Nursing Process

 

 

Is used to identify diagnose and treat human response to health and illness. Variation of scientific reasoning that allows nurses to organize and systematize nursing practice. Applies to the care of the clients, systems, individual, family, group or community. Allows the nurses to differentiate their practice from that of physicians and other health care professionals.

Assessment

 

Is the deliberate and systematic collection of data to determine a client current and past health status and functional status and determine the client’s present and past coping patterns. To establish database about the clients perceived needs, problems and responses to these problems, related experience. It practices goals, values, expectations held about the health care system. Must be relevant to the patient’s health problems. Assessment is dynamic.

2 steps

1.Collection and verification of data from a primary source (client) and secondar (Family,health professionals, medical records) source. 2.Analysis of all data as a basis for developing nursing diagnosis and an individualized plan of care for the client.

Critical thinking

The nurse systematize relevant knowledge, clinical experience ,critical thinking standards and attitudes and standard of practice simultaneously,

Knowledge

Enable the nurse to ask relevant questions and collect record, history and physical assessment data related tot eh client’s presenting health care needs.

Prior clinical experience

Curiosity, perseverance risk taking and confidence to the nurse client relationship. An overview is usually based on the clients presenting priorities ,..Nurse specialty of practice.

One must be able to differentiate important data from the data mass.

Cue

Information that nurse acquires through use of 5 senses.

2 approaches in conducting a more comprehensive assessment

1. Use a structured data base format base upon an accepted theoretical framework or practice standards, from general to specific. Ex. Gordon's functional health patterns, Agency for health care research and quality’s Conducting a compeehnsive assesment is the problem-oriented approach focuses on the client’s presenting situation.

Organization of data gathering
 

 

The nurse must know which data must be collected, Interactions…during the nurse-client interactions, the nurse continuously process data. The client should present physiological responses that relay information When making judgment the nurse connects sense of experiences to nursing knowledge to ensure accurate reasoning

Data collection
 

 

Must be descriptive, concise and complete, We must encourage our client to tell their story about their sickness with openmindedness, As client begins to reveal data, Nurse must immediately anticipate the need for other questions and considers what the existing data means.. The information is summarized in a short format using medical terms. Confirm the data

Types of data.
Subjective data-client’s perception about their health problems,  Only clients can provide this information Ex.pain,fear

Objective data

 

Observations data are observations or measurements made by the data collector the measurement of objective data is Ex. identification of the size of a localized body rash. based on an accepted standard. Ex. celsius/farenheit.

Sources of data
    

 

Client-best source of information… Family and significant others Health care team members Medical records Other record such as..educational,military,employment records. Literature review Nurse’s experience

Nursing health history
          

Data collected about the client’s current level of wellness, including a review of body system, family and health history Biographical information Reason for seeking health care Client expectations Present illness or health concerns Health history Family history Environmental history Psychosocial history Spirirtual health Review of systems

Methods of Data Collection

  

Interview-organized conversation wit the client. Being introduced to the client Explain each roles Establish sense of caring fro the client Gain insight about the clients worries, Determine client’s goal and expectations of the health care systems Obtain cues about which parts of the data collection phase require further in depth investigation.

Phases of the interview
  

 

1. Orientation phase Introduction to the client, Establishing of trust and confidence of the client. “nurse-client relationship” Enhanced by the professionalism and competence conveyed by the nurse’s attitude, professional manner and appearance a supportive therapeutic relationship with the client.

Working phase

The nurse gather information about the client's health status. The nurses uses interview techniques, communication strategies to gather a comprehensive and complete data base as possible

Termination phase

The interviewer should give clue that the interview is coming to an end. The nurse summarizes the important points and ask the client whether the summary is accurate.

Sign up to vote on this title
UsefulNot useful