Nursing Process - Presentation Transcript NURSING PROCESS "the cornerstone of the nursing profession" HISTORY The term nursing

process and the framework it implies are relatively new. In 1955, Hall originated the term (care, cure,core), 3 steps: note observation, ministration, validation Johnson (1959), Nursing seen as fostering the behavioral functioning of the client . Orlando (1961), identified 3 steps: client s behavior, nurse s reaction, nurse s action. Nursing process set into motion by client s behavior Weidenbach (1963) were among the first to use it to refer to a series of phases describing the process. Wiche (1967) Nursing is define as an interactive process between client and nurse . 4 steps: Perception, Communication, Interpretation, Evaluation. Yura and Walsh (1967) suggested the 4 components APIE. Knowles (1967) described nursing process as: discover, delve, decide, do, discriminate.

American Nurses Association Published standards of nursing practice. Diagnosis distinguished as separate step of nursing process (1973) Published Nursing a Social Policy Statement. Diagnosis of actual and potential health problems delineated as integral part of nursing practice (1980) Published Standard of Clinical Nursing Practice. Outcome identification differentiated as a distinct step of the nursing process. Therefore, the six steps of the nursing process are as follows: A.D.OI.P.I.E. (1991). What is a Process? It is a series of planned actions or operations directed towards a particular result or goal. It is a systematic, rational method of planning and providing individualized nursing care. Nursing Process The Nursing Process Is the underlying scheme that provides order and direction to nursing care. It is the essence of professional nursing practice.

It has been conceptualized as a systematic series of independent nursing actions directed toward promoting an optimum level of wellness for the client. It is cyclical; the components follow a logical sequence, but more than one component may be involved at any one time. Purpose of Nursing Process To identify a client s health status, actual or potential health care problems or needs, to establish plans to meet the identified needs, and to deliver specific nursing interventions to meet those needs. It helps nurses in arriving at decisions and in predicting and evaluating consequences. It was developed as a specific method for applying a scientific approach or a problem solving approach to nursing practice. Nursing Process... Organized Systematic Goal-Oriented Humanistic Care Efficient Effective PHASES OF THE NURSING PROCESS Assessment Diagnosis Outcome Identification Planning

Implementation Evaluation ASSESSMENT To establish baseline information on the client. To determine the client s normal function. To determine the client s risk for diagnosis function. To determine presence or absence of diagnosis function. To determine client s strengths. To provide data for the diagnostic phase. Activities of Assessment COLLECT DATA VALIDATE DATA ORGANIZE DATA RECORDING DATA Assessment involves reorganizing and collecting CUES: Objective (overt) Subjective (covert) Types of Assessment Initial Assessment

- initial identification of normal function, functional status and collection of data concerning actual and potential dysfunction. Focus Assessment - status determine of a specific problem identified during previous assessment. Time Lapsed Reassessment - comparison of client current status to baseline obtained previously, detection of changes in all functioning health problems after an extended period of time . Emergency Assessment - identification of life threatening situation. Clinical Skills used in Assessment Observation act of noticing client cues. *looking, watching, examining, scrutinizing, surveying, scanning, appraising. *uses different senses: vision, smell, hearing, touch. Interviewing interaction and communication. Physical Examination INSPECTION PERCUSSION

AUSCULTATION INTUITION - defined as insights, instincts or clinical experiences to make judgment about client care. 4 PHASES OF INTERVIEW: Preparatory Phase (Pre-interaction) Introductory Phase (Orientation) Maintenance Phase (Working) Concluding Phase (Termination) COMMUNICATION A process in which people affect one another through exchange of information, ideas, and feelings. Documentation/Recording is a vital aspect of nursing practice. Include both oral and written exchange of information between caregivers.

