Scribd
Upload
465 views

Nursing Process ASSESSMENT Lecture Notes PDF

The nursing process is a systematic, rational method for planning and providing nursing care. It consists of 5 phases: assessment, diagnosis, planning, implementation, and evaluation. During the assessment phase, nurses collect client data through various methods such as observation, interviews, and examination. Data is organized according to functional health patterns. The nurse then validates and documents the data.

Uploaded by

iqra shezadi
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as PDF, TXT or read online on Scribd
465 views

Nursing Process ASSESSMENT Lecture Notes PDF

The nursing process is a systematic, rational method for planning and providing nursing care. It consists of 5 phases: assessment, diagnosis, planning, implementation, and evaluation. During the assessment phase, nurses collect client data through various methods such as observation, interviews, and examination. Data is organized according to functional health patterns. The nurse then validates and documents the data.

Uploaded by

iqra shezadi
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as PDF, TXT or read online on Scribd
You are on page 1/ 7

NURSING PROCESS

- systematic, rational method of planning and providing nursing care.


-refers to a series of phases describing the practice of nursing.

PURPOSES:
1. To identify client’s health status and actual or potential health care problems or needs.
2. To establish plans to meet the identified needs, and to
3. Deliver specific nursing intervention to meet those needs.

5 PHASES/ STEPS OF NURSING PROCESS (ADPIE)


1. ​A​-SSESSMENT
2. ​D​-IAGNOSIS/ ANALYSIS
3.​ P​-LANNING
4. ​I​- MPLEMENTATION/ INTERVENTION/ INTERVENING
5. ​E​-VALUATION

CHARACTERISTICS OF NURSING PROCESS


*C​yclic and Dynamic- each phase provide input into the next phase
>CYCLIC​- regularly repeated events
>DYNAMIC-​ continuously changing
*C​lient centered- organize plan of care according to client’s problem
*U​niversally Applicable- used as framework for nursing care
*F​ocus on problem solving
*I​nterpersonal collaborative- communicate in client, families, etc.
*U​se of critical thinking- very important in nursing process

1. ASSESSMENT (COVD)
-collection, organization, validation and documentation of data.
-is a continuous process carried out during all phases of the nursing process.

* 4 TYPES OF ASSESSMENT (IPET)

TYPE TIME PURPOSE EXAMPLE


I-​NITAL ASSESSMENT -after admission -complete database -nursing admission
assessment

P​-ROBLEM FOCUSED -ongoing process -determine specific -hourly I&O in pt


problem status in ICU
E​-MERGENCY –during physiologic/ -identify life -assess ABC
psychological crisis threatening problems -suicidal
tendencies

T​-IME LAPSED -several months after -compare current -reassessment


initial assessment status to baseline data

a) C-ollection of Data
-gathering info. about a client’s health status
*DATABASE​- all information about a client
includes: -​nursing health history​ (Biographical Data, Present Health/ Illness, Past History,
Family History, Psychosocial History, Review of Body Systems)
-physical assessment
-primary care providers history and physical examination
-results of laboratory and diagnostic tests
-material contributed by other health personnel

*TYPES OF DATA (SOCV)


1. S-UBJECTIVE DATA​- also called as ​Symptoms/ Covert Data
-verified only by the patient
ex. pain, itching, feelings of worry, sensation, feelings, values, beliefs, attitudes
2. O-BJECTIVE DATA​- also called as ​Signs/ Overt Data
-measurable and observable
ex. discoloration of the skin, BP 120/80, Temperature 41 degree Celsius
3. C-ONSTANT DATA​- does not change over time
ex. blood type, race
4. V-ARIABLE DATA​- can change quickly
ex. vital signs, age, level of pain

*​SOURCES OF DATA
1. Primary Source​- client best source of data
2. Secondary​ support people, client records, healthcare professionals, literature
*Support People​- useful if pt is too young, too ill, confused
*Client Records-​ ​medical records, therapy and laboratory records
*Healthcare professionals​-​ nurses, social workers, primary health providers <sharing
information among professionals ensure continuity of care
*Literature-​ review of nursing/ related literature, journals

*DATA COLLECTION METHODS (OIE)


1. O-bservation​ –gather data by using senses
Vision-​ overall appearance, facial/ body gestures, skin color/lesions
Smell-​ body/ breathe odors
Hearing-​ lung sounds, heart sounds, bowel sounds, ability to communicate
Touch-​ skin temperature, skin moisture, muscle strength, pulse rate, palpatory lesions

2. Interviewing​ -planned communication


-conversation with a purpose get information, identify problem, teach,
provide support and therapy and counseling

*2 TYPES OF INTERVIEW
1. Directive​- nurse controls, get specific information
- used when time is limited (emergency situation)
2. Non Directive​- rapport building interview
- client control the interview
*RAPPORT​- understanding between two or more people

*TYPES OF INTERVIEW QUESTION (CONL)


1. Closed Questions- ​require only yes or no
-give short, factual answers giving specific information
>W questions Who? What? When? Where?
2. Open Ended Question- ​invite client to discover, explore, elaborate feelings and thoughts
>What? How?
3. Neutral Question​-client can answer without direction and pressure; open-ended and non
directive
>How? Why?
4. Leading Question-​client has less opportunity to decide whether the answer is true or not;
closed ended/directive
>Aren’t you? Won’t you?

