Fundamentals of Nursing 2nd Lecture PDF

Fundamentals of Nursing 2nd Lecture Dr. Motasem AlDaieflih RN, MSN,PhD  Nursing Process The nursing process is a systematic ,rational method of planning and providing nursing care. A process is a series of steps or acts that lead to accomplishment...

Fundamentals of Nursing 2nd Lecture Dr. Motasem AlDaieflih RN, MSN,PhD  Nursing Process The nursing process is a systematic ,rational method of planning and providing nursing care. A process is a series of steps or acts that lead to accomplishment of some goal or purpose. The purposes of the nursing process are to identify a client's healthcare status, and to actual or potential health problems, to establish plans to meet the identified needs, and to deliver specific nursing interventions to address those needs.  Steps of Nursing Process Assessment. Diagnosis. Planning. Implementation. Evaluation.  Characteristics of Nursing Process Nursing Process is clients-centered. Nursing Process is cyclic and dynamic (The steps of the nursing process build upon each other, but they are not linear. There is overlap of each step with the previous and subsequent steps). Nursing Process is Universally applicable (is designed to be used with clients throughout the life span and in any setting in which a nurse provides care for clients).  Assessment Assessment is the systematic and continuous collection, organization, validation, and documentation of data (information). Assessment is continuous process carried out during all phases of nursing process. All phases of nursing process depend on accurate and complete collection of data.  Types of assessment Initial Assessment. Problem-focused assessment. Emergency assessment. Time –lapsed assessment.  Initial Assessment Performed within specified time after admission to a health care agency. To establish a complete database for problem identification, reference and future comparison. Example: Nursing admission assessment.  Problem – Focused Assessment Ongoing process integrated with nursing care. To determine the status of a specific problem identified in a earlier assessment , and to identify new or overlooked problems. Example: Hourly assessment of client’s fluid intake and output.  Emergency Assessment Performed during any physiologic or psychological crisis of the client. Its purpose is to identify life-threatening problems. Example: Rapid assessment of airway, breathing, circulation during a cardiac arrest.  Time- lapsed reassessment Performed several months after initial assessment. Its purpose is to compare the client’s current status to baseline data previously obtained. Example: Reassessment of the patients in outpatient setting after being discharged.  Components of Nursing Health History Biographic data: Name, Age, Gender, Marital status, Occupation, religion, Education, Income. Chief Complaint: - Is the answer of the patient to question of : “ What brought you to the hospital or clinic. - Should be recorded in patient’s own words. - Example : Patient said: “ I had sever pain in my chest , I was unable to breathe since last night”  Components of Nursing Health History History of present illness: - Onset : When the symptoms started? - Pattern of onset : Gradual or sudden. - Setting: Place where the patient was when the symptom started? - Severity: Mild, Moderate , Severe. - Location. - Quality: characteristics of problem. - Radiation. - Duration. - Palliative and aggravating factors. - Associated symptoms.  Components of Nursing Health History Example of “ History of present illness”: 1) Onset: pain started suddenly last night at 3.30 AM. 2) Setting: patient stated that he was in bed at home when pain started. 3) Location: pain is originated in the chest. 4) Quality: pain is like tightness on the chest. 5) Severity: patient said that pain was severe. 6) Radiation: patient stated that the pain is radiated to left arm and back. 7) Duration: patient stated that the pain was continuous. 8) Palliative factors: patient stated that the pain was slightly decreased with rest. 9) Aggravating factors: patient stated that pain was increasing with movement, and exposure to cold. 10) Associated symptoms: this pain was associated with Dyspnea, and nausea.  Components of Nursing Health History Past History: - Childhood illnesses : Chickenpox, Rubella, measles, rheumatic fever, …..etc. - Childhood immunizations. - Allergies to drugs, animals, food, insects. - Accidents and injuries. - Previous hospitalizations.  Components of Nursing Health History Family History:  Components of Nursing Health History Lifestyle: - Personal habits: include amount, frequency, and duration of substance use (Coffee, Tea, cola, Tobacco). - Diet. - Sleep. - Hobbies. - Daily activities.  Types of data Subjective data ( Symptoms) : data which is only can be described and verified by client himself/herself. Objective data ( Signs): data which can be detected by the observer or the nurse. They can be seen, heard, smelled, felt, and they obtained through observation or physical examination.  Examples of Subjective & Objective Data Subjective data Objective Data “ I feel pain in my chest”. Blood Pressure: 140/90 mmHg. “I drink 2 cups of tea daily” Skin is pale. “I feel weak when I walk tow steps Client cried during interview. forward” Vomited 100 mL green fluid.  Sources of data Primary source: includes only the client. Secondary Source: All sources other than client such as family members, records and reports, laboratory and diagnostic findings, and health care providers.  Data collection methods Observing. Interviewing. Examining.  Observing To observe is to gather data by using the senses. Sense Example of client data Vision Body size, posture, grooming, skin color. Smell Body or breath odors Hearing Lung and heart sounds, bowel sounds, orientation. Touch Skin temperature, pulse rate, muscle strength.  Interviewing Interview: is a planned communication or conversation with purpose to get or give information. Types of interview: - Directive interview: the nurse establishes the purpose of the interview and control the interview. - Nondirective interview: the nurse allow the client to control purposes of the interview. It is better to use a combination of both directive and nondirective in interviewing clients.  Types of Interview Questions Close questions: used in directive interview, and generally requires only “yes” or “No” or short factual answers. - Example: “ What medication did you take?” “ Are you having pain now?” “ How old are you?” “ When did you fall?”  Types of Interview Questions Open questions: used in nondirective interview, ad invites the client to elaborate, discover, discuss, explore feelings and thoughts. - Example: “ What brought you to the hospital?” “ Describe the pain you feel in more details?” “ What would you like to talk about today?”  Factors affecting interview planning Time: nurse need to plan interviews with hospitalized clients when the clients is physically comfortable, free of pain, minimal interruptions by friends and family members. Place: a well-lightened, well-ventilated, moderate sized room, free of noises. Distance: must be neither too small nor too great. It is about 8 -12 inches in Arab countries. Language: The nurse must convert complicated medical terminology to simple language.  Stages of Interview The Opening. The Body. The Closing.  The opening In this stage, the nurse introduces her/himself to the client, and explain the purpose of the interview. Through thus stage , the rapport between nurse and client is established. It can be begin with greeting ( “Good morning, Mr. Salem”) or a self introduction ( “ I am Ibrahim, I am a nursing student”), accompanied by nonverbal gestures such as smile, handshake.  The body In this stage the client communicates what he/she thinks, feels, knows, and perceives in responses to questions of the nurse.  The closing The nurse terminates the interview when the needed information is obtained. The closing is important for maintaining rapport and trust and for facilitating future interactions. Techniques for closing interview: - offer to answer questions : “ do you have any questions?” - conclude by saying: “ well, that’s all I need to know for now?” - Thank the client : “ thank you for your time and help” - Express concern for person's welfare: “ take care of yourself” - Plan for next meeting. - Provide a summary to verify accuracy and agreement.  Organizing data We use nursing and non-nursing models. Non-nursing models such as Maslow hierarchy of needs, and body system models.  body systems model Integumentary system. Respiratory system. Cardiovascular system. Nervous system. Musculoskeletal system. Gastrointestinal system Genitourinary system. Reproductive system Immune system. Do not forget to document every thing you assess