Modes of Communication Verbal Communication - Uses spoken or written words. Non-verbal Communication - Uses gestures, facial expression, posture/gait, body movements, physical appearance (also body language), eye contact, tone of voice. Characteristics of Communication SIMPLICITY - commonly understood words, brevity, and completeness CLARITY - exactly what is meant TIMING and RELEVANCE - appropriate time and consideration of client s interest and concerns ADAPTABILITY - adjustment depending on moods and behavior CREDIBILITY - worthiness of belief

Components of Communication sender (encoder) message receiver (decoder) response (feedback) Documenting & Reporting DOCUMENTATION - Serves as a permanent record of client information and care. REPORTING - takes place when two or more people share information about client care NURSING DOCUMENTATION : the charting of documents, the professional surveillance of the patient, the nursing action taken in the patient s behalf, and the patient s programs with regards to illness. Purposes of Client s Record /Chart Communication Legal Documentation Research Statistics Education Audit and Quality Assurance Planning Client Care

Reimbursement TYPES OF RECORDS Source Oriented Medical Record traditional client record FIVE BASIC COMPONENTS: Admission sheet Physician s order sheet Medical history Nurse s notes Special records and reports B. Problem-oriented medical record (POMR) - arranged according to the source of information. FOUR BASIC COMPONENTS: Database Problem list Initial list f orders or care plans Progress notes: Nurse s notes

(SOAPIE) Flow sheets Discharge notes or referral summaries KARDEX Concise method of organizing and recording data. Readily accessible to health care team. Series of Flip cards Ensure continuity of care Tool for change of shift report For planning & communication purposes. Parts of a Kardex Personal Data Basic needs Allergies Diagnostic tests Daily Nursing Procedures Medications and IV therapy, BT. Treatments like O 2 , steam inhalation, suctioning, change of dressings, mechanical ventilation.

Characteristics Of Good Recording BREVITY. USE OF INK / PERMANENCE. ACCURACY. APPROPRIATENESS. COMPLETENESS & CHRONOLOGY / ORGANIZATION / SEQUENCE / TIMING. USE OF STANDARD TERMINOLOGY. SIGNED. In case of ERROR. CONFIDENTIALITY. LEGAL AWARENESS. LEGIBLE. DO NOT use the word PATIENT or PT in the chart. A HORIZONTAL LINE drawn to fill up a partial line. REPORTING CHANGE-OF-SHIFT REPORTS OR ENDORSEMENT. -for continuity of care / health care needs. TELEPHONE REPORTS.

-provide clear, accurate, & concise information -includes: when, who made/was, whom, what info given/received. TELEPHONE ORDERS. - RN s duty, must be signed w/in 24 hours. TRANSFER REPORTS - from one unit to another. Some Legal Significance of CHARTING Chart Accurately Chart Objectively Chart Promptly Make No Mention of an Incident Report in the Chart Write Legibly and Use Only Standard Abbreviations THIRTEEN CHARTING RULES Write Neat and Legibly Use Proper Spelling and Grammar Write with Blue or Black Ink and Use Military time Use Authorized Abbreviations Transcribe Orders Carefully

Document Complete Information About Medication Chart Promptly Never Chart Nursing Care or Observation Ahead of Time. Clearly Identify Care Given by Another Member of the Health Care Team. Don t Leave Any Blank Spaces on Chart Forms. Correctly Identify Late Entries. Correct Mistaken Entries Properly. Don t Sound Tentative Say What You Mean. SIX More Charting Rules Don t Tamper with Medical Records. Don t criticize other Health Care Professionals in the chart. Don t Document any Comments that a patient or family member makes about a potential lawsuit against a health care professional or the hospital. Eliminate bias from written descriptions of the patient. Precisely document any information you report to the doctor. Document any potentially contributing patient acts. How to Document Non-Compliance

Refusing to comply with dietary restrictions. Getting out of bed without asking help. Ignoring follow-up appointments at the clinic, emergency department, out-patient or doctor s office. Leaving against medical advice (AMA) Abusing or refusing to take medications. Personal Items at the Bedside Your notes should contain a description of what was found and how you disposed of it. TAMPERING w/ MED. EQUIPMENT Document what you saw the patient doing or what you believe he s doing. SIX PHASES NURSING PROCESS con't. ASSESSMENT To establish data base. Sources of Data: Primary: Patient / Client

Secondary: Family members, SOs, Record/Chart, Health team members, Related Lit. Approaches to Collecting Data for Assessing Client s Health: ABDELLAH S 21 Nursing Problems DOROTHEA OREM S Components of Universal Self-Care GORDON S Functional Health Patterns Correlating a Body Systems Physical Examination with Data Gathered by Functional Health Area. ABDELLAH s 21 Nursing Problems: To promote good hygiene and physical comfort. To promote optimal activity, exercise, rest and sleep. To promote safety through the prevention of accident, injury, or other trauma and through the prevention of the spread of infection. To maintain good body mechanics and prevent and correct deformities. To facilitate the maintenance of a supply of oxygen to all body cells. To facilitate the maintenance of nutrition of all body cells.

