Unit 2 Nursing Process PDF

UNIT – 2 THE NURSING PROCESS NURSING PROCESS BACKGROUND  The nursing process is based on a nursing theory developed by Ida Jean Orlando.  From her observations she learned that the patient must be the central character.  Nursing care needs to be directed at improving outcomes for the...

UNIT – 2 THE NURSING PROCESS NURSING PROCESS BACKGROUND  The nursing process is based on a nursing theory developed by Ida Jean Orlando.  From her observations she learned that the patient must be the central character.  Nursing care needs to be directed at improving outcomes for the patient, and not about nursing goals.  The nursing process is an essential part of the nursing care plan. DEFINITION OF THE NURSING PROCESS:  An organized sequence of problem- solving steps used to identify and to manage the health problems of clients  A systematic, rational method of planning and providing individualized nursing care. PURPOSES OF NURSING PROCESS 1- Identify a client health status and actual or potential health care problems and needs. 2- Establish plans to meet the identifying needs. 3- Deliver specific nursing intervention to meet needs.  CHARACTERISTICS  Systematic o The nursing process has an ordered sequence of activities and each activity depends on the accuracy of the activity that precedes it and influences the activity following it.  Dynamic o The nursing process has great interaction and overlapping among the activities and each activity is fluid and flows into the next activity  Interpersonal o The nursing process ensures that nurses are client-centered rather than task-centered and encourages them to work to enhance client’s strengths and meet human needs  Goal-directed o The nursing process is a means for nurses and clients to work together to identify specific goals (wellness promotion, disease and illness prevention, health restoration, coping and altered functioning) that are most important to the client, and to match them with the appropriate nursing actions  Universally applicable o The nursing process allows nurses to practice nursing with well or ill people, young or old, in any type of practice setting BENEFITS OF NURSING PROCESS  Provides an orderly & systematic method for planning & providing care.  Enhances nursing efficiency by standardizing nursing practice.  Facilitates documentation of care.  Provides a unity of language for the nursing profession.  Stresses the independent function of nurses.  Increases care quality through the use of deliberate actions. 5 STEPS OF THE NURSING PROCESS: 1. Assessment 2. Diagnosis 3. Planning 4. Implementing 5. Evaluating Diagnosis DIAGNOSIS  1ST STEP OF THE NURSING PROCESS ASSESSMENT: Is a systematic collection of facts or data Types of data: 1. Objective data-observable and measurable facts (Signs) Main way to collect objective data: Physical assessment Lab and diagnostic testing Patient record  ASSESSMENT 2. Subjective data-information that only the client feels and can describe (Symptoms)  Primary source - the client’s point of view, Feelings, Perceptions, Concerns  Usually BEST source  Main way to collect subjective data:  Interview with Family & significant others  When patient is a child or impaired adult  Spouses  Consider confidentiality when including friends SUBJECTIVE VS. OBJECTIVE  Example: ❖ Patient comes to the ER because he cannot move his arm, stating, “it happened about an hour ago when headache got worse. Now I’m nauseated and dizzy”. (Subjective) ❖ The nurse takes his vital signs: T 37.9, P 100, BP 170/95, and observes that he cannot move his left arm and his face is flushed. (objective)  ASSESSMENT  Sources of Data  Primary sources  Client  Interview  Physical examination & vital signs  Secondary sources  Family members  Other health care providers  Medical records  test results ASSESSMENT  Step #1 involves Collecting data (from variety of sources) Validating the data Organizing the data Grouping of related information Organization of assessment data into small groups to be analyzed Interpreting the data Documenting the data  ASSESSMENT  Data Collection  Assessment involves taking vital signs (T, P, R , BP & Pain assessment.  Performing a head to toe assessment  Listening to the patient's comments and questions about his health status  Observing his reactions and interactions with others. It involves asking pertinent questions about his signs (observable) and symptoms (Non- observable), and listening carefully to the answers. DATA COLLECTION  Demographics  Medical history  Habits  Medications, allergies  Environmental/familial factors  Potential for injury  Ability to participate in plan of care ASSESSMENT  Types of Assessment: 1. Comprehensive Assessment 2. Focused Assessment 3. Ongoing Assessment  TYPES OF ASSESSMENT 1. Comprehensive assessment “Initial”  Performed on entry to healthcare facility  Information you gather on initial contact with the person to assess all aspects of health status is the Baseline.  