Nursing Process Module 1

Study Notes

Nursing Process Overview

Systematic approach for managing patient care includes four key steps: determining problems, planning solutions, initiating interventions, and evaluating effectiveness.
Evidence-Based Practice (EBP) integrates research and best practices into nursing, facilitating problem-solving and patient care through a universal language.

Assessment

First step in the nursing process, encompassing data collection and analysis.
Types of physical assessments include comprehensive, focused, and emergency assessments (triage).
Physical assessment includes systematic examination to identify physical, psychological, and emotional needs.
Utilizes the five senses (sight, hearing, touch, smell) along with interview techniques.
Data types:
- Subjective: gathered from patient/family input.
- Objective: obtained from nursing exams using IPPA (Inspection, Palpation, Percussion, Auscultation).

Patient Profile Considerations

Past life events, current medications, education, occupation, financial resources, and lifestyle patterns must be considered.
Important aspects include disability, sexuality, risk for abuse, and stress coping responses.

Health History Components

Essential elements: biographical data, chief complaint, current and past health history, family health history, review of systems, and detailed patient profile.

Effective Communication Strategies

Building rapport through eye contact, active listening, and awareness of nonverbal cues.
Understand patient’s educational and cultural background, as well as language proficiency.
Avoid medical jargon and summarize discussions at the end of consultations.

Ethical Considerations

Clearly explain the health history and examination process, information usage, and ensure a private setting.
Adhere to HIPAA regulations to protect patient privacy.

Nursing Diagnosis

Second step in the nursing process involves creating nursing diagnosis statements: problem-focused, risk, and health promotion diagnoses.
Nursing diagnosis describes patient responses to conditions that are unhealthy.
Structure includes unhealthful response (diagnostic label), probable cause (R/T), and validation (AMB for observed signs/symptoms).
Example: "Acute Pain R/T Surgical Incision AMB patient states ‘I have pain level of 8 in my abdomen.’"

Categories of Nursing Diagnosis

Actual Problem Diagnosis indicates the presence of defining characteristics and validated signs/symptoms.
Potential Problem Diagnosis recognizes risk factors without current symptoms or signs.

Planning

Third step involves establishing priorities for nursing diagnoses using Maslow's hierarchy.
Set attainable and measurable outcomes and establish immediate (24 hours) goals.
Determine nursing interventions, planning interventions, and identifying nursing orders for effective care delivery.

Description

Explore the Nursing Process in this quiz, focusing on the systematic approach to identifying patient problems, planning solutions, and evaluating the effectiveness of nursing interventions. This module provides a foundational understanding essential for nursing practice and evidence-based care.