Nursing Process: Goals, Critical Thinking, Assessment

Nursing Process Overview

• Model for nursing that encompasses the actions taken by registered nurses.
• Forms a base for decision making.
• Consists of 5 steps: assessment, diagnosis, planning, implementation, and evaluation.

Nursing Goals

• Prevent illness and promote, maintain, or restore health.
• Control and promote comfort and well being until death for terminal illness.
• Maximize well being and ability to function in desired roles.
• Provide cost-effective efficient care that focuses on wants and needs.
• Find ways to improve consumer satisfaction with healthcare.

Critical Thinking

• Based on nursing process and scientific method.
• Entails purposeful, informed, outcome-focused thinking, requiring identification of key issues and risks.

Assessment

• Collect and record all information needed to predict, detect, prevent, manage, or eliminate health problems.
• First step in determining health status.
• Involves physical examination, interview to get a picture of the patient's health.

Five phases of assessment

• Collecting data
• Validating data
• Organizing data
• Identifying patterns and testing first impressions
• Decide on what to record and report

Focus Assessment

• A part of comprehensive data-base assessment used to monitor specific problems or aspects of care.
• Focus is guided by the following questions:
  • Current status of the problem compared to baseline data.
  • Contributing factors to the problem.
  • Patient's perspective on the problem's status and its management

Types of Data

• Subjective data: What the person states verbally
• Objective data: What you observe.

Sources of Data

• Client: Best source of data.
• Support People: To supplement or verify information
• Client records: Information documented by healthcare professionals.
• Healthcare professionals: Verbal reports.
• Literature: To provide additional information for the database.

Data Collection Methods

• Observing: Gathering data by use of the senses.
• Interviewing: Planned communication or conversation with a purpose.
• Examining: Systematic data collection using observation to detect health problems.

Observation

• Vision to observe the client data.
• Smell to observe the client data.
• Hearing to observe the client data.
• Touch to observe the client data.

Interview

• Ethical, spiritual, and cultural considerations during interview.
• Provide services with respect to human dignity.
• Safeguard the patient's right to privacy and be honest.
• Respect individual cultural and religious beliefs.

Guidelines for Caring Interview

• Get organized and plan, ensure privacy, get focused, visualize yourself as confident, warm, and helpful.
• Introduce yourself, verify the person's name and position, explain your purpose.
• Give the person your full attention, listen for feelings even if they conflict with words.
• Be patient, avoid interrupting, and allow for pauses in conversation.

Nursing Health History Components

• Biographic Data: Clients name, address, age, sex, marital status, occupation, religious preference, healthcare financing.
• Chief complaint: The answer given to the question "what is troubling you?" recorded in the client's own words.
• History of illness and whether the client's illness presents financial concerns.
• Home and neighborhood conditions.

Psychological Data

• Assesses a client's stressors, coping mechanisms, verbal and nonverbal communication
• Examines the client's past and current healthcare usage, satisfaction, and access to care.

Assessment

• Inspection: Observation using all senses.
• Palpation: Feeling internal structures through touch and pressure.
• Auscultation: Listening to internal sounds using a stethoscope.
• Percussion: Tapping the body's surface to detect internal conditions (e.g., fluid, reflexes).

Organization of Assessment

• Influenced by the patient's condition and the assessor's personal preference.

Gordon's Functional Health Patterns

• Health Perception/Health Management
• Nutritional and Metabolic:
• Elimination patterns
• Activity-Exercise
• Patterns of Sleep-Rest
• Cognitive-Perceptual:
• Self-Perception/Self-Concept:
• Role-Relationship patterns
• Sexuality-Reproductive pattern
• Coping-Stress Tolerance

Value-Belief

• Describes the client's values, beliefs, goals that guide their choices.
• Identify Patterns and Get some initial impression of health functioning.

Record & Report

• Self-reflection by pausing to consider what report.
• Timeliness in reporting abnormal findings and prioritizing urgent issues.
• Accurate information and preparation for reporting.
• Record & Report are Final steps of the assessment

Diagnosis

• Creating a list of suspected problems/diagnoses
• Ruling out similar problems/diagnoses
• Naming actual and potential diagnoses and clarifying what's causing them
• Determine risk factors that must be managed
• Identifying resources, areas of health promotion and strengths
• PPMP Advantages: Proactive; evidence-based; utilizes technology

Nursing Diagnosis Types

• Actual Diagnosis
• Possible Diagnosis
• Risk Diagnosis
• Syndrome Diagnosis

Nursing Diagnosis

• Diagnostic label/label
• Defining characteristics: Major/minor defining characteristics

Three-part Nursing Diagnosis Format

• Problem which states the nursing diagnosis
• Etiology identifies the factors contributing to the problem
• Signs and Symptoms describes the observable evidence

Planning

• Planning: The deliberative and systematic phase

Variations From Basic Planning Format

• Unknown Etiology
• Complex Factors
• Possible to gather needed the client’s problem or etiology

Nsg Care Plan

• Informal NSG Care
• Formal NSG Care
• Standardized Care
• Individualized
• Multidisciplinary

Statements

• States and Summary
• Visual Tool on Concepts
• Deliberative systematic phase
• Direct/Promote communication

Goal

• What you intent patient do to.
• Expected outcome
• Indicators cue
• Prioriy setting diagnosis with intervention
• Nsg Intervention
• Rationales for justifying
• Promotes communication and
• Guidance for intervention
• Delegate 5 items

Types of nursing interventions.

• Clinical: Problem resolution.
• Functional: Ability to perform activities.
• Quality of Life: Overall well-being.

Outcome

• Realism: Consider patient health, prognosis, and expected length of stay.
• Intervention Types: Distinguish between direct & indirect interventions
• Intervention Goals: Should directly prevent and manage health problems and risks like and promote optimum.
• Individualized & Empowerment care to emphasize
• Evaluate results categorized by health issues.

Overview of the nursing process, encompassing actions by registered nurses. It forms a base for decision making and consists of assessment, diagnosis, planning, implementation, and evaluation. Nursing goals include preventing illness, promoting health, maximizing well-being, providing cost-effective care, and improving consumer satisfaction.