Untitled Quiz

Fundamentals of Nursing - 2nd Lecture

• This is a lecture on the nursing process.
• The nursing process is a systematic, rational way to plan and provide care.
• A process is a set of steps or actions that lead to achieving a goal.
• The nursing process identifies a client's health status, potential problems, establishes plans to meet needs, and delivers interventions.

Steps of the Nursing Process

• Assessment: Gathering, organizing, validating, and documenting data.
• Diagnosis: Identifying health problems and strengths.
• Planning: Establishing goals and interventions.
• Implementation: Carrying out the planned interventions.
• Evaluation: Evaluating the effectiveness of interventions.

Characteristics of the Nursing Process

• Client-centered
• Cyclic and dynamic (steps build on each other, not strictly linear)
• Universally applicable across the lifespan and settings.

Assessment

• Systematic and continuous collection, organization, validation, and documentation of data.
• Continuous process during all phases of the nursing process.
• Accurate and complete data collection is crucial for all phases.

Types of Assessment

• Initial Assessment: Performed soon after admission to healthcare agencies to create a complete database for problem identification and future comparisons. Example: Nursing admission assessment.
• Problem-focused Assessment: An ongoing process integrated with nursing care to determine the status of specific problems and identify new or overlooked ones. Example: Hourly assessment of fluid intake and output.
• Emergency Assessment: Performed during a physiologic or psychological crisis to identify life-threatening problems. Example: Rapid assessment of airway, breathing, and circulation during cardiac arrest.
• Time-lapsed Assessment: A reassessment made months after an initial assessment to compare current and baseline status. Example: Reassessment of patients in outpatient settings after discharge.

Components of Nursing Health History

• Biographical Data: Name, age, gender, marital status, occupation, religion, education, income.
• Chief Complaint: Patient's response to "What brought you to the hospital/clinic?" Recorded in their own words.
• History of Present Illness:
  • Onset: When symptoms started
  • Pattern of onset: Gradual or sudden
  • Setting: Place where the symptoms started
  • Severity: Mild, moderate, or severe
  • Location: Where the symptom is
  • Quality: Characteristics of the problem
  • Radiation: Areas to which the symptom spreads
  • Duration: How long the symptom has lasted
  • Palliative factors: Factors reducing the symptoms
  • Aggravating factors: Factors worsening the symptoms
  • Associated symptoms: Other symptoms linked to the main one.
• Past History: Childhood illnesses, immunizations, allergies, accidents, and injuries, previous hospitalizations.
• Family History: Relevant family medical history. Example: family history of asthma , MI
• Lifestyle: Personal habits like substance use, diet, sleep patterns, hobbies, daily activities.

Types of Data

• Subjective Data (Symptoms): Information that only the patient can describe and verify. Example: "I feel pain in my chest."
• Objective Data (Signs): Measurable information that can be observed and documented by a healthcare professional. Example: Blood pressure, skin color, vomiting.

Sources of Data

• Primary Source: The client himself/herself.
• Secondary Source: Family members, records, lab reports, diagnostic findings, and healthcare providers

Data Collection Methods

• Observing Data using the senses (e.g., vision, smell, hearing, touch)
• Interviewing Structured communication to gather information.
• Examining Physical assessment techniques.

Organizing Data

• Nursing and non-nursing models (e.g., Maslow's hierarchy of needs, body systems models)

Stages of Interview

• Opening: Introducing yourself, explaining the purpose.
• Body: Gathering information through questioning.
• Closing: Summarizing, thanking the patient, any further plans.