To facilitate the maintenance of eliminations. To facilitate the maintenance of food and electrolyte balance. To recognize the physiological responses of the body to disease conditions pathological, physiological, and compensatory. To facilitate the maintenance of regulatory mechanisms and functions. To facilitate the maintenance of sensory functions. To identify and accept the positive and negative expressions, feelings, and reactions. To identify and accept the inter-relatedness of emotions and organic illness. To facilitate the maintenance of effective verbal and non-verbal communication. To promote the development of productive interpersonal relationships. To facilitate progress toward achievement of personal spiritual goals. To create/or maintain a therapeutic environment.

To facilitate awareness of self as an individual with varying physical, emotional, and developing needs. To accept the optimum goals in the light of physical and emotional limitations. To use community resources as an aide in resolving problems arising from illness. To understand the role of social problems as influencing factors in the cause of illness. Dorothea Orem s Components of Universal Self-Care Maintenance of sufficient intake of air, water and food. Provision of care associated with elimination process and excrements. Maintenance of a balance between solitude and social interaction. Prevention of hazards to life, functioning and well-being. Promotion of human functioning and development within social groups in accord with potential known limitations and the desire to be normal. GORDON S FUNCTIONAL HEALTH PATTERNS Health Perception Health Management Pattern

- describes client s perceived pattern of health and well being and how health is managed. Nutritional Metabolic Pattern - describes pattern of food and fluid consumption relative to metabolic need and pattern indicators of local nutrient supply. Elimination Pattern - describes pattern of excretory function (bowel, bladder, and skin) Activity Exercise Pattern - describes pattern of exercise, activity, leisure, and recreation. Cognitive Perceptual Pattern - describes sensory, perceptual, and cognitive pattern Sleep Rest Pattern - describes patterns of sleep, rest, and relaxation. 7. Self-perception Self-concept Pattern - describes self-concept and perceptions of self (body comfory, image, feeling state) Role Relationship Pattern - describes pattern of role engagements

and relationships. Sexuality Reproductive Pattern - describes client s pattern of satisfaction and dissatisfaction with sexuality pattern, describes reproductive patterns. Coping Stress Tolerance Pattern - describes general coping patterns and effectiveness of the pattern in terms of stress tolerance. Value Belief Pattern - describes pattern of values and beliefs, including spiritual and /or goals that guide choices or decisions. DIAGNOSING Clinical act of identifying problems. Identify health care needs. Prepare diagnostic statements. Uses critical thinking skills of analysis and synthesis. (PRS PES) ACTIVITIES: - organize cluster or group data. - compare data against standards. - analyze data after comparing with standards.

- identify gaps / inconsistencies in data. - determine health problems, risks, and strengths. - formulate Nursing Diagnosis. Outcome Identification refers to formulating and documenting measurable, realistic, client-focused goals. PURPOSES: To provide individualized care To promote client participation To plan care that is realistic and measurable To allow involvement of support people ESTABLISH PRIORITIES!!! Classification of NURSING DIAGNOSIS: High priority - life threatening and requires immediate attention. Medium priority - resulting to unhealthy consequences. Low priority - can be resolve with minimal interventions.

