Nursing process assessment

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1. NURSING PROCESS RATHEESH R L

2. INTRODUCTION The nursing process provides a useful description of how nursing should be performed. Practice of nursing is caring which is directed by the way the nurses view the client, the client’s environment, health and the purpose of nursing.

3. DEFINITION The nursing process is a professional nurses approach to identify, diagnose, and treat human response to health and illness. American Nurses Association

4. Nursing process is a systematic, rational method of planning and providing individualized nursing care.

5. The nursing process is a series of organized steps designed for nurses to provide excellent care.

6. The purpose of nursing process To identify client’s health status, actual or potential healthcare problems or need. To establish plans to meet the identified needs and to deliver specific interventions to meet those needs. It provides a framework in which to practice nursing.

7. Benefits of Nursing Process Improves the quality of care that the client receives Ensures a high level of client participation together with continuous evaluation designed to meet the client’s unique needs Enables nurses to use time and resources efficiently to both their own and their client’s benefit.

8. Characteristics of a nursing process: Dynamic and cyclic Patient centered Goal directed Open and Flexible Problem Oriented Planned Universally accepted Interpersonal and collaborative Holistic Systematic

9. Dynamic and Cyclic The dynamic nature involves continuous assessment and evaluation of changing client’s responses to nursing interventions so as to achieve the outcomes. Client-centered The plan of care is organized in terms of client problems rather than nursing goals. The nurse-client relationship is shaped around the needs of the client.

10. Planned and Goal-directed Interventions are considered according to the nursing diagnoses and are based on scientific principles rather than tradition. Universally Applicable Nursing process can be used with clients of any age, with any medical diagnosis, and at any point on the wellness-illness continuum.

11. Problem-oriented Care plans are organized according to client’s problems. Interventions are carried out to eliminate the problems related to any aspect of an individual. Cognitive Process Nursing process involves the use of intellectual skills in making judgments, decisions and eliminating client’s problems.

12. FACTORS AFFECTING NURISNG PROCESS Knowledge Skill Beliefs

13. Knowledge: Nursing process is the application of the nurses knowledge. As part of her/his academic preparation nurse learns basic concepts of biochemistry, biophysics, microbiology, anatomy, physiology, psychology, sociology, and nutrition.

14. The knowledge of these sciences enables the nurse to recognize the problem more clearly and also determine how the client’s health is getting disturbed.

15. Skills: Nurse uses technical and interpersonal skills to collect information about the client. The effectiveness of the nursing process depends on the intellectual (cognitive) skills of the nurse that she uses in creative and critical thinking, and decision making.

16. Beliefs: The nurse’s personal belief about nursing, health, the client as an individual, as a health care consumer forms the basis of nursing practice. The nurse is also faced with a moral and ethical dilemma of providing care to such a client and his family members.

17. Components of Nursing Process Assessment Nursing Diagnosis Planning Implementation Evaluation

18. steps of the Nursing Process

19. Assessment “Let me look at that.” “Tell me about it.”

20. Assessment Assessment is the deliberate and systemic collection of data to determine client current and past health status and copping pattern

21. Assessment Assessment (Data Collection) = Observation + Interview + Examination

22. Components of Assessment: Collection of data Verification of data Organization of data Recording of data

23. Types of Data Subjective Data: These are client’s perception about their health problem. e.g. pain Objective Data: These data are observable and measurable by data collector e.g. Vital signs

24. Primary Sources Primary sources are usually defined as first hand information or data that is generated by witnesses or participants in past events.

25. Secondary data Secondary data is the data that have been already collected by and readily available from other sources. 

26. Sources of data: Primary Sources : Client 2. Secondary sources: Family & significant others Health care team members Medical records Other records Literature review Nurses experience

27. Method of data collection Observation Interview technique It is a organized conversation with the client or family members to obtain the current health information regarding patient. Physical examination Laboratory tests Review of the records, books & related literature

28. Observation It is the action or process of closely observing or monitoring something or someone.

29. Interview technique It is a organized conversation with the client or family members to obtain the current health information regarding patient. Phases of Interview: Orientation phase Working phase Termination phase

30. Orientation phase It begins with the nurse’s introduction with client which includes the nurse’s name, position and explanation of purpose of the interview. The nurse client relationship is enhanced by the professionalism and competence conveyed by the nurse’s attitude, manner & appearance

31. Working phase During the working phase of the interview the nurse gather information about the client’s health status. Nurse use variety of communication strategies such as listening, paraphrasing, focusing, summarizing & clarifying to facilitate communication and ensure that nurse & client clearly understood each other.

32. Termination phase This phase also require skill on the part of the interview . The client should be given a clue that the interview is coming to an end. e.g. There are just two more questions or We will be finished within 5 to 6 minutes This approach also gives the client an opportunity to ask questions. The interview terminated in a friendly manner

33. Elements for effective interview: Clear goal Aware about background of the client Self introduction Choose strategy Maintain rapport Confidentiality Recovery Closure

34. Types of Interview Technique: Open ended questions: It prompts clients to describe a situation in more that one or two words. This questions give chance to client to speak freely. e.g. What do you know about your condition? How do you feel in hospital?

35. Close ended questions: It prompts client to give answer in only one or more words e.g. Do you have pain? How many time you go for toilet?

36. Physical examination It is a medical examination to determine a person's bodily fitness.

37. Validation of Data Data validation to be done to ensure its accuracy Validation of collected data involves comparing the data with other sources

38. Organization of data Clustering of data & arrangement in a systematic and logical order which gives clue for nursing diagnosis e.g. Anger is a cue for the diagnosis for anxiety, fear

39. Recording/ DOCUMENTATION of data Documentation should be concise, thorough and accurate Documentation depends upon the institutional policy It is descriptive in nature