Nursing process, Fundamentals of Nursing

detailed description of nursing process for students from fundamentals of nursing subject

1. Nursing Process Prepared by: Pooja Koirala Lecturer NMCTH

2. Nursing process

3. Nursing process The nursing process is a systematic, rational method of planning and providing individualized nursing care within the scope of nursing practice. It is defined as a systemic way of assessing the patient’s need, planning care, implementation and evaluating the outcome of care given. It is a scientific and problem solving approach used by the nurses to meet the needs of the patient.

4. Principles of nursing process The patient is an individual and needs individualized care. The kind of nursing care required is based on the individual health problem or needs. The patient and those close to him need to participate and be consulted about care to be given.

5. Principles of nursing process cont… The nursing staff needs to communicate more with each other in giving care. The patient is a human being who has worth (value) and dignity (self respect) There are basic needs that must be met. The nursing process is a cyclical and ongoing process

6. Characteristics of nursing process Dynamic Client centered Planned Interpersonal and collaborative Universally applicable Open, flexible Humanistic and individualized Cyclical Outcome focused Emphasizes feedback and validation Use of critical thinking and reasoning

7. Purpose of nursing process Identify a client’s health care status, actual or potential health problems Establish plans to meet the identified needs Deliver specific nursing interventions to address those needs Enhance communication and interpersonal relationship with clients and team members

8. Purpose of nursing process cont… Provides continuity of care by reducing omission and duplication of actions Assists to deliver optimum, need based nursing care to the clients effectively and intelligently. Encourages for identification and utilization of client’s strength

9. Advantages of nursing process For the patient Individualized care: it provides framework for meeting the needs of individual patient. Holistic care: it helps nurses to focus attention on the individual in all aspect of his/her health Participation in the care: it promotes the active involvement of the patient in his/ her health condition. It also stimulates the patient’s commitment to achieve identified goals.

10. For the patient cont…. Continuity of care: nursing process provides a common language for practice that clearly communicates the plan of care to co workers and patients. It strengthens the patient’s commitment to achieve the identified goals. Quality of care: it provides an organized, systematic method of problem solving. It minimizes dangerous errors in care giving.

11. Advantages of nursing process For the nurse: Job satisfaction and professional growth: It enables the nurse to have more control over their own practice. It also enhances the opportunity to use their knowledge and expertise constructively and dynamically Confidence build up: nursing process provides continuous feedback and helps to build up confidence.

12. Advantages for nurse cont… Legal protection: it is an organized, systematic method of problem solving. It also acts as a good record and help in legal protection. Save energy and time: it acts as a means of communication and omits repetition in care.

13. Steps of nursing process

14. Assessment Assessment is the first step of nursing process It is the systematic and continuous collection, organization, validation and documentation of data. Assessment is the deliberate and systematic collection of data to determine a client’s current and past health status and to determine the client’s present and past coping patterns.

15. Assessment Nursing assessment does not focus upon the disease as a medical assessment. Nursing assessments focus on a client’s responses to a health problem. It is based on a broad scientific knowledge, keen observation and purposeful listening. Assessment starts with the admission of patient and continuous while the patient is under the care of nurse

16. 4 types of assessment

17. Purpose of assessment To establish baseline information on the client To determine the client’s risk for dysfunction To determine the client’s strength To provide data for the diagnosis To identify the patient’s problems

18. Methods of assessment Interview (history taking) Physical examination Review of clinical record Consultation

19. Methods of assessment:

20. Components of assessment Data collection Data organization Data validation Documentation

21. Data collection Data are facts or realities either expressed by the patient himself or collected by the health personnel such as the nurse using a systematic method. It is the process of gathering information about a client’s health status Data collection must be both systematic and continuous to prevent the omission of significant data and reflect a client’s changing health status.

22. Types of data Subjective data / symptoms or covert data: It consists of information given by the patient or his relatives to the nurse as in history taking. It is given from the patient’s or relative’s own point of view. Example: “I have a fever”

23. Objective data/ signs / overt data: The information about the person obtained by the nurses through observation or physical examination and tested through the accepted standards. They can be heard, seen, felt or smelled. E.g. discoloration of the skin or blood pressure readings

24. Objective data/ signs / overt data cont… The data are said to be objective because the data are found to be the same by any observer. During the physical examination, the nurse obtains objective data to validate subjective data and to complete the assessment phase of the nursing process.

