Nursing Process

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Nursing Process

• Assessment
• Raquel D. Esguerra RN, MAN, CCRN

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Overview of the Nursing Process
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Characteristics of the Nursing Process

• Data from each phase provides input to the next
  phase (cycle, dynamic, constantly changing)
• It is client centered
• It is an adaptation of problem solving and
  systems theory. Parallel but separate from the
  process used by physicians. The medical process
  focuses on physiologic systems and disease
  processes, whereas the nursing process is
  directed towards a clients responses to disease
  and illness
• Decision making is involved in every phase of the
  nursing process. Facilitates individualization
  of the nurses plan of care

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Assessment

• Assessing is a systematic and continuous
  collection, organization, validation, and
  documentation of data (information)
• Data must be
• relevant
• collected
• documented

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Purpose of Assessment

• To establish a database concerning a clients
  physical, psychosocial and emotional health in
  order to identify health promoting behaviors as
  well as actual and/or potential health problems.

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Types of Assessment

• Initial assessment
• Problem-focused assessment
• Emergency assessment
• Time-lapsed assessment

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Assessment
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Sources of Data
Types of Data
Data Collection
Data Collection Methods
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Data Collection

• The process of gathering information about a
  clients health status
• Database all the information about the client
  which includes
• Nursing health history
• Physical assessment
• Physicians history and health examination
• Results of lab. diagnostic tests
• Past history current medical problems

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Types of Data

• Objective data or overt data are signs
  detectable by an observer, can be seen, heard,
  felt, smelled and they are obtained by
  observation or physical examination
• Examples discoloration of skin, BP reading
• Subjective data or covert data are symptoms
  that are apparent only to the person affected and
  can be described or verified only by that person
• Pain, anxiety

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Sources of Data

• Client
• Support People
• Client records
• Health care professionals
• Literature

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Data Collection Methods

• Observing
• Interviewing
• Approaches
• Directive
• Nondirective
• Types of interview questions
• Open-ended questions
• Neutral question
• Leading question
• Planning the interview
• Time
• Place
• Seating arrangement
• Distance
• language
• Examining

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• Non
• Nursing
• Models
• Body Systems Model
• Maslows hierarchy of Needs
• Develop-mental Theories

• Nursing
• Conceptual
• Models
• Gordons Functional Health Patterns
• Orems Self-care Model
• Roys Adaptation Models

Organize Data
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Clarify
Make a comparison
Avoid inferences
Validate Data
Double check data
Use references
Consider all factors
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Accurate
Timely
Complete
Document Data
Legible
Accepted Terminology
Concise
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Exam 2

• 8 items Legal Aspects of Nursing
• 9 items Values, Ethics, Advocacy
• 8 items Critical Thinking, Assessing
• 5 items Dosage Calculation
• 10 items Medical Terminology
• (Matching type)
• 10 items True/False

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Study Guide

• Legal Aspects
• Sources, Types of Laws
• Informed Consent
• Impaired Nurse
• Six Elements of Nursing Malpractice
• Legal Responsibilities for Students
• Values, Ethics, Advocacy
• Personal vs. Professional Values
• Values of Nursing
• Steps to Clarify Values
• Moral vs. Ethical Values
• Making Ethical Decisions
• Advocacy

• Critical Thinking, Assessing
• Case Scenarios
• The Nursing Process
• Assessment
• Medical Terminology
• Most common suffix, prefix
• Dosage Calculation
• Temperature Conversion
• Grams-mg-mcg
• Ml tsp tbsp
• Formula for dosage Calculation

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