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Scientific nursing process
- 1. C. Louw
- 2. Discuss the fundamental elements of the Scientific Nursing Process Name the various patient records Discuss the principles of effective record keeping
- 4. What: Systematic and continuous collection and interpretation of data relating to patient When: within 2 hours Who: RN/ EN under supervision Types of data: Subjective/ objective Sources of data: File, interview, physical exam, family, previous records, test results, multi-professional team
- 5. Privacy, quiet – no interruptions Comfort, no pain Sit next to patient Friendly and professional Confidentiality Low authority Personal space Use most reliable source Do not repeat Understandable Language No personal opinions
- 6. Level of dependency Actual + potential problems Basic needs ◦ Breathing, eat and drink, elimination, mobility and comfort, rest and sleep, clothing, hygiene, safety, communication, religion, work, learning, play/ relaxation
- 7. Compiling objectives and interventions to ◦ Supply basic needs of patient ◦ Solve problems ◦ Prevent possible complications Patient Care Plan ◦ ◦ ◦ ◦ Prioritise Goal/ expected outcomes Discuss with patient Record
- 8. All categories Continuous assessment Implement according to care plan
- 9. What should be continuously recorded? ◦ ◦ ◦ ◦ ◦ ◦ ◦ Patient complaints Observations Nursing interventions Abnormalities reported Health education Safety Care plan adapted/ continued
- 10. Continuous comparison of patient’s condition with set objectives/ goals Evaluate whether the patient’s condition is improved Evaluate the quality of nursing care Final evaluation= cancellation of care plan
- 11. Legible Accurate Concise Chronological Trustworthy Permanent Free of erasure Identifiable Distinguishable Signatures and ranks Comprehensive No abbreviations Confidential No personal opinions
- 12. Assessment/ admission form Care plan documents Progress reports Treatment charts Observation record Intake/ output records Diabetic chart Informed consent Theatre records