The nursing process
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The Nursing Process. ASSESSMENT. Nursing Process. Dynamic, ongoing Facilitates delivery of organized plan of nursing care Involves 5 parts Assessment Diagnosis Planning (goal making) Implementation Evaluation. Assessment. Systematic Deliberate (planned, organized)

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The Nursing Process

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The nursing process

The Nursing Process

ASSESSMENT


Nursing process

Nursing Process

  • Dynamic, ongoing

  • Facilitates delivery of organized plan of nursing care

  • Involves 5 parts

    • Assessment

    • Diagnosis

    • Planning (goal making)

    • Implementation

    • Evaluation


Assessment

Assessment

  • Systematic

  • Deliberate (planned, organized)

  • Collection of information (data)

    • Patient’s current and past health status

    • Functional status

    • Past and present coping patterns


Types of nursing assessments

Types of Nursing Assessments

  • Initial

  • Focused

  • Emergency

  • Time-lapsed


Assessment priorities

Assessment Priorities

  • Health orientation

  • Development stage

  • Need for nursing

  • Practical considerations


2 parts of assessment

2 parts of Assessment

Collection and verification of data from

primary source (the patient)

secondary source (family, health records, other healthcare professionals)

Analysis of data


Assessment purpose

Assessment Purpose

  • Formulate a database about the patient’s

    • Perceived needs

    • Health problems

    • Responses to the problems

  • Extra information about

    • Related experiences

    • Health practices

    • Goals/values/expectations about healthcare system


Critical thinking

Critical Thinking

  • Used by nurse collecting data

  • An active, organized thought process

  • A simultaneous synthesis of nurse’s

    • Knowledge

    • Clinical experience

    • Standards of practice

    • Critical thinking standards and attitudes


Data collection characteristics

Data Collection Characteristics

  • Complete

  • Factual

  • Accurate

  • Relevant


Data collection methods

Data Collection Methods

  • Observation

  • Interview

    • Preparatory

    • Orientation

    • Working

    • Termination

  • Techniques of Physical Assessment


Data collection

DATA COLLECTION

  • Types of Data

    • Subjective

    • What the patient or family member says

    • Goes in “---” (quotation marks)

    • Other sources

      • Health care team members

      • Health record


Data collection1

DATA COLLECTION

  • Objective

  • Observed data (What is not spoken)

  • Findings from physical exam

  • Results from diagnostic or lab tests

  • Information from pertinent nursing or medical literature


Documentation of data

Documentation of Data

  • Clear and concise

  • Appropriate terminology

    • Usually on a designated form

  • Physical assessment

    • Usually by Review of Systems

      • Overview of symptoms

      • Diet

      • Each body system


Data validation

Data Validation

Verifies understanding of information

Comparison with another source

patient or family member

record

health team member


Data interpretation

Data Interpretation

Process of inferential reasoning and judgment (critical thinking)

  • Interpretation of what information is relevant to present status

  • Summary of data

  • Provides focus for nursing attention


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