Review of Nursing Process PDF

REVIEW OF NURSING PROCESS Focused assessment- The nurse gathers data about a specific problem that has already been identified....

REVIEW OF NURSING PROCESS Focused assessment- The nurse gathers data about a specific problem that has already been identified. Emergency assessment- The nurse performs this type of assessment on a It is systematic, rational method of planning and physiological and psychological crisis to providing individualized nursing care. identify the life-threatening problems. OBJECTIVE OF NP ( Nursing Process) Time lapsed assessment- This assessment is done to compare a patient current status to - Identify needs of the patient. the base line data obtained earlier. - To establish priorities of care. - To maximize strengths. ASSESSMENT SKILLS - To resolve actual or potential patient OBSERVATION problem. - To apply health promotion to possible each INTERVIEWING- Interaction and patient. communication. Direct interview Non-directive interview PHYSICAL EXAMINATION TECHNIQUES PHASES - Inspection - Six phases of the nursing care - Palpation ASSESSMENT - Percussion DIAGNOSIS - Ausculatation OUTCOME IDENTIFICATION ASSESSMENT ACTIVIIES PLANNING IMPLEMENTATION - Identify assessment priorities determined by EVALUATION the purpose of the assessment and the patient condition. ASSESSMENT - Organize or cluster the data to ensure - Is the systematic and continuous collection, systematic collect. validation and communication of the patient - Establish the data by Nursing history and data. Data base; includes all patient nursing examination; Review of patient record information, collected by the health care and & nursing literature. professionals to enables an effective plan to - Patient consultation & health care personal be implement for the patient. - Continuously update the data base, validate the data & communicate the data. SOURCE OF DATA - Patient/client is the PRIMARY source of information. NURSING DIAGNOSIS - SECONDARY; Family, friends, medical Diagnosing ( Patient problem ) the 2nd step of nursing history, physical examination, laboratory test, process. & other health professionals. - Clinical judgement about individual , family TYPES OF ASSESSMENT or community response to actual or potential Initial assessment- Is performed shortly health problems. It provides the bases for the after patient admission to a health agency or collection of nursing interventions. hospitals. Activities of nursing diagnosis; Interpret and analyze patient data  Identify patient strengths and health TYPES OF NURSING DIAGNOSIS problems ❖ Actual nursing diagnosis- represent a Formulate and validate nursing diagnosis problem that has been already validated Detect and refer signs and symptoms that by the presence of its characteristics. Ex; may indicate a problem beyond the nurses Impaired physical mobility, fatigue, experience. ineffective breathing pattern. Parts of nursing Diagnosis ❖ Risk nursing diagnosis- It’s a clinical judgement that individual family or PROBLEM – Statement that describes the health community is more vulnerable ( able) to problem of the patient clearly and concisely. develop the problem. Ex; Risk for ETIOLOGY- The reason that identifies the deficient fluid volume. physiological , psychological , social, spiritual and ❖ Possible nursing diagnosis – Statements environmental factors related to the problem. describing the a suspected problem. Ex; chronic low self-esteem. DEFINING CHARACTERISTICS ( Signs or symptoms ) ❖ Wellness diagnosis- Clinical judgement - The objective and subjective data that signal about individual, group or community in the existence of the problem. transition in specific level of wellness to a higher level. Ex; Readiness for enhanced health maintenance or readiness for Ex; enhanced self-esteem. CHARACTERISTICS ETIOLOGY PROBLEM ❖ Syndrome nursing diagnosis- A cluster Dry skin & dryness Diarrhea Deficient of an actual or risk nursing diagnosis of the mouth of fluid suspected to be present according to volume certain events. Differentiating the NUSING DIAGNOSIS vs NURSING PLANNING MEDICAL DIAGNOSIS The third step of nursing process includes the NURSING MEDICAL D. formulation of guidelines that established the - Focus on - Identify proposed course of nursing action in the resolution unhealthy Disease of nursing diagnosis and the development of the response to health and client’s plan of care. illness Activities of planning phase - Describe - Describe nurses treated problems by - Establish priorities by nurse within which the - Identify expected patient outcome the scope of physician - Select evidence- based nursing interventions independent directs the - Communicate the plan of care nursing primary practice. treatment. Stages of planning Initial Planning – Is developed by the nurse, who - May change - Remains the performs the admission nursing history and the from day to same as long change as the as the physical assessment. patient disease ids Ongoing Planning- Is carried by the nurse to keep responses present. the plan update, by analyzing the data to make plan change. more accurate. Discharge Planning- Is best carried out by the nurse, Three possible outcomes of the evaluation who has worked most closely with the patient and - Outcomes not met- continue plan as family. written - Outcomes not met- modify the plan - Outcomes met- terminate the plan The four critical elements of the planning include; Factors affecting outcome attainment: Facilitators Established priority & Barriers Setting goals and developing expected outcomes Evaluating compliance: Performance appraisal & Planning nursing intervention ( with quality assurance. collaboration and consultation as needed) Documenting PHYSICAL ASSESSMENT IMPLEMENTATION Consist of doing and documenting the activities that are the nursing actions need to carry out the PHYSICAL ASSESSMENT Collecting Objective intervention or nursing orders. Data Types of intervention; Dependent, Independent & Physical assessment is the collection of objective Collaborative information that is directly observed or elicited through examination techniques. Direct intervention- Actions performed through interactions with the clients. To become proficient with