of the
patient, family and community can be met.
Purpose of nursing process:
10. Elements of assessment process:
A. Data collection
B. Data verification
C. Data Organization
D. Data interpretation
E. Data documentation
11. Priorities in data collection:
A system must be established to determine
which data will be collected first. One of such
systems is Maslow's hierarchy of needs that
include: physiological, safety and security,
social, self-esteem and self-actualization
needs.
12. Current data
Historical data Objective data
Subjective data
The nurse during assessment collects four types of data:
13. Data from patient's point of view and include
feelings, perceptions, and concerns. They cannot
be readily observed by another e.g. pain, nausea.
Are observable and measurable data that are obtained
through observation, standard assessment
techniques performed during the physical
examination, and laboratory and diagnostic testing
e.g. blood pressure, edema.
Subjective data
Objective data
14. Includes situations or events that have occurred in
the past, which are important in identifying patient's
health patterns and past experiences that may have
an impact upon patient's health e.g. previous
hospitalization.
Data related to events that are occurring now e.g.
vomiting, post operative pain.
Historical data
Current data
15. A- Primary sources B- Secondary sources
Patient
- Family members and friends
- Health team members
- Patient’s health record
19. Health history
* Demographic information (name, age, sex, education... etc).
* Reason for seeking health care
* Previous hospitalization, illnesses, and surgeries.
* Patient/family medical history
Medical
Family
Surgical
Past history
20. Physical examination:
The purpose of physical examination is to make direct
observations of any deviations from normal and to
validate subjective data gathered through the
interview.
25. Data documentation:
Accurate and complete recording of assessment
data, which is essential for communicating
information to other health care team members. It is
the basis for determining quality of care and should
include appropriate data to support identified
problems.
26. 1- Social condition of the patient.
2- Physical condition.
3- Mental and psychological condition.
4- Therapeutic aspect.
27. Subjective
- These conditions that perceived by the patient such as
pain and the observer may not see the deviation
Pain ---- Nausea
Objective
- These conditions are identified by the observer
whether the nurse or the physician.
Pallor – Cyanosis --Swelling
28. e are abnormalities in the vital signs (temperature,
pulse, and respiration).
Those that are produced by the effect of the disease
on the whole body.
These are occurring in the initial stages of the
disease e.g. running nose as an initial stage of
measles.
29. It is a combination of symptoms that make up a
characteristic picture of a particular disease.
These are noticed in special area or part of the body
as swelling in hands.
31. 1- Location or site and radiation of pain .
2- Frequency.
3- Precipitating factors.
4- Aggravating factors.
5- Alleviating factors.
6- Associated manifestations.
7- Duration.
8- Pain character.
9- Effect of pain upon activities of daily living.
32. Vomits- Stool – Sputum- Discharge from wound
1- Amount or volume. 2- Frequency.
3- Precipitating factors
4- Constituents.
5- Odor
6- Associated symptoms or abnormal manifestation.
33. Preparation for Nurse
Hand washing
Keep fingernails clean, short & smooth
Avoid undesirable nonverbal communication
Initiate physical contact in nonthreatening ways
Nurse should be stand at the right side of the
patient to perform the examination
34.
35. Preparation of the Equipment
- Gather necessary equipment
- Secure the forms required for documenting the
assessment findings
- Draping
- Warm instruments before placing it on a
patient
37. Preparation of the Environment
- Adjust the environment to perform the
examination
- Check that nothing is on floor that place the
patient at risk for falling
- Keep the room quiet, warm, without drafts
- Maintain privacy
38. Preparation of the Patient
- Keep the patient informed while performing the
examination
- Positioning
- Draping
- Encourage the patient to void
- Measuring & recording Vital signs , weight &
height
- Keep the patient warm
71. - A clinical judgment about individual, family, or
community responses to actual and potential
health problems/life processes.
- Nursing diagnoses provide the basis for
selection of nursing interventions to achieve
outcomes for which the nurse is accountable"
72. -Nursing diagnosis is a standardized statement
about the health of a patient (who can be an
individual, a family, or a community) for the
purpose of providing nursing care.
- Nursing diagnoses are developed during the
course of performing the nursing assessments.
74. The diagnostic process
• The diagnostic process uses the critical-
thinking skills of analysis. The diagnostic
process has three steps:
● Analyzing data.
● Identifying health problems, risks for health
problem.
● Formulating diagnostic statements.
75. - Once the nurse have identified the
patient's problems related to his health
status, then formulate a nursing
diagnosis for each of them.
-The nursing diagnoses are categorized
by a system commonly referred to as
NANDA. (North American nursing
diagnosis association)
76. Identifying a Nursing Diagnosis
The types of Nursing Diagnoses can be
broken down into two subsets:
• Actual problem
• Risk for problem
77. 1- Diagnostic Label
5- Related Factors
4- Risk Factors
2- Qualifiers
3- Definition and Defining
Characteristics
78. Components of a nursing diagnosis
I. Diagnostic Label
- Name of nursing diagnosis listed in
taxonomy, describes essence of problem
- Example: Stress Incontinence; Anxiety; Self-
Care Deficit
II. Qualifiers
- add additional meaning to a nursing
diagnosis, changes in condition, etc.
- Example: Altered; Impaired; Ineffective; etc.
79. III. Definition and Defining Characteristics
- NANDA approved, gives major and minor clinical
cues that validate presence of actual nursing
diagnosis
IV. Risk Factors
- Intrinsic and extrinsic characteristics of patient
- makes patient vulnerable or at risk
80. V. Related Factors
- Conditions, circumstances, etiologies that
contribute to the problem
- Can be described as "related to. "It is helpful
to formulate a nursing diagnosis using a PES
Statement (problem, etiology, and signs &
symptoms).
