Nursing Process Overview: NCMA 111 Topic-1

Overview of the Nursing Process: NCMA 111 Topic-1

• The nursing process is reviewed within the context of health assessment, including its phases and characteristics.
• Discussion points includes orientation, the nursing process, and the collection of subjective data.
• Objectives are to describe the phases and characteristics of the nursing process and relate critical thinking to the nursing process.

Health Assessment

• Health assessment is a systematic, deliberative, and interactive process where nurses use critical thinking to collect, validate, analyze, and synthesize information.
• The goal is to make judgments about the health status and life processes of individuals, families, and communities.
• Health assessment provides a necessary foundation for quality nursing care and intervention.
• It assists in pinpointing client needs, clinical problems, and nursing diagnoses, along with evaluating responses to health issues and interventions
• Thorough health assessments reflects the knowledge and skills of professional nurses.

The Nursing Process

• It provides a framework for providing quality nursing care.
• It represents a systematic, rational method for planning and delivering individualized nursing care.
• The nursing process aims to identify a client's health status as well as actual or potential healthcare problems or needs.
• The nursing process helps to establish plans to meet the identified needs and deliver specific nursing interventions.

Characteristics of the Nursing Process

• Cyclic and Dynamic: It is continuously changing, and involves a regularly repeated sequence of events.
• Client-centered: Focuses on the client's specific problems, where nurses collect data to understand client's habits, routines, and needs, incorporating them into the care plan.
• Adaptation of Problem Solving and Systems Theory: It functions parallel to, but separate from, the medical model used by physicians.
• Decision-making: Involved in every phase of the nursing process, facilitates the individualization of the nurse’s plan of care.
• Interpersonal and Collaborative: Requires consistent, direct communication and collaboration between the healthcare team members to provide quality client care.
• Universal applicability: The framework is used in all types of healthcare settings, and with clients of all age groups.
• Critical thinking is essential for focused and reflective decision-making, in every phase.
• Clinical reasoning is used throughout the delivery of nursing care to make sure the outcome of care is appropriate.

ADPIE: Steps of the Nursing Process

• Assessment involves collecting data about a client in a systematic and dynamic way, it serves as the first step in delivering nursing care.
• Diagnosis involves the process of diagnostic reasoning, from assessment through problem identification, to inform nursing practice.
• Planning involves setting goals and standards to achieve for helping the client and defining what outcomes and achievements would be.
• Implementation includes interventions to help the clients that are both safe and beneficial to execute the goals.
• Evaluation involves assessment of the planning and implementation and whether the goals are achieved.

Phase 1: Assessment

• It is a systematic and dynamic method to collect and analyze client data.
• Assessment marks the first step in delivering nursing care.
• Assessment encompasses physiological, psychological, sociocultural, spiritual, economic, and lifestyle factors.

Types of Assessment

• Initial Assessment: It is performed within a specified amount of time after admission to a healthcare facility.
• Initial Assessment: It Establishes a complete database for problem identification, reference, and future comparison; an example is a Nursing Admission Assessment.
• Problem-Focused Assessment: It is an ongoing process integrated with nursing care.
• Problem-Focused Assessment: Determines the status of a specific problem identified in an earlier assessment.
• Problem-Focused Assessment: An example is hourly assessment of client's fluid intake and output in an ICU.
• Emergency Assessment: Occurs during any physiological or psychological crisis of the client.
• Emergency Assessment: Identifies life-threatening problems. An example includes rapid assessment of airway, breathing, and circulation during a cardiac arrest.
• Time-Lapsed Assessment: Conducted several months after the initial assessment.
• Time-Lapsed Assessment: The goal is to comparecurrent status with baseline data previously obtained.
• Time-Lapsed Assessment: Examples include reassessment of functional health patterns in home care, outpatient settings, or during shift changes in a hospital.

Steps of Health Assessment: Collecting Data

• Collecting Data- The assessment process to gather a client's health status involves being systematic and continuous, to prevent omission of important information.
• Assessment involves collecting, organizing, validating, and documenting data
• Critical thinking skills are essential for effective assessment
• In most cases, the nurse will first encounter the client, the nurse is expected to assess health problems and emotional state, to establish a database about the client’s response to health concerns.
• Establishing a Database contains subjective data/ history taking (biographical information, history of present health concern, personal health history, family history, health and lifestyle practices and review of systems)

Components of a Nursing Health History

• Biographic Data: Includes client's name, address, age, sex, marital status, occupation, religious preference, health care financing, and usual source of medical care.
• Chief Complaint or Reason for Visit: Reason for seeking medical care recorded in the client's own words.
• History of Present Illness: Includes when symptoms started, whether onset was sudden or gradual, frequency, location and character of the distress, activity involved, and factors that alleviate or aggravate the problem.
• *COLDSPA method of questioning: Character, Onset, Location, Duration, Severity, Pattern, Associated factors/ how it affects the patient
• Past History: Illnesses, immunizations, allergies, accidents/injuries, hospitalizations, and medications.
• Lifestyle: Personal habits, diet, sleep patterns, ADL (Activities of Daily Living), and recreation/hobbies.
• Social Data: Ethnic affiliation, educational history, occupational history, economic status, home and neighborhood conditions.
• Psychological Data: Major stressors experienced and client’s perception of them, usual coping patterns, and communication style.
• Patterns of Health Care: Includes all healthcare resources used.