physical assessment skills, the nurse needs knowledge and practice in Indirect intervention- Actions performed away from these areas: the client or behalf of a client or group of clients. Types and operation of equipment needed for the particular examination EVALUATION Preparation of the setting, oneself, and the The last phase of nursing process, follows client for the examination interventions of the plan of care, it’s the judgement of Performance of the four assessment the effectiveness of nursing care to meet client goals techniques: inspection, palpation, based on the clients behavioral responses. percussion, and auscultation Evaluating: EQUIPMENT - Measure how well the patient has achieved -Before the examination, collect the necessary desires equipment and place it in the area where the - Final phase of nursing process examination will be performed. - Occurs whenever nurse interacts with the client PREPARING FOR THE EXAMINATION Before - Determining status of outcomes beginning the examination, make sure that you have - Systematic and ongoing prepared for all these aspects by: Outcomes: Preparing oneself - Identify factors contributing to the patients Preparing the physical setting success of failure - Modify the plan of care, if indicated. Approaching and preparing the client  Preparing Oneself Describe how health status influences the client’s abilities. Self-assessment Identify what changes the client had made to Preparing the Physical Setting The examination adapt to the health status. setting meets the following conditions: Comfortable room temperature - provide a warm blanket if the room temperature cannot 4 PHASES OF INTERVIEW: be adjusted. Preparatory Phase (Pre-interaction) Private area free of interruptions for the next Introductory Phase (Orientation) 30 to 60 minutes - close the door or pull the curtain if possible. Maintenance Phase (Working) Quiet area free of distractions - turn off the Concluding Phase (Termination) radio, television, or other noisy equipment. Preparatory Phase: Preparing the client and environment Health Assessment Thoughtful preparation of the client and the environment is advantageous for both the Health assessment is an essential nursing client and the nurse since it can eliminate function that provides the foundation for sources of anxiety and help the patient to quality nursing care and intervention. provide more accurate and complete It helps to identify the strengths of the clients information. in promoting health. Introductory Phase Health assessment helps to identify the After introducing self, explain the purpose of client's needs and clinical problems. the interview, discuss the types of questions To evaluate responses of the person to health that will be asked. problems and interventions. Explain the reason for taking notes, and assure the client that confidential information will remain confidential. Nurse’s Role in Health Assessment The nurse also makes sure that the client is Collecting and analyzing data comfortable (physically and emotionally) and has privacy. Components Develop trust and rapport at this point in the interview. The information is obtained through interviewing. Working Phase Therefore, effective interviewing skills are vital to the During this phase, the nurse elicits the accurate and thorough collection of subjective data. client’s comments about: The Interview Purpose of the interview: o major biographic data, Obtain the client's history and perception of o reasons for seeking care, past experiences. o history of present health concern, Identify factors that either positively or o past health history, negatively influence health status. o family history,  o review of body systems for current Focus on the client and the upcoming health problems, interview and assessment. o lifestyle and health practices, and Do not enter the room laughing loudly, yelling developmental level. to a co-worker, or muttering under your breath. Greet the client calmly and focus your full Concluding Phase: Summary and Closing Phase attention on her. Summarizes information obtained during the Do not be overwhelmingly friendly or working phase. "touchy"; many clients are uncomfortable Validates problems and goals with the client. with this type of behavior. It is best to maintain a professional distance. Identifies and discusses possible plans to resolve the problem (nursing diagnoses and Attitude collaborative problems). Develop a nonjudgmental attitude. All clients Ensures the nurse asks if anything else should be accepted, regardless of beliefs, concerns the client and if there are any ethnicity, lifestyle, and health care practices. further questions. Do not act superior to the client or appear Guidelines of an Effective Interview shocked, disgusted, or surprised at what you are told. Communication During the Interview Being nonjudgmental involves not o The client interview involves two types "preaching" to the client or imposing your of communication: own sense of ethics or morality on him. ▪ Nonverbal Accept the client, be understanding of the ▪ Verbal habit, and work together to improve the client’s health. Nonverbal Communication Appearance FACIAL EXPRESSION o Ensure that your appearance is professional. Facial expression often shows what you are truly thinking (regardless of what you are o Wear comfortable, neat clothes and a saying), keep a close check on your facial laboratory coat or a uniform. expression. o Be sure your name tag is clearly No matter what you think about a client or visible. what kind of day you are having, keep your o Your hair should be neat and not in expression neutral and friendly. any extreme style. If your face shows anger or anxiety, the client o Fingernails should be short and neat; will sense it and may think it is directed jewelry should be minimal. toward him or her. Demeanor If you cannot effectively hide your emotions, you may want to explain that you are angry or When you enter a room to interview a client, upset about a personal situation. display poise. SILENCE  Another nonverbal technique to use during occur once every year, day, month, or hour?" the interview process is silence. Repeat choices as necessary. Periods of silence allow you and the