Fundamentals of Nursing - 2nd Lecture

Fundamentals of Nursing - 2nd Lecture

• This is a lecture on the nursing process.
• The nursing process is a systematic and rational method for planning and providing nursing care.
• A process is a series of steps or acts leading to a goal or purpose.
• Purposes of the nursing process include identifying a client's health status, potential health problems, establishing plans to meet identified needs, and delivering specific interventions.

Steps of the Nursing Process

• Assessment: Gathering data about the client.
• Diagnosis: Identifying the client's health problems.
• Planning: Developing a plan to meet the identified needs.
• Implementation: Carrying out the plan.
• Evaluation: Assessing the effectiveness of the plan.

Characteristics of the Nursing Process

• Client-centered: Focuses on the client's needs.
• Cyclic and dynamic: Steps build on each other but are not linear.
• Universally applicable: Can be used with clients across the lifespan in various settings.

Assessment

• Systematic and continuous collection, organization, validation, and documentation of data (information).
• A continuous process throughout all phases of the nursing process.
• All phases of the nursing process depend on accurate and complete data collection.

Types of Assessments

• Initial Assessment: Performed after admission to a health care agency to establish a complete database for problem identification, reference, and future comparison. Example: Nursing admission assessment.
• Problem-focused Assessment: An ongoing process integrated with nursing care to determine the status of a specific problem, and identify new or overlooked problems. Example: Hourly assessment of a client's fluid intake and output.
• Emergency Assessment: Performed during a physiologic or psychological crisis to identify life-threatening problems. Example: Rapid assessment of airway, breathing, circulation during a cardiac arrest.
• Time-lapsed Assessment: Performed several months after an initial assessment to compare the client's current status to previously obtained baseline data. Example: Reassessment of patients in an outpatient setting after discharge.

Components of Nursing Health History

• Biographical Data: Name, age, gender, marital status, occupation, religion, education, income.
• Chief Complaint: The patient's response to "What brought you to the hospital/clinic?" (recorded in the patient's own words).
• History of Present Illness:
  • Onset: When symptoms started?
  • Pattern of Onset: Gradual or sudden?
  • Setting: Where was the patient when symptoms started?
  • Severity: Mild, moderate, or severe?
  • Location: Where is the pain located?
  • Quality: Describe the characteristics of the problem.
  • Radiation: Does the pain radiate anywhere?
  • Duration: How long has the problem lasted?
  • Palliative/Aggravating factors: What makes the problem better/worse?
  • Associated Symptoms: Other related symptoms?
• Past History: Childhood illnesses, immunizations, allergies, accidents/injuries, previous hospitalizations.
• Family History: Relevant medical history of family members (e.g., diagram).
• Lifestyle: Personal habits (e.g., substance use), diet, sleep, hobbies, daily activities.

Types of Data

• Subjective Data: Data that is only described and verified by the client. Examples include feelings, perceptions, and what the client reports.
• Objective Data: Data that can be detected by an observer or nurse. Examples include physical examination findings (e.g., blood pressure, skin color), and observations.

Sources of Data

• Primary Source: The client.
• Secondary Source: Family members, records, reports, laboratory findings, diagnostic results, and health care providers.

Data Collection Methods

• Observing
• Interviewing
• Examining

Observing

• Using the senses (vision, smell, hearing, touch) to gather data. Examples of client data include body size, posture, grooming, skin color, body/breath odors, lung and heart sounds, bowel sounds, orientation, skin temperature, pulse rate, muscle strength.

Interviewing

• A planned communication or conversation to get or give information.
  • Directive Interview: The nurse directs the interview and controls the questions.
  • Non-directive Interview: The client controls the questions.
• Different types of interview questions:
  • Close questions: Require brief “yes” or “no” answers or short factual answers (e.g., "What medication did you take?").
  • Open questions: Allow for detailed responses and exploration of feelings and thoughts (e.g., "Describe the pain you feel in more detail?").

Factors Affecting Interview Planning

• Time: The client's comfort, absence of pain and minimal interruptions.
• Place: Well-lit, well-ventilated, moderate sized room with minimal noise.
• Distance: Appropriate distance as in Arab countries (8-12 inches).
• Language: Use simple language, avoid complicated medical terminology, and provide necessary translations as needed.

Stages of Interview

• The Opening: Introducing yourself and explaining the purpose of the interview; establishing rapport.
• The Body: Collecting data based on established questions and patient responses.
• The Closing: Summarizing the information to ensure accuracy and agreement; providing a plan/ next steps.

Organizing Data

• Using nursing and non-nursing models. Examples include Maslow's Hierarchy of Needs and body system models.

Documenting

• Importantly document all collected data from the assessment.

This lecture focuses on the nursing process, a systematic method for planning and delivering nursing care. It encompasses five critical steps: assessment, diagnosis, planning, implementation, and evaluation. Understanding these steps is essential for effective client-centered care.