nursing process l.
Download
Skip this Video
Loading SlideShow in 5 Seconds..
Nursing Process PowerPoint Presentation
Download Presentation
Nursing Process

Loading in 2 Seconds...

play fullscreen
1 / 31

Nursing Process - PowerPoint PPT Presentation


  • 121 Views
  • Uploaded on

Nursing Process. Ch 11. What Is It?. Framework = method = formula Systematic approach Dynamic Interpersonal Patient-centered Goal-oriented. Steps (Parts). Assessing Diagnosing Planning Implementing Evaluating. Quote . . .

loader
I am the owner, or an agent authorized to act on behalf of the owner, of the copyrighted work described.
capcha
Download Presentation

PowerPoint Slideshow about 'Nursing Process' - dutch


An Image/Link below is provided (as is) to download presentation

Download Policy: Content on the Website is provided to you AS IS for your information and personal use and may not be sold / licensed / shared on other websites without getting consent from its author.While downloading, if for some reason you are not able to download a presentation, the publisher may have deleted the file from their server.


- - - - - - - - - - - - - - - - - - - - - - - - - - E N D - - - - - - - - - - - - - - - - - - - - - - - - - -
Presentation Transcript
what is it
What Is It?
  • Framework = method = formula
  • Systematic approach
  • Dynamic
  • Interpersonal
  • Patient-centered
  • Goal-oriented
steps parts
Steps (Parts)
  • Assessing
  • Diagnosing
  • Planning
  • Implementing
  • Evaluating
quote
Quote . . .
  • Nurses are responsible for a unique dimension of healthcare – “ the diagnosis and treatment of human responses to actual or potential health problems”
evolution
Evolution
  • In 1960s nursing recognized as distinct entity
  • 1973 the ANA Congress developed Standards of Practice
  • Ongoing reassessments and revisions
trends
Trends
  • Initially plans of care were long and handwritten
  • Today’s care plans are
    • Standardized
    • Computerized
    • Focus on similarities between illnesses, etc
problem solving
Problem Solving
  • Combination of
    • Trial-and-error
    • Scientific process
    • Intuition
purpose
Purpose
  • Provide patient care that is
    • Scientific
    • Holistic
    • Creative
critical thinking
Critical Thinking
  • Ability to
    • identify a problem
    • analyze it
    • develop a response
    • follow through
  • Based on
    • experience
    • Knowledge
    • Intuition
critical thinking cont d
Critical Thinking, cont’d.
  • “…active, organized, cognitive process used to carefully examine one’s thinking and the thinking of others.”
  • Involves use of MIND
    • Form conclusions
    • Make decisions
    • Draw inferences
    • reflect
c t characteristics
C. T. Characteristics
  • Independent thinker
  • Fair-minded
  • Intellectually humble
  • Intellectually courageous
  • Good faith & integrity
  • Curious & persevering
  • Disciplined
  • Creative
  • Confident
4 types
4 Types
  • Initial
    • Shortly after contact with patient
    • Most facilities have specific time-frames
    • Establishes database for development of plan
slide15
Focused
    • Gathers data about specific problem
    • May be part of initial assessment, but more often is not
  • Emergency
    • Identifies life-threatening problems
  • Time-Lapse
    • Compares current to previous data
data collection
Data Collection
  • Consider
    • time
    • needs of patient
    • developmental stage
    • physical surroundings
    • past and present coping patterns
data characteristics
Data Characteristics
  • Complete
  • Factual
  • Accurate
  • Relevant
data sources
Data Sources
  • Subjective
    • Patient
      • Primary source
      • Usually BEST source
    • Family & significant others
      • When patient is a child or impaired adult
      • Spouses
      • Consider confidentiality when including friends
data sources cont d
Data Sources, cont’d
  • Objective
    • Observed data (What is not spoken)
    • Findings from physical exam
    • Results from diagnostic or lab tests
    • Information from pertinent nursing or medical literature
objective sources cont d
Objective Sources cont’d.
  • Patient record
    • H & P
    • Laboratory
    • Consultations
    • X-ray, CT, PT/OT, other ancillary departments
data collection21
Data Collection
  • Demographics
  • Medical history
  • Habits
  • Meds, allergies
  • Environmental/familial factors
  • Potential for injury
  • Ability to participate in plan of care
data collection22
Data Collection
  • Physical assessment
    • Usually by Review of Systems
      • Overview of symptoms
      • Diet
      • Each body system
interview
Interview
  • Planned
    • Consider schedule of tests
    • Patient preferences
    • Family or visitor presence
interview phases
Interview Phases
  • Preparatory
  • Introduction
  • Working
  • Termination
interview phases25
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
Phases cont’d.
  • Introduction
    • Nurse introduces self
    • Identifies purpose of interview
    • Ensure confidentiality of information
    • Provide for patient needs before starting
phases cont d27
Phases cont’d.
  • Working
    • Nurse gathers info for subjective data
    • Excellent communication skills are needed
      • Active listening
      • Eye contact
      • Open-ended questions
phases cont d28
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
data validation
Data Validation
  • Verifies understanding of information
  • Comparison with another source
  • patient or family member
  • record
  • health team member
data documentation
Data Documentation
  • Clear and concise
  • Appropriate terminology
    • Usually on a designated form
  • Physical assessment
    • Usually by Review of Systems
      • Overview of symptoms
      • Diet
      • Each body system
documentation
Documentation
  • 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 – describe - e.g. patient is being ornery should be patient resists instruction or patient states “Don’t talk to me, I don’t care about that”