25. Examples

26. Sources of data Primary sources: A client is the primary source of the data. The information collected from the client is considered to be most reliable, unless the patient is semi conscious, has mental problems. Family members and significant others are considered as the primary source of information for infants and children, critically ill adults, mentally ill patients or patients with reduced cognitive function

27. Secondary source Family members or other supporting persons, other health professionals, records and reports, laboratory and diagnostic analysis and relevant literature. Sources other than patient

28. Methods of data collection Observation Interview / history taking Physical examination

29. History taking History taking is a type of interview that is used to collect relevant data from the patient. Here the information is gained by a physician / nurse by asking specific questions, either to the patient or to other people who know the person. About 80% of the information in the assessment is obtained by history taking

30. Purposes To eliminate confusion about the patient’s identity and obtain the information required for contacting the patient if the need arises To provide with an introduction to the patient and some indication of the habit, life style and beliefs which may be explored in greater depth in the personnel and social history To initiate a relationship based on recognition of the importance of informant’s role in sharing in the care of the patient.

31. Purposes cont… To find out the patient’s condition (present and past) To support for nursing care To support for diagnosis, treatment and management

32. Component of history taking Biological information / patient identification data: Name Age Sex Education Marital status Occupation Religion Provisional diagnosis Ward Bed number Inpatient number (IP no.) Attending doctor Source of information Date of admission (DOA) Date of discharge

33. Procedure of history taking

34. Articles required for history taking Patients chart Pen / pencil

35. Techniques Be dressed neatly and in a culturally acceptable way for the interview Establish rapport with the patient: greet the patient warmly create a friendly and congenial atmosphere make him / her feel secure and free to talk

36. Techniques cont… Introduce yourself in a friendly manner Maintain privacy. Room should be quiet Arrange the seating in such a way that both the patient and nurse are seated at the same level facing each other Show respect to the patient and his ideas. Call the patient as per the social system like dai , vai , buwa , ama

37. Techniques cont… Explain the purpose of the interview to the patient. Indicate the approximate amount of time required for the interview Observe the patient’s non verbal cues such as anger, guilt, frustration, anxiety etc. when she / he is talking

38. Techniques cont… Make conversation at the level of the patient’s understanding Be an attentive listener Maintain eye contact to make the patient feel that you are listening to him / her Do not interrupt him / her in between unless he / she is moving of the point

39. Techniques cont… Use the history taking format to collect the information. Make notes in short sentences and make them brief as possible Keep the data obtained in the interview confidential and share it with the appropriate health team members only

40. Physical examination Physical examination is an important tool in assessing the patient’s health status. About 15% of the information used in the assessment comes from the physical examination. It is performed to collect objective data and to correlate it with subjective data.

41. Physical examination cont… It is a systematic data collection method that uses the senses of sight, hearing, smell and touch to detect health problems The physical examination, thoughtfully performed, should yield 20% of the data necessary for the patient diagnosis and management.

42. Purposes of physical examination To obtain baseline data about the client’s functional abilities To obtain data that will help the nurse establish nursing diagnosis and plan the care To evaluate the physiologic outcomes of health care and thus the progress of a client’s health problem

43. Purposes of physical examination cont… To make clinical judgments on a client’s health status To determine the client’s eligibility (suitable fitness) for health insurance, military service

44. General guidelines / principles for physical examination Mnemonics: WIPER W: wash the hands I: Introduce yourself to the patient P: permission, P: Pain Expose: expose the necessary parts of the patient. Ensure adequate privacy R: Reposition the patient. In this examination the patient should be lying flat with one pillow under the head.

45. General guidelines / principles for physical examination It should proceed in an orderly fashion with a minimum of required position shifts by the patient. Generally cephalocaudal approach is used. In case of infant and child, examination of heart and lungs function should be done before the examination of other body parts, because as the infant starts crying, his / her respiratory and heart rate may change.

46. Anatomica l area Patient Examiner Vital signs, general inspection Sitting or reclining (lie down) Standing before patient or at right bed side Head and neck Sitting Standing before patient Anterior torso (trunk) Sitting Standing before patient initially, later behind the patient Posterior torso Sitting At patient’s side Anterior chest and abdomen Supine Before the patient Male genitalia Standing Before the patient Gait, station, coordination Variable positions Behind the patient Female genitalia Reclinining on examining table, draped, knees flexed, legs adducted, feet in stirrups Sitting on chair at times or standing

47. Equipment required for physical examination A tray containing: Paper bag with cotton swab Sphygmomanometer Flashlight Stethoscope Lubricating jelly Thermometer ,tape measure Oto – opthalmoscope Weighing machine

48. Equipment cont…. Cotton Tongue depressors Tuning fork (128Hs) Rectal gloves Reflex hammer

49. Methods of physical examination A systematic approach should be used while doing physical examination Generally cephalo caudal approach e.g. head to toe approach is used But the flexibility may be used as per the need of the patient.

50. Methods of physical examination cont… The procedure can vary according to the age of the individual, severity of the illness. The preferences often lies on nurse, location of the examination and the agency’s priorities and procedures In children examination of heart and lung’s function may be done before the examination of other body parts.