81. The NANDA-International system of
nursing diagnosis provides for two
categories.
Components of a nursing diagnosis
- airway clearance (Diagnostic Label)
- Ineffective (Qualifiers)
- stagnation of secretion. (Definition and Defining Characteristics)
- related to decreased energy secondary to prolonged bed rest( Related
Factors)
-as manifested by an ineffective cough ( symptoms)
A- Actual diagnosis: a statement about a health problem
that the patient has and the benefit from nursing care.
Example of an actual nursing diagnosis is: Ineffective
airway clearance stagnation of secretion related to
decreased energy secondary to prolonged bed rest as
manifested by an ineffective cough
82. B- Risk diagnosis: a statement about health
problems that a patient doesn't have yet, but is
at a higher than normal risk of developing in the
near future.
Example of a risk diagnosis is :
- Risk for injury related to altered mobility and
disorientation.
Components of a nursing diagnosis
Risk for injury (Diagnostic Label)
altered mobility and disorientation
( Related Factors)
.
83. Risk diagnosis
• The persons data base contains evidence
of risk factors of the diagnosis, but no
evidence of the defining characteristics
• Problem + etiology
• Risk for impaired skin integrity/related
to excessive diaphoresis and
confinement to bed
• No signs and symptoms
84. Activity 1
• Identify what step in the nursing process is
the following?
• Pain related to myocardial ischemia as
evidence by guarding left chest,
grimacing, moaning pain score of 10/10,
Bp 170/80 HR123
• Actual nursing diagnosis
85. Activity 2
• Identify what kind of nursing diagnosis
• Impaired communication /related to
language barrier/as evidenced by inability
to speak or understand Arabic and use of
Spanish
actual nursing diagnosis
86. Activity # 3
• Identify if the statement is correct. If
not correct the statement
• Risk for injury related to lack of the side
rails on bed
X
• do not write statement in such a way that it
maybe legally incriminating
• √: risk for injury related to disorientation
87. Activity # 4
• Mastectomy related to cancer
X
• do not state the nursing diagnosis using
medical terminology. Focus on the
persons response to medical problems
• √:Risk for self concept disturbance related
to effects of the mastectomy
88. Activity # 5
• Pain and fear related to diagnostic
procedure
X
• do not state two problems at the same
time
√:fear related unfamiliarity with diagnostic
procedures
√ pain related to diagnostic procedure
89. Domain 1 Health Promotion
• Deficient diversional activity
• Sedentary lifestyle
Domain 2 Nutrition
Imbalanced nutrition: less than body
requirements
Risk for imbalanced nutrition: more than body
requirements
91. Guidelines for writing goals
•Patient centered
•Singular goal or outcome
•Observable
•Measurable
•Time-limited
•Realistic
92.
93. - Setting goals to improve the outcomes for the
patient are a primary focus of the nursing process.
- Based on the nursing diagnoses, what are the
expectations for this patient? This not about
nursing goals. This is about improving the quality of
life for the patient.
-Planning involves making plans to carry out the
necessary interventions to achieve those goals.
-The use of formal care plans or care maps and
protocols is highly advised.
94. Characteristics of the nursing care plan
1. It focuses on actions which are designed to solve or
minimize the existing problem.
2. It is a product of a deliberate systematic process.
3. It relates to the future.
4. It is based upon identifiable health and nursing
problems.
5. Its focus is holistic.
95.
96. - All members of the health care team should be
informed of the patient's status and nursing
diagnosis, the goals and the plans.
They are also responsible to report back to the
nurse all significant findings and to document
their observations and interventions as well as
the patient's response and outcomes.
97. The nurse selects interventions based on:
1. Characteristics of the nursing diagnosis.
2 expected outcomes.
3. Research base, or nursing knowledge/or interventions
4. Feasibility of the intervention.
5. Acceptability to the patient.
6. Competencies of the nurse.
98. Types of Interventions
Three categories of nursing interventions:
-Nurse-initiated interventions.
- Physician-initiated interventions.
- Collaborative interventions
99.
100. - The nursing process is an ongoing event.
- Evaluation involves not only analyzing the success of the
goals and interventions, but examining the need for
adjustments and changes as well.
- Evaluation leads back to assessment and the whole process
begin again. The evaluation incorporates all input from the
entire health care team, including the patient.
101. Summary of Nursing Process
Assessment
Purpose
To gather, verity, and communicate data about
the patient so data base is established.
To identify health care need of the patient
steps
1. Collecting nursing health history
2. Assessing physical, psychological, social,
and spiritual needs/desires
3. Assisting with physical examination
4. Collecting all relevant data.
102. Planning
Purpose
To identify the patient's goals;
to determine priorities of care;
to determine expected outcomes,
to design nursing strategies to achieve goals of care
steps
1. Identifying patient goals.
2. Establishing expected outcomes
3. Selecting nursing actions
4. Delegating actions
5. Writing nursing care plan
6. Consulting
103. Implementation
Purpose
To complete nursing actions necessary for
accomplishing plan
steps
1 -Reassessing patient
2. Reviewing and modifying existing care plan
3. Performing nursing actions
104. Evaluation
Purpose
To determine the extent to which goals of care have
been achieved
steps
1. Comparing patient response to criteria
2. Analyzing reasons for results and conclusions
3. Modifying care plan