Nursing process,,,Assessment

NURSING PROCESS INTRODUCTION AND PHASE 1 ASSESSMENT

1. NURSING PROCESS INTRODUCTION

2. INTRODUCTION Defined by “hall” in 1955 1967 Yura And Walsh proposed four elements of nursing process Assessment Planning Implementation and Evaluation

3. PURPOSES To identify a client health status and 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

4. DEFINITION The nursing process is a systematic, rational method of planning and providing nursing care. The nursing process is cyclical ,that is its components follow a logical sequence , but more than one components may be involved at one time.

5. COMPONENTS Assessment Nursing diagnosis Planning Implementing and Evaluating

6. CHARACTERISTICS Dynamic Client centered Planned Interpersonal and collaborative Universally applicable Can focus on problems and strength

7. CHARACTERISTICS Open and flexible Humanistic and individualized Cyclical Outcome focused Emphasizes feedback and validation

8. BENEFITS Continuity of care Prevention of duplication Individualized care Standards of care Increased client participation Collaboration of care

9. STEPS OF NURSING PROCESS

10. ASSESSMENT

11. Assessment Assessing is the systematic and continuous collection , organization , validation and documentation of data (information) as compared to what is standard norm. It is continuous process. All phases of nursing process depend on the accurate and complete collection of data.

12. Purposes of assessment To establish a data base To identify health‐promoting behaviors To identify actual and/or potential health problems

13. Types of assessment Initial assessment Problem focused assessment Emergency assessment Time lapsed assessment

14. INITIAL ASSESSMENT:- It is done within specified time after admission to Hospital Pur p ose : T o e st abl i s h a c omp le t e d a t a bas e f or problem identification, reference and future comparison Eg: Admission assessment PROBLEM FOCUSED ASSESSMENT :- Ongoing process integrated with nursing care Purpose : To determine the status of specific problem identified in an earlier assessment Eg: Hry assessment of clients fluid intake and urinary output in an ICU

15. EMERGENCY ASSESSMENT: - During any physiologic or psychologic crisis of the client Pur p ose : To identify the threatening problem and to identify new or overlooked problem Eg: Rapid assessment of person’s airway and breathing status and circulation during a cardiac arrest TIME LAPSED REASSESSMENT :- Several months after initial assessment Purpose : To compare the clients current status to baseline data previously obtained Eg: Reassessment of the clients functional health patterns in a home care or outpatient setting or in a hospital at shift change.

16. Steps of assessment/activities in assessment phase Collect data Organize data Validate data Document data

17. Collection of data It is the process of gathering information a client’s health status Systematic and continuous Reflect the clients changing health status Needs client and nurse active participation

18. Data can be………

19. Described by only the person who affected Included client sensations ,feelings, beliefs ,attitudes and perception of health status Eg:- Itching Pain Feelings of worry Referred to as signs or overt data Related on observer Can be measured or tested Eg:- Discoloration of skin Blood pressure Temprature

20. Methods of data collection Observing Interviewing Examining

21. Observing Observation is conscious, deliberate skill that is developed through effort and with an organized approach. Eg:- Using the senses to observe client data Methods observation : Vision Smell Hearing Touch Aspects of data : Noticing data Selecting, organizing and interpreting the data

22. Interviewing An interview is a planned communication or a conversation with a purpose Eg: Nursing health history Approaches of an interview: Direct interview Indirect interview Types of interview questions: Closed questions ( Are you having pain now?) Open ended question (what brought you to hospital?) Neutral questions (how do you feel about that?) Leading questions (you are stressed about surgery tomorrow aren't you?)

23. Interviewing Planning the interview and setting: Time Place Seating arrangement Distance Language Stages of an interview The opening and introduction The body or development The closing

24. Examination Techniques Inspection Palpation Percussion Auscultation Physical examination can be, Cephalocaudal approach Screening examination Review of systems

25. Organizing data The nurses use a written (or computerized) format that organizes the assessment data systematically Conceptual models or frame works Nursing models or frame work Gordon's functional health pattern Orem’s self care model Roy’s adaptation model Wellness model Non nursing models Body system model Maslow’s hierarchy of needs Developmental theories

26. Orem’s self care model……

27. Body system model………….

28. Maslow’s hierarchy of needs……….

29. Validating data Validation is the act of “double checking "or verifying the data to confirm that it is accurate and factual.

30. Documenting data Assessment data must be recorded and reported. Accurate and complete record communicates information to health care team.

31. Thank you