Nursing process
A critical thinking process that professional nurses use to apply the best available evidence to caregiving and promoting human functions and responses to health and illness.
Nursing Process Five Steps
Def. Fundamental blueprint for how to care for a patient. "Standard of Practice"
1. Assessment - Collection, verification, and analysis of data.
2. Diagnose - identify the patient's problems
3. Plan- Set goals of care and desired outcomes and id appropria
Assessment
Def. The deliberate and systematic collection of information about a patient to determine his or her current and past health and functional status and his or her present and past coping patterns.
Nursing Assessment includes two steps:
1. Collection of inf
Database
The purpose of assessment is to establish a database about the patient's perceived needs, health problems, and responses to these problems. In addition, the data reveal related experiences, health practices, goals, values, and expectations about the healt
Data Collection
Gather information (assessment) to make an accurate judgment about a patient's current condition.
Your information comes from:
1. The patient, through interview, observations, and physical examinations
2. Family members or significant others' reports and
Cue
Information that a nurse obtain through the use of the senses (hearing, visual observations, touch, and smell).
Inference
Your judgment or interpretation of the cues
Example: A patient crying is a cue that possibly implies fear or sadness
Observational overview using cues and forming inferences.
Male patient in bed, looks uncomfortable. Patient presents with discomfort in surgical area.
Cues
- Lies still with arms along sides; tense
- States has not turned for some time
- Reports pain a 7 on a scale of 0 to 10
Inferences
- Pain is severe
- Pain l
11 Functional health patterns
An example of a structured database format, one approach to perform a comprehensive assessment. Gordon's functional health patterns model offers a holistic framework for assessment of any health problem. The health patterns are listed below.
1. Health perception-health management pattern
Describes patient's self-report of health and well-being; how patient manages health. Example: frequency of health care provider visits, adherence to therapies at home; knowledge of preventative health practices
2. Nutritional-metabolic pattern
Describes patient's daily/weekly pattern of food and fluid intake. Example: food preferences or restrictions, special diet, appetite; actual weight, weight loss or gain
3. Elimination pattern
Describes pattern of excretory function. Example: bowel, bladder, and skin
4. Activity-exercise pattern
Describes patterns of exercise, activity, leisure, and recreation; ability to perform activities of daily living
5. Sleep-rest pattern
Describes patterns of sleep, rest, and relaxation.
6. Cognitive-perceptual pattern
Describes sensory-perceptual patterns; language adequacy, memory, decision-making ability
7. Self-perception-self-concept pattern
Describes patient's self-concept pattern and perceptions of self. Example: self-concept/worth, emotional patterns, body image
8. Role-relationship pattern
Describes patient's patterns of role engagements and relationships
9. Sexuality-reproductive pattern
Describes patient's patterns of satisfaction and dissatisfaction with sexuality pattern; patient's reproductive patterns; premenopausal and postmenopausal problems
10. Coping-stress tolerance pattern
Describes patient's ability to manage stress; sources of support; effectiveness of the patterns in terms of stress tolerance
11. Value-belief pattern
Describes patterns of values, beliefs including spiritual practices, and goals that guide patient's choices or decisions
Example of problem-focused patient assessment: Pain
1. Nature of Pain - Describe your pain for me. Place your hand over the area that hurts or is uncomfortable. Observe nonverbal cues, observe where patient points to pain; note if it radiates or is localized
2. Precipitating factors - Do you notice if pain
Types of Data:
Subjective data- Patients' verbal descriptions of their health problems. Includes feelings, perceptions, and self-report of symptoms.
Once a patient provides subjective data, explore findings further by collecting objective data.
Objective data- Observati
Sources of Data:
Patient- (Best Source) when conscious, alert, and able to answer questions.
Family & Significant others- (Primary sources of information for infants or children; critically ill adults; and the mentally handicapped, disoriented, or unconscious)
Health Care
Data Collection/ Interview Techniques
Open-ended questions- prompts patients to describe a situation in more than one or two words.
Back Channeling- Active listening technique that prompts a respondent to continue telling a story or describe a situation. Involves use of phrases such as "Go on
Methods of Data Collection
Patient-centered Interview: an approach for obtaining from patients the data that are needed to foster a caring nurse-patient relationship, adherence to interventions & treatment effectiveness.
1. Setting the stage-
Example: greet using patient by full na
Nursing health history
You gather a nursing health history during either your initial or early contact with a patient. Major part of assessment. Includes biographical information, reason for seeking health care, patient expectations, present illness or health concerns, health h
Biographical Information
Factual demographic data about the patient. The patient's age, address, occupation and working status, marital status, source of health care, and types of insurance are included. Admitting office staff usually collects this information.
Reason for Seeking Health Care
(aka Chief Concern)This is the information you gather when you initially set an agenda during the patient-centered interview. Compare what you learn from the patient with the "chief complaint", which is often typed on the patient's admission sheet. Ask th
Patient Expectations
Patient's understanding of why he or she is seeking health care. The assessment of patient expectations is not the same as the reason for seeking medical care, although they are often related. Failure to identify a patient's expectations of health care pr
Present Illness or Health Concerns
Essential and relevant data about the nature and onset of symptoms. If a patient presents with an illness, collect essential and relevant data about the symptoms and their effects on the patient's health. Apply the critical thinking intellectual standards
Health History
Health care experiences and current health habits and lifestyle patterns.
Family history
To determine whether the patient is at risk for illnesses of a genetic or familial nature and identify areas of health promotion and illness prevention.
Environmental history
Patient's home and work, focusing on determining the patient's safety.
Psychosocial history
Reveals the patient's support systems and coping mechanisms.
Spiritual Health
Represents the totality of one's being.
Review of systems (ROS)
A systematic approach for collecting the patient's self-reported data on all body systems.
Physical examination
An investigation of the body to determine its state of health. Techniques used: Inspection, palpation, percussion, auscultation, and smell.
Examination includes: patient's height, weight, vital signs, and a head-to-toe examination of all the body systems.
Interpreting Assessment Data:
You determine the presence of abnormal findings.
Recognize that further observations are needed to clarify information.
Begin to identify the patient's health problems.
The patterns of data reveal meaningful and usable clusters.
Data cluster- A set of sig
Validation of Assessment Data
The comparison of data with another source to determine data accuracy. Compare with unclear interview information and physical examination findings.
Common practices related to Documentation
Documentation should be timely, thorough, and accurate.
Record all observations.
Pay attention to facts and be descriptive.
Record objective information in correct, accurate terminology.
Do not generalize or form judgements.