Collecting Data: Types of Data

• Subjective Data: It involves covert information, such as feelings, perceptions, thoughts, sensations and concerns that are shared by the patient.
• Objective Data: It is overt, measurable, tangible data collected via the senses and compared to an accepted standard.
• Verbal Data: Data are spoken or written such as statements made by the client or by a secondary source.
• Nonverbal Data: Include observable behavior transmitting a message without words, such as the patient's body language, general appearance, facial expressions, gestures, eye contact, proxemics (distance), body language, touch, posture, and clothing.
• Constant Data: Information that does not change over time, such as race and blood type.
• Variable Data: Information that can change quickly, frequently, or rarely, such as blood pressure, level of pain and age.

Collecting Data: Sources of Data

• Primary: The client is the primary source of data.
• Secondary:Family members or other support persons, other health professionals, records and reports.
• The best source of data is the client, unless the client is too ill, young, or confused.
• Family members, friends, and caregivers can provide valuable information on the client's response to illness, stresses, attitudes, and home environment.
• Client Records: Include information documented by healthcare professionals, types include medical records, records of therapies and laboratory records
• Healthcare Professionals: Sharing of information facilitates continuity of care when clients are transferred.
• Literature: Professional journals and reference texts with standards to compare findings, cultural and social health practices, spiritual beliefs and assessment data for specific conditions.

Data Collection Methods: Interviewing

• Data Collection Methods: An interview involves planned communication with a specific purpose.
• Data Collection Methods: There are two approaches to interviewing (directive, and non directive)
• Directive Interview: Elicits specific information, the purpose is defined, and limited opportunities to discuss concerns.
• Non Directive Interview: Used for rapport-building and client controls the subject matter
• Closed questions: “yes” or “no” or short factual answers and directive
• Open-ended questions: To elaborate, clarify, or illustrate thoughts or feelings and non directive
• Neutral question: The client can answer without direction or pressure, open ended and non directive
• Leading questions: The client's answer is directed and directive
• Interview Setting: time(client is comfortable and free of pain), place(free of noise, distractions) Seating Arrangement (nurse at 45 degree angle), Distance should be 2 to 3 feet and Language simplified.
• Phases of Interview: The Pre Introductory, The Introductory, The working and The summary/closing

Phases of Interview

• Preintroductory Phase: The nurse reviews the medical record.
• Introductory Phase: The nurse introduces self, explains the interview's purpose, assures confidentiality, and ensures comfort and privacy to help to develop rapport.
• Working Phase: The nurse elicits data and uses critical thinking skills to interpret and validates it with the client taking cues by listening and observing
• Summary and Closing Phase: The nurse summarizes information, validates problems/goals with the client, identifies/discusses plans to resolve issues, and addresses any further questions/concerns.

Methods of Data Collection: Observing

• Observation is an assessment tool that depends on the use of the five senses (sight, touch, hearing, smell and taste) to learn information.
• Using the Senses to Observe Data through sight, smell, hearing and touch.
• Nursing observations organized to avoid missing.
• Observe in the following order, clinical signs of distress, threats to client’s safety, Presence/Functioning of equipment and Immediate environment.

Methods of Data Collection: Examining

• Examining: Consists of establishing a good physical assessment, that would provide a more accurate diagnosis, interventions and evaluation with inspection, palpation, percussion and ascultation.
• Examining: carried out systematically and organized (head-to-toe, body systems approach)
• Examining: A screening examination, also called a review of systems, is a brief review of essential functioning of various body parts or systems.

Organizing/ Validating/ Documenting Data

• Organizing Data: Written or electronic format used that organizes the assessment data systematically using Gordon’s Functional 11 health patterns.
• Validating data involves verifying data accuracy to ensure it is factual; Cues: subjective or objective data that is observed, inferences involves nurse's interpretation or conclusions made based from cues.
• Documenting Data: Once all the information has been collected, data can be recorded with excellent record keeping fundamental so that all the data gathered can be sorted.

An overview of the nursing process within health assessment. Discussion points include orientation, the nursing process, and the collection of subjective data. Objectives are to describe the phases/characteristics and relate critical thinking to the nursing process.