client to PROVIDING INFORMATION reflect and organize thoughts, which Provide the client with information as facilitates more accurate reporting and data questions and concerns arise. Make sure you collection. answer every question as well as you can. LISTENING If you do not know the answer, explain that Listening is the most important skill to learn you will find out for the client. and develop fully in order to collect complete The more clients know about their own and valid data from your client. health, the more likely they are to become To listen effectively, you need to maintain equal participants in caring for their health. good eye contact, smile or display an open, WELL-PLACED PHRASES appropriate facial expression, and maintain an open body position (open arms and hands Client verbalization can be encouraged by and lean forward). well-placed phrases from the nurse. Avoid crossing your arms, sitting back, tilting If the client is in the middle of explaining a your head away from the client, thinking symptom or feeling and believes that you are about other things, or looking blank or not paying attention, you may fail to get all inattentive. the necessary information. Verbal Communication OPEN-ENDED QUESTIONS Listen closely to the client during his or her description and use phrases such as "uh Used to elicit the client’s feelings and huh," "yes," or "I agree" to encourage the perceptions. They typically begin with the client to continue. words “how” or “what.” INFERRING An example of this type of question is “How have you been feeling lately?” Inferring information from what the client tells you and what you observe in the client’s CLOSED-ENDED QUESTIONS behavior may elicit more data or verify Use closed-ended questions to obtain facts existing data. and to focus on specific information. The Nonverbal Communication to Avoid client can respond with one or two words. The questions typically begin with the words 1. Excessive or Insufficient Eye Contact “when” or “did.” o Avoid extremes in eye contact. An example of this type of question is “When did your headaches start?” o Therefore, it is best to use a moderate amount of eye contact. o For example, establish eye contact LAUNDRY LIST when the client is speaking to you but look down at your notes from time to Provide the client with a choice of words to time. choose from in describing symptoms, conditions, or feelings. For example, "Is the pain severe, dull, sharp, Distraction and Distance mild, cutting or piercing?" "Does the pain  Avoid being occupied with something else Biographic data usually include information while you are asking questions during the that identifies the client: interview. o Name, Address, Gender, Age, Marital Avoid appearing mentally distant as well. Status, Occupation, Religion, Family Income (Monthly), Educational Also, try to avoid physical distance exceeding Qualification, etc. 2 to 3 feet during the interview. CHIEF COMPLAINTS/Reason(s) for Seeking Health Physical distance may portray a non-caring Care attitude or a desire to avoid close contact with the client. It is a brief assessment of the client’s problem for which they seek medical care. Standing This category includes the question "What is Avoid standing while the client is seated your major health problem or concern at this during the interview. time?" Standing puts you and the client at different This question helps the client focus on their levels. You may be perceived as the superior, most significant health concern and answers making the client feel inferior. the nurse's question of "Why are you here?" Care of the client’s health should be an equal or "How can I help you?" Physicians call this partnership between the health care provider the client’s chief complaint (CC). and the client. History of Present Illness Verbal Communication to Avoid This section of the health history takes into Biased or Leading Questions account several aspects of the health problem and asks questions whose answers Rushing Through the Interview can provide a detailed description of the Reading the Questions concern. HEALTH HISTORY First, encourage the client to explain the health problem or symptom in as much detail Health History as possible by focusing on the onset, It is a collection of subjective data in detail progression, and what the client perceives as regarding the client’s health in a causing the problem. chronological order. H/O Present Illness Factors Affecting The Collection of Subjective Onset Data Signs and Symptoms (S&S) Physical setting Duration Client’s personality and behavior Treatment taken (if any) Nurse’s personality and behavior Other complaints such as loss of appetite, Communication skill insomnia, disorders of the stomach, etc. Patient’s problem Client’s Health Habits - Eating, Sleeping, etc. FORMAT OF HEALTH HISTORY Biographic Data/personal profile Past Health History  This portion of the health history focuses on o "How much beer, wine, or other questions related to the client's past, from alcohol do you drink on average?" the earliest beginnings to the present. Food habits and Food fads The information gained from these questions o Likes and dislikes assists the nurse to identify risk factors that stem from previous health problems. Risk o Pattern of sleep factors may be to the client or to his significant others. o Exercises Past Health History Childhood Illness - Mumps, Measles and so on. Allergies Medical disease - HT, DM, Anemia etc. Surgery - Any history of surgery Hospitalization - Any hospitalization in the past Obstetric History - Number of live births, abortions, mode of delivery Family Tree Information about family members Family history of any illness (Diabetes Mellitus, Hypertension, etc.) Current Medications The information gathered about medication provides the nurse with information concerning lifestyle and a client's self-care ability. Sample questions include: o "What medications have you used recently and currently, both those that your doctor prescribed and those you can buy over the counter at a drug or grocery store?" o "For what purpose did you take the medication? How much dose and how often did you take the medication?" Psycho-Social History Smoking - Alcoholism