NURSING

PROCESS

Presented by: Dave Jay S. Manriquez RN.

THE NURSING PROCESS

A systematic problem-solving approach used to identify, prevent and treat actual or potential health problems and promote wellness.

Nursing process

A systematic way to plan, implement and evaluate care for individuals, families, groups and communities.

Characteristics of the Nursing Process Dynamic Client-centered Planned Interpersonal and collaborative Universally applicable Can focus on problems or

strengths

Open, flexible

Humanistic and individualized

Cyclical

Outcome focused ( results oriented)

Emphasizes feedback and validation

STEPS IN NURSING PROCESS

AssessmentNursing DiagnosisPlanningImplementationEvaluation

AssessmentAssessmentAssessmentAssessment

Nursing Nursing DiagnosiDiagnosiss

Nursing Nursing DiagnosiDiagnosiss

PlanningPlanningPlanningPlanningImplementatiImplementationonImplementatiImplementationon

EvaluationEvaluationEvaluationEvaluation

Nursing ProcessNursing Process Nursing ProcessNursing Process

Benefits of using the nursing process

Continuity of care Prevention of duplication Individualized care Standards of care Increased client participation Collaboration of care

EVALUATION

IMPLIMENTATION

PLANNING

ASSESSMENT

DIAGNOSIS

INTER RELATIONSHIP BETWEEN THE STEPS OF NURSING PROCESS

ASSESSMENT

Assessment Assessing is a continuous process

carried out during all phases of nursing process. All phases of the nursing process depend on the accurate and complete collection of data.

Assessing is the systematic and continuous collection, organization, validation and documentation of data.

- Potter and Perry( 2006)

Assessment is the deliberate and systematic collection of data to determine a clients current and past health status and to determine the clients present and past coping patterns

- Carpenito 2000  Assessment is the systematic and

continuous collection, validation and communication of patient data. - Carol Taylor

 

Types of Assessment 1. Initial Assessment: Performed within specified time after

admission to a health care agency  Eg. Nursing Admission Assessment  2. Problem Focused Assessment: Ongoing process integrated with

nursing care to determine specific problem identified in an earlier assessment and to identify new or overlooked problems.

  E.g.. Assessment of clients ability to perform self-care while

assisting client to bathe.   3. Emergency Assessment: Done during psychiatric or physiological

crisis of the client to identify life threatening problems  Eg. Rapid assessment of airway, breathing and circulation

during cardiac arrest  4. Time lapsed-Reassessment: Done several months after initial

assessment to compare the clients status to baseline data previously obtained.

Assessment

ASESSMENT

Collect dataOrganize dataValidates DataDocument data

DIAGNOSIS

PLANNING

IMPLIMENTATION

EVALUATION

1.COLLECTION OF DATA

Data Collection is the process of gathering information about a clients health status.

Collection of Data: 

Data base: A data base is all information about a client. It includes the nursing health history, physical assessment, the physician’s history, physical examination, results of laboratory and diagnostic tests and material contributed by other health personnel.

   

Medical vs. Nursing Assessments

Medical assessments Target data pointing to pathologic

conditions

Nursing assessments Focus on the patient’s response to

health problems

Types of Data: 

SUBJECTIVE DATA: Also referred to as symptoms or covert data are apparent only to the person affected and can be described or verified only by that person

  Eg. Itching, Pain, Feelings of worryOBJECTIVE DATA: Also referred to as signs or overt

data. These are detectable by an observer or can be measured or tested against an accepted standard.

  They can be seen, heard, felt or smelled and they

are obtained by observation or physical examination  Eg. A Blood Pressure Data Discolouration of the Skin 

Objective Data vs. Subjective Data Objective data

Observable and measurable data that can be seen, heard, or felt by someone other than the person experiencing them

E.g., elevated temperature, skin moisture, vomiting

Subjective data Information perceived only by the affected person E.g., pain experience, feeling dizzy, feeling

anxious

Sources of Data:

Primary Source (Direct Source

client: Usually BEST source

Secondary Source (Indirect Source) Family Members

Client’s records 1. Medical Records Eg. Medical History, Physical Examination, Operation notes, Progress notes, Consultation done by Physicians 2. Records of therapies done by other health professionals

Eg. Social Workers, Dieticians, Physical Therapist 3. Laboratory Records Other health care professionals Verbal reports

Literature

Data Collection

Consider time needs of patient developmental stage physical surroundings past and present coping patterns

Data Characteristics

Complete

Factual

Accurate

Relevant

Data collection methods

OBSERVATION

INTERVIEWING

PHYSICAL ASSESSMENT

Observation To gather data using senses

Eg: laboured breathing, pallor or flushing,pain

a lowered side rail ,functioning of an equipment , pt environment and people in it etc…

Interviewing An interview is

a planned communication or a conversation with a purposeTypes of questions and SettingRapport are important

Collection of Health History

Four Phases of a Nursing Interview

Preparatory phase

Introduction

Working phase

Termination

Interview Phases

Preparatory Nurse collects background info

from previous charts Ensure environment is conducive Arrange seating

3 – 4 ft apartInterviewer at 45° angle to patient

Allow adequate time

Phases cont’d.

IntroductionNurse introduces selfIdentifies purpose of interviewEnsure confidentiality of information

Provide for patient needs before starting

Phases cont’d.

WorkingNurse gathers info for subjective

dataExcellent communication skills

are neededActive listeningEye contactOpen-ended questions

Phases cont’d.

TerminationInform patient when nearing end of interview

Ensure patient knows what will happen with info

Offer patient chance to add anything

Physical assessment Appraisal of health

status

Usually by Review of Systems

Overview of symptoms

Observable, measurable data

Objective data Possible approaches—body systems,

head to toe, or functional health patterns

Methods of physical assessment Inspection Percussion Palpation Auscultation

Problems Related to Data Collection Inappropriate organization of the

database Omission of pertinent data Inclusion of irrelevant or duplicate data,

erroneous or misinterpreted data Failure to establish rapport and

partnership Recording an interpretation of data

rather than observed behavior Failure to update the database

2.ORGANISING DATA

Nurses uses a written or computerized format for arranging he data systematically

3.VALIDATING DATA

VALIDATING -THE ACT OF DOUBLE CHECKING

Verifies understanding of information

Comparison with another source -patient or family member -record -health team member

4. DOCUMENTING DATA

Record in permanent record ASAPUse patient’s own words in

subjective data – enclose in “ ___” (quotation marks)

Avoid generalizations – be specific

Don’t make summative statements

Thank you