51. Steps of physical examination Inspection Palpation Percussion Auscultation

52. Inspection It is the visual examination, which by assessing the sense of sight to discover some signs of illness. E.g. The nurse inspects with the naked eyes and with a lighted instrument such as an otoscope . Visual inspection helps to assess moisture, color, texture of the body surfaces as well as shape, size, symmetry of the body Inspection reveal more information than other method

53. Palpation Palpation follows inspection It is the examination of the body using the sense of touch Different parts of the hands are used for different sensations such as temperature, texture of skin, vibration, tenderness etc Finger tips are used for fine tactile details, the back of fingers for temperature and the flat of the palm and fingers for vibrations such as cardiac thrill All the assessable parts of the body should be palpated

54. Palpation cont… Palpation may be either light or deep and is controlled by the amount of pressure applied to the fingers or hand Light palpation is done with the hand parallel to the floor with the fingers together as in palpation of the abdomen The palm lies lightly on the part and the fingers depress the part about ½ inch, 1 cm deep. Light palpation of structure such as abdomen determines the area of tenderness.

55. Palpation cont… Deep palpation is performed by pressing the distal half of the palmer surface of the fingers into the abdominal wall. It is used to examine the condition of organs It also helps to obtain specific information about the mass detected by light palpation.

56. Palpation is used to determine Texture e.g. the hair Vibration e.g. of a joint Position e.g. size, consistency and mobility of organs or masses Distention e.g. of the urinary bladder Pulsation The presence of pain upon pressure

57. Principles of palpation You should have short fingernails You should warm your hands prior to placing them on the patient Encourage the patient to continue to breathe normally throughout the palpation If pain is experienced during the palpation discontinue the palpation immediately Inform the patient where, when and how the touch will occur, especially when the patient cannot see what you are doing

58. Percussion It is the act of striking the body surface to elicit sounds that can be heard or vibrations that can be felt when they are tapped with the fingers. They are of two types Direct percussion Indirect percussion

59. Process of indirect percussion Put the middle finger of her left hand against the body part to be percussed Tap the end joint of this finger with the middle finger of the right hand. Move the right hand from the wrist to tap the left middle finger Give two or three taps at each area to be percussed Compare the sound produced at different areas.

60. Types of sound produced in percussion Tympanic: it is a musical or drum like sound produced from an air filled stomach Resonance: it is a hollow sound such as that produced by lungs filled with air (normal lungs sound) Hyper resonance: it is not produced in the normal body. It is described as booming and can be heard over the emphysematous lungs

61. Dullness: it is the thud like sound produced b dense tissue such as the liver, spleen, heart etc Flatness: it is an extremely dull sound produced by very dense tissue, such as muscle or bone

62. Auscultation Auscultation means listening to the sounds transmitted by a stethoscope. The stethoscope is used to listen to the heart, lungs and bowel sounds Auscultation may be direct and indirect. The stethoscope should be always be placed on naked skin because clothing obscures sounds.

63. Steps of doing physical examination Take clinical measurements like height, weight and vital signs Prepare the patient for physical examination Explaining the purposes and procedure for physical examination Telling the patient how long the examination will take Asking him to urinate Arranging for a quiet, private area for assessment

64. Asking the patient to remove his clothes and giving him a drape to cover Inspect the patient’s general appearance Assess the physical status of the patient in a systematic way by using various methods of physical examination After completing the physical examination, allow the patient to put on his clothes Explain the findings to the patient Record the relevant findings of the physical examination on the patient’s assessment form.

65. Organization data After collecting the data, the data must be organized to make it meaningful. Various methods may be used to organize data Abraham Maslow has given Maslow’s Hierarchy of needs

66. For example Physiological needs: The patient has 39 degree temperature No bowel movement for 2 days Safety and security needs: Worried about surgery Afraid of being along in the room Love and belonging needs: Wife is rooming – in with him I am missing children Self esteem needs “I need to be fed like children” “ I do not think will be able to walk again like children”

67. After collecting data, it should be reviewed for any omissions, incompleteness and inconsistency. If the data is missing go back to the patient and collect the additional data

68. Validation of data Validation is the act of double checking or verifying data to confirm that they are accurate and factual Validating data helps the nurse ensure that assessment information is complete and ensures that objective and related subjective data agree Obtain additional information that may have been overlooked

69. Avoid jumping to the conclusions and focusing in the wrong direction to identify problems

70. Documentation of data To complete the assessment phase, the nurse records the client's data. Accurate documentation is essential to communicate the information of the patient and should include all the data collected data about the client’s health status Data are recorded in a factual manner and not interpreted by the nurse e.g. the nurse records the client’s breakfast intake (objective data) as coffee 240 ml, 1 egg and 1 slice of toast rather than as “appetite good”

71. Thank you