Characteristics of Outcome Criteria: S - SPECIFIC M - MEASURABLE A - ATTAINABLE R - REALISTIC T - TIME FRAMED CAN BE SHORT TERM OR LONG TERM GOAL. PLANNING Involves determining beforehand the strategies or course of actions to be taken before implementation of nursing care. To be effective, involve the client and his family in planning! IMPLEMENTATION Putting nursing care plan into ACTION! To help client attain goals and achieve optimal level of health. Requires: Knowledge, Technical skills, Communication skills, Therapeutic Use of Self. ..SOMETHING THAT IS NOT WRITTEN IS CONSIDERED AS NOT DONE!!! EVALUATION

IS ASSESSING THE CLIENT S RESPONSE TO NURSING INTERVENTIONS. COMPARING THE RESPONSE TO PREDETERMINED STANDARDS OR OUTCOME CRITERIA. FOUR POSSIBLE JUDGMENTS: The goal was completely met. The goal was partially met. The goal was completely unmet. New problems or nursing diagnoses have developed. Characteristics of NURSING PROCESS Problem-oriented. Goal oriented. Orderly, planned, step by step. (systematic) Open to new information. Interpersonal. Permits creativity. Cyclical. Universal.

Benefits of the NURSING PROCESS: for the Client QUALITY CLIENT CARE CONTINUITY OF CARE PARTICIPATION BY CLIENTS IN THEIR HEALTH CARE Benefits of the NURSING PROCESS: for the Nurse CONSISTENT AND SYSTEMATIC NURSING EDUCATION. JOB SATISFACTION. PROFESSIONAL GROWTH. AVOIDANCE OF LEGAL ACTION. MEETING PROFESSIONAL NURSING STANDARDS. MEETING STANDARDS OF ACCREDITED HOSPITALS. HEART OF THE NURSING PROCESS KNOWLEDGE SKILLS - manual, intellectual, interpersonal. CARING - willingness and ability to care. Willingness to CARE

Keep the focus on what is best for the patient. Respect the beliefs / values of others. Stay involved. Maintain a healthy lifestyle. CARING BEHAVIORS Inspiring someone / instilling hope and faith. Demonstrating patience, compassion, and willingness to persevere. Offering companionship. Helping someone stay in touch with positive aspect of his life. Demonstrating thoughtfulness. Bending the rules when it really counts. Doing the little things Keeping someone informed. Showing your human side by sharing stories

The Nursing Process - Presentation Transcript THE NURSING PROCESS Objectives: At the end of 3 hours, the student should be able to: Define nursing process State importance of nursing process in nursing profession State and define interrelated phases of nursing process Be able to identify subjective and objective data gathered Be able to formulate nursing diagnosis according to NANDA using the nursing process NURSING PROCESS The cornerstone of the nursing profession Includes: ADOPIE Assessment, Diagnosis, Outcome identification, Planning, Implementation and Evaluation NURSING PROCESS IS: ORGANIZED & SYSTEMATIC 6 sequential and interrelated steps HUMANISTIC

The plan of care is developed and implemented with great consideration to the unique needs and concerns of the individual client It is individualized It involves aspect of human dignity EFFICIENT Relevant to the needs of the client Promotes client satisfaction and progress EFFECTIVE Utilizes resources wisely in terms of human, time, cost resources THE HEART OF THE NURSING PROCESS Knowledge broad, varied Skills K knowledge; S skills; C - caring A. MANUAL B. INTELLECTUAL C. INTERPERSONAL TECHNICAL SKILLS CRITICAL THINKING careful deliberate, goal-directed to solve problems/make decisions check for evidence

Keeping an open mind Avoid jumping into conclusions TO ESTABLISH POSITIVE INTERPERSONAL RELATIONSHIPS, WITH CLIENT, CO-WORKERS (REQUIRES COMMUNICATION SKILLS) CARING WILLINGNESS AND ABILITY TO CARE UNDERSTANDING OURSELVES To be able to understand others To be more objective / non-judgmental Requires ability to listen empathetically Listen with intent Enter into another s way of thinking and viewing the world Connecting with another s feelings and perception Identify with another s struggles, frustrations and desires Being able to detach from feelings and returning to our own frame of reference WILLINGNESS TO CARE Keep the focus on what is best for the patient Respect beliefs / values of others Stay involved

Maintain a healthy lifestyle CARING BEHAVIORS Inspiring someone / instilling hope and faith Demonstrating patience, compassion and willingness to persevere Offering companionship Helping someone stay in touch with positive aspect of the life Demonstrating thoughtfulness Bending the rules when it really counts Doing the little things Keeping someone informed Showing your human side by sharing stories