*PLANNING THE INTERVIEW AND SETTING (TP SA DL)

CONSIDER:​ TIME, PLACE, SEATING ARRANGEMENT, DISTANCE, LANGUAGE

1. T​IME​- ​when client is physically comfortable and free from pain


-minimal interruptions

2. P​LACE​-​ well lighted, well ventilated


-free of distractions
-place where others cannot overhear or see client
3. S​EATING ARRANGEMENT- *client in bed- 45 degree angle to bed
*initial admission- overbed table between
*standing and looking down at a client can be intimidating

4. D​ISTANCE- neither too small or too far


-pts feel uncomfortable when talking to someone who is too close or too far away
-2 to 3 feet during interview
-also varies in ethnicity
8-12 inches-​ Arab 24 inches-​ Britain
18 inches-​ US 36 inches-​ Japan

5. L​ANGUAGE-convert medical terminology into common English usage


-interpreters/ translators if nurse don’t speak the same language or dialect

*STAGES OF AN INTERVIEW (OB C)

1. Opening-​most important part


-establish ​RAPPORT​ that will create trust and goodwill (greeting, self-introduction)
-orient the interviewee (purpose, what info. needed, how long it will take, how info. will be
used)

2. Body- ​client communicates what he/she thinks, feels, knows, perceives


-nurse use communication techniques that make both parties feel comfortable

3. Closing-​terminates interview when needed information has been obtained


-important for maintaining trust/ rapport and for facilitating future interactions

TECHNIQUES TO CLOSE THE INTERVIEW


 
1. Offer to answer questions (​do you have any questions?)
2. Conclude​ ( Well, that’s all I need to know for now)
3. Thank the client​ (Thank you for your time and help)
4. Express concern​ (Take care of yourself)
5. Plan for next meeting​ (I’ll be here to see you on Monday)
6. Summary/ Summarize​ (Let's review what we have just covered in this interview…)
3. Examining-​systematic data collection​ ​method that uses observation to detect health
problems
-major method used in physical health assessment

TECHNIQUES: (IPPA)

I-nspection ​assessing by the use of sense of sight


P-alpation examination​ by sense of touch using fat pads of the finger
P-ercussion​ tapping body part to produce sounds
A-uscultat​ion ​listening to body sounds with the use of stethoscope

3 WAYS OF EXAMINING

1. Cephalocaudal​- “head to toe approach”


head-neck-thorax-abdomen-extremities-toes
2. Body System- ​respiratory system, circulatory system, nervous system, etc.
3. Screening examination- “​review of systems”
-brief review of essential functioning (nursing admission assessment form)

b) O-rganizing data
-nurses use an organized assessment framework.

*11 Typology of Functional Health Pattern (Gordon)


1.Health perception/ Health Management​-describes the clients perceived pattern of health
and well-being and how health is managed.
2.Nutritional/ Metabolic Pattern-​describes client’s pattern of food and fluid consumption.
3.Elimination Pattern​-describes pattern of excretory function (bowel, bladder and skin).
4.Activity-Exercise Pattern​-describes pattern of exercise, activity, leisure and recreation.
5.Sleep-Rest Pattern-​describes pattern of sleep, rest and relaxation
6.Cognitive-Perceptual Pattern​-describes sensory-perceptual and cognitive patterns.
7.Self Perception/ Self Concept Pattern-​describes client’s self concept and perception of self
pattern (self-worth, comfort, body image, feeling state).
8.Role-relationship Pattern​-describes pattern of participation and relationship.
9.Sexuality-reproductive Pattern-​describes client’s pattern of satisfaction and dissatisfaction
with sexuality patterns; describes reproductive patterns.
10.Coping/ Stress- tolerance Pattern-​describes client’s general coping pattern and
effectiveness of pattern in terms of stress tolerance.
11.Values-beliefs Pattern-​describes patterns of values, beliefs and goals that guide the client’s
choices or decisions.
*Abraham Maslow’s Hierarchy of Needs

c) V-alidating Data​-​ double checking or verifying data to ensure that it is accurate and
factual
(C2 D2 R)
C-​ompare- subjective vs. objective
C​-larify- ambiguous/ vague statement
D-​ouble check- extremely abnormal data
D-​etermine factors that may interfere accurate measurement
R-​eferences- explain phenomena
*differentiate CUES from INFERENCES!
CUES​- are subjective or objective data that can be directly observed by the nurse
INFERENCES-a​ re the nurse’s interpretation or conclusion based on the cues

d) D-ocumenting Data
-​data are recorded in a factual manner and not interpreted by the nurse.
-for example, the nurse must record the client’s intake as “coffee 240 ml, juice 120 ml, 1 egg
and 1 slice of toast” rather than as “appetite good” or “normal appetite” a judgment​.
F-​actual
A-​ctual
T-​imely

You might also like