Often includes: Health history Physical exam and psychosocial assessment TYPES OF ASSESSMENT 2. Focused Assessment  The data you gather to determine the status of a specific condition.  Occurs after initial assessment and period of time.  Limited in scope  Screening for a specific problem  Short stay TYPES OF ASSESSMENT 3. Ongoing assessment  Follow-up  Monitoring and observation related to specific problems  ASSESSMENT  Observation  Interview  Physical Examination Is a systematic data collection method that uses the senses of sight, hearing, smell, and touch to detect health problems. Four techniques are used: inspection, palpation, percussion, and auscultation A physical assessment may be carried out before, during, or after the health history, depending on a patient’s physical and emotional status and the immediate priorities of the situation. HEALTH ASSESSMENT TECHNIQUES INSPECTION PALPATION PERCUSSION AUSCULTATION  PHYSICAL ASSESSMENT TECHNIQUES 1. Inspection – critical observation “to see”  Take time to “observe” with eyes, ears, nose  Use appropriate lighting  Look at color, shape, symmetry, position  Odors from skin, breath, wound  Provide privacy for client  Expose body areas adequately  Use instruments when appropriate, i.e. otoscope, ophthalmoscope, penlight Inspection is done alone and in combination with other assessment techniques INSPECTION visual examination using sense of sight. It includes observation of patient's  a. Physical appearance  b. Behavior, mood, and emotions  c. General survey and body systems  d. Skin condition, color  e. Body parts- size, shape, position and symmetry  f. Gait and walking patterns  g. Pertinent abnormal findings  EQUIPMENT NEEDED FOR INSPECTION  Natural light- adequate lighting allows the nurse to see clearly body to be examined  Pen light, flashlight- artificial lighting used to illuminate the body parts to be examined  Ophthalmoscope- lighted instrument to visualize the eyes  Otoscope- lighted instrument used to visualize eardrums and external meatus  PHYSICAL ASSESSMENT TECHNIQUES 2. Palpation – using sense of touch  Uses the sense of touch  Back of hand to assess skin temperature  Fingers to assess texture, moisture, areas of tenderness  Assess organ location, size, shape, and consistency of lesions, swelling, masses, and tenderness.  Palpation requires a calm, gentle approach and is used systematically, with light palpation preceding deep palpation and palpation of tender areas performed last.  PALPATION  Body examination using sense of touch. It includes assessment of patient's  a. Skin- elevation, depression  b. Temperature- warmth, cool clammy  c. Presence of- tenderness, mass, pain, pressure, lesions, distention  d. Organ- size, contour, position and consistency  e. Hair texture  f. Pulsation TYPES OF PALPATION   Light Palpation-  We press gently one hand to cause slight depression and feel skin surface  Deep (Bimanual) Palpation- It uses two hands (dominant hands over non- dominant hand) over areas to be palpated EQUIPMENT NEEDED FOR PALPATION  Fingers, palms and finger pads-  It contains nerve endings that is highly sensitive to tactile sensation, pressure and discrimination.  Hands- during palpation must be clean, warm and short (fingernails) PHYSICAL ASSESSMENT TECHNIQUES 3- Percussion – to tap Uses short, tapping strokes on the surface of the skin to create vibrations of underlying organs. It is used for assessing the density of structures or determining the location and the size of organs in the body. PERCUSSION  It includes  Plexor- Third fingtertip on right or dominant hand  -Deliver rapid tap or blow  Pleximeter- distal 3rd finger of the left or non- dominant hand  -Placed against body surface/skin 2 TYPES OF PERCUSSION   Direct Percussion - Nurse strike body surface area to be percussed directly by finger pads. - Example- Sinuses  Indirect Percussion  -Striking another fingers hold against body area examined.  Example- abdominal areas. PERCUSS – TO TAP  Percussion Sounds - elicits 4 percussion notes on selected body surfaces  Flatness (thigh muscle)  Dullness (liver)  Resonance (normal lung)  Tympani (gastric air bubble)  PHYSICAL ASSESSMENT TECHNIQUES 4- Auscultation - listening to sounds produced by the body that are created by movement of air or fluid.  Direct auscultation – sounds are audible without stethoscope (eg. Respiratory wheezes)  Indirect auscultation – uses stethoscope (eg. Bowel, heart and lungs)  AUSCULTATION  Listen sounds produced by the body  To assess the pitch, intensity, duration and quality of sounds  It includes hearing of patient's o Normal sounds  -Chest, bowel, diaphragm, and heart o Abnormal sounds  - murmur, bruit, adventitious breath sounds  ASSESSMENT TECHNIQUES - CONT. AUSCULTATION  Stethoscope – an instrument that uses bell and diaphragm to auscultate body sounds.  Diaphragm –high pitched sounds  Heart  Lungs  Abdomen  Bell – low pitched sounds 36 – Blood vessels