ASSESSMENT Collecting, validating, organizing and recording data about the client s health status (individual, family, community) PURPOSE: To establish a data base ACTIVITIES: COLLECTING DATA:

Gathering information. Include the physical, psychological, emotional, socio-cultural, and spiritual factors TYPES OF DATA: SUBJECTIVE DATA (SYMPTOMS) - experienced by the client - EX. Pain, dizziness, OBJECTIVE DATA (SIGNS) - those that can be observed and measured - EX. Pallor, diaphoresis, blood pressure, reddish urine, body temp. METHODS OF COLLECTING DATA: INTERVIEW. Planned purposeful conversation OBSERVATION. (use of senses, lab results interpretation, physical examination) SOURCE OF DATA: PRIMARY: Patient/ Client SECONDARY: Family members, S.O., patient s chart/record, health team members, related literature

VERIFYING / VALIDATING DATA. Make sure your information is accurate. ORGANIZING DATA. Cluster facts into groups of information (subjective and objective information) Let s review! SUBJECTIVE OR OBJECTIVE??? Headache Temp 37.9 C RR: 20 bpm Toothache Client states, I haven t moved my bowel since Friday (3 days). Cyanosis Urine output: 60ml Ate only half of the food served DIAGNOSING Is a process which results to a diagnostic statement or nursing diagnosis The clinical act of identifying problems

It means to analyze assessment and derive meaning from this analysis. PURPOSE: To identify the client s health care needs and to prepare diagnostic statements NURSING DIAGNOSIS Is a statement of client s potential or actual alteration of health status. Uses critical thinking and skills analysis Uses PRS/PES format P- PROBLEM R-RELATED TO FACTORS S- SIGNS AND SYMPTOMS P-PROBLEM E-ETIOLOGY S-SIGNS AND SYMPTOMS ACTIVITIES DURING DIAGNOSING: Organize cluster or group data. Ex. Pallor, dyspnea, weakness, fatigue pertain to problems with oxygenation Compare data against standards (accepted norms). Ex. Amber, clear urine VS cloudy urine or tea colored urine.

Analyze data after comparing with standards Identify gaps and inconsistencies in data Determine the client s health problems, health risks, strengths Formulate Nursing Diagnosis statements Examples of Nursing Diagnoses: Anxiety related to insufficient knowledge regarding surgical experience Ineffective airway clearance related to tracheobronchial infection as manifested by weak cough, adventitious breath sounds, and copious green sputum production. Types of Nsg. Diagnoses: ACTUAL NURSING DIAGNOSIS A judgment about the client s response to a health problem that is present at the time of nursing assessment Based on the presence of signs and symptoms Ex. - ALTERED COMFORT: PAIN - PAIN: SEVERE HEADACHE RELATED TO FEAR OF ADDICTION TO NARCOTICS RISK NURSING DIAGNOSIS

A clinical judgment that a problem does not exist, but the presence of risk factors indicates that a problem is likely to develop Ex. RISK FOR INFECTION RISK FOR CONSTIPATION POSSIBLE NURSING DIAGNOSIS Is one in which evidence about a health problem is unclear or the causative factors are unknown. Requires more data either to support or to refute it. Ex. Possible Social Isolation related to unknown etiology COMPONENTS of a NANDA NURSING DIAGNOSIS PROBLEM (diagnostic label) and DEFINITION Describes the client s health status clearly and concisely in a few words Qualifiers: Deficient inadequate in amount, quality, or degree; not sufficient Impaired made worse, weakened, damaged Ineffective not producing the desired effect ETIOLOGY (related factors & risk factors)

Identifies one or more probable causes of health problem Gives direction to what health needs to attend to. DEFINING CHARACTERISTICS A cluster of signs and symptoms that indicate the presence of a particular diagnostic label ACTUAL DX: signs and symptoms HIGH RISK/ RISK: factors that cause the client to be more vulnerable to the problem Ex. ACTIVITY INTOLERANCE RELATED TO IMMOBILITY as manifested by verbal reports of fatigue or weakness during leg exercises Formulating statements: Problem Etiology format Problem etiology signs and symptoms format OUTCOME IDENTIFICATION Refers to formulating and documenting measurable, realistic, client focused goals. Provides the basis for evaluating nursing diagnosis and interventions. ACTIVITIES INCLUDE:

ESTABLISH PRIORITIES. Life-threatening should be given highest priority ABC s (airway, breathing, circulation) Maslow s hierarchy of needs (physiologic needs over psychosocial) Unstable clients vs. clients with stable conditions Actual problems vs. potential concerns ESTABLISH GOALS & OUTCOME CRITERIA GOALS: broad statements SHORT-TERM GOAL (STG) LONG-TERM GOAL (LTG) OUTCOME CRITERIA: specific, measurable, realistic statements of goal attainment S M A R T Specific, measurable, attainable, time-framed Ex. GOAL: The client will be able to improve mobility and the ability to bear weight on left leg DESIRED OUTCOMES:

By the end of the week, client will be able to ambulate with crutches By end of the month, client will be able to stand without assistance PLANNING Involves determining beforehand the strategies or course of actions to be taken before implementation of nursing care. Involve the client and his family Begins with the first client contact until client is discharged from the facility Activities: Plan nursing interventions (also called nursing orders); may be dependent, independent, interdependent. Write nursing care plan a written summary of the care that a client is to receive. the blueprint of the nursing process the plan of care is a step-by-step process evidenced by the following: Sufficient data are collected to support nsg. Diagnoses At least one goal must be stated for each nsg. dx

Outcome criteria must be identified for each goal Each intervention should be supported by scientific rationale Evaluation.To assess whether goals are met or unmet. TYPES OF PLANNING Initial planning Starts upon initial assessment/admission Ongoing planning Done by all nurses who work with the client to: Determine change in the health status. Set priorities for the client s care during the shift. Decide which problems to focus on during the shift. Plan nursing activities during the shift. Discharge planning The process of anticipating and planning for needs after discharge. Includes: ff. up care, referrals, medications, diet modifications, significant other/care provider, health teachings, which signs and symptoms to watch for. IMPLEMENTATION

Putting the nursing care plan into action Purpose: to carry out planned nursing interventions to help the client attain goals and achieve optimal level of health Activities: Set priorities. To determine the order in which nsg interventions are carried out. Perform nsg. Interventions Record actions. SOMETHING THAT IS NOT WRITTEN IS CONSIDERED NOT DONE!!! EVALUATION Is assessing the client s response to nsg intervention and then comparing the response to predetermined standards or outcome criteria. Purpose: To appraise the extent to which goals and outcome criteria of nsg care have been achieved Activities: Collect data about the client s response Compare response to goals and outcome criteria Assess whether goals are met (partially/completely) or unmet

Analyze reasons for outcomes Modify care plan as needed BENEFITS OF THE NURSING PROCESS FOR THE CLIENT Quality client care. It meets standards of care. Continuity of care. Participation by the clients in their health care. BENEFITS OF THE NURSING PROCESS FOR THE NURSE Consistent and systematic nursing education Job satisfaction Professional growth Avoidance of legal action Meeting professional nsg standards Meeting standards of accredited hospitals

NURSING PROCESS - Presentation Transcript NURSING PROCESS Ms.JEENA AEJY 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 Assessment Nursing Diagnosis Planning Implementation Evaluation Nursing Process Assessment Nursing Diagnosis Planning Implementation Evaluation 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 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 data Organize data Validates Data Document 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 worry OBJECTIVE 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 purpose Types of questions and Setting Rapport 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 apart Interviewer at 45 angle to patient Allow adequate time Phases cont d. Introduction Nurse introduces self Identifies purpose of interview Ensure confidentiality of information Provide for patient needs before starting Phases cont d. Working Nurse gathers info for sub jective data Excellent communication skills are needed Active listening Eye contact

Open-ended questions Phases cont d. Termination Inform 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 asessment 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 ASAP Use patient s own words in subjective data enclose in ___ (quotation marks) Avoid generalizations be specific Don t make summative statements Thank you