Nursing Process and Ida Jean Orlando

• The nursing process is used by nurses to provide care and promote health.
• The acronym ADPIE can be used to remember the steps in the nursing process: Assessment, Diagnosing, Planning, Implementation, Evaluation.
• The nursing process is cyclic, dynamic, client-centered, interpersonal, collaborative, and universally applicable.
• Critical thinking and clinical reasoning are used in the nursing process.

Introduction to Biography of Ida Jean Orlando

• Ida Jean Orlando was a first-generation Irish American born in 1926.
• She received a nursing diploma from New York Medical College at the Lower Fifth Avenue Hospital School of Nursing.
• She earned a Bachelor of Science in Public Health from St. John's University in Brooklyn.
• She earned a Master of Arts Degree in Mental Health Nursing from Teachers College, Columbia University

Definition of Nursing Process

• It is a critical thinking process that nurses use to apply the best available evidence to caregiving and promoting human functions and responses to health and illness.
• The American Nurses Association defined nursing process in 2010.

Purposes of Nursing Process

• To identify a client's health status and actual or potential health care problems or needs.
• Establish plans to meet the identified needs.
• Deliver specific nursing interventions to meet those needs.

Assessment (Data Collection)

• Assessment involves data collection, nursing diagnosis, planning, implementation, and evaluation.
• Assessment is defined as the systematic and continuous collection, organization, validation, and documentation of data (information).
• The steps for assessment are data collection, data organization, data validation, and data documentation

Types of Assessment

• Initial nursing assessment involves performance is done within a specified time after administration to establish a complete database for problem identification, like the nursing admission assessment.
• Problem-focused assessment determines the status of a specific problem identified in an earlier assessment, like hourly checking vital signs of a fever patient.
• Emergency assessment is done during emergency situations to identify life-threatening situations, focusing on airway, breathing status, and circulation during cardiac arrest.
• Time-lapsed reassessment is done several months after the initial assessment to compare the client's current health status with previously obtained data.

Collection of Data

• Data collection is the process of gathering information about a client's health status.
• It includes health history, physical examination, results of laboratory and diagnostic tests, and material contributed by other health personnel.

Types of Data

• Data can be subjective or objective
• Subjective data, is clear only to the person affected and can be described only by that person, e.g., itching, pain and feelings of worry.
• Objective data are detectable by an observer or can be measured/tested against an accepted standard, e.g., discoloration of the skin or a blood pressure reading.

Sources of Data

• Primary sources are direct sources of information, with the client being the primary.
• Secondary sources are indirect sources.
• All sources other than the client are considered secondary sources.
• Examples of secondary sources: Family members, health professionals, records and reports, laboratory and diagnostic results.

Methods of Data Collection

• Methods of data collection: Observation, interview and examination
• Observation: Gathering data by using the senses, like Vision, Smell and Hearing
• Interview: Planned communication or a conversation with a purpose.
• Two approaches to interviewing: directive and nondirective.
• The directive interview: Highly structured and asks questions directly.
• A nondirective interview, or rapport building interview, allows the client to control the interview.
• Interview: Consists of an opening or introduction, a body or development, and a closing.
• The physical examination is a systematic data collection used to detect health problems.
• Examination involves inspection, palpation, percussion and auscultation.

Organization, Validation, and Documentation of data

• The nurse uses a format that organizes the assessment data systematically called Nursing health history or nursing assessment form.
• Validation of data involves double-checking or verifying data to confirm it is accurate and complete.
• Documentation of data: Recording client data as part of the assessment phase.

Diagnosis

• It is the second phase of the nursing process, the nurses use critical thinking skills to interpret assessment data to identify client problems.
• NANDA (North American Nursing Diagnosis Association) define or refine nursing diagnosis.
• The official NANDA definition of a nursing diagnosis is A clinical judgment concerning a human response to health conditions/life processes, or a vulnerability for that response, by an individual, family, group, or community.

Status of Nursing Diagnosis

Statuses of nursing diagnosis: Actual, health promotion and risk.

• An actual diagnosis is a client problem present at the time of the nursing assessment.
• A health promotion diagnosis relates to clients' preparedness to improve their health condition.
• A risk nursing diagnosis indicates a problem does not exist but risk factors may cause its development if adequate care is not given.

Components of a NANDA Nursing Diagnosis

• The first is the problem and its definition
• The second is the etiology
• The third is the defining characteristics.
• The problem statement describes the client's health problem.
• The etiology component identifies the causes of the health problem.
• Defining characteristics are signs and symptoms that indicate a health problem.

Formulating Diagnostic Statements

• The basic three-part nursing diagnosis statement is called the PES format.
• Problem (P): statement of the client's health problem (NANDA label)
• Etiology (E): causes of the health problem
• Signs and symptoms (S): defining characteristics manifested by the client.
• An example is acute pain related to abdominal surgery as evidenced by patient discomfort and pain scale.
• Problem: pain
• Etiology: surgery of abdomen
• Signs and symptoms: pain scale and discomfort of patient