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DefinitionâŚ
Nursing Process is a critical thinking process that professional
nurses use to apply the best available evidences to caregiving and
promoting human functions and responses to health and illness
(American Nurses Association, 2010)
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â˘Introduction Nursing process is a systematic method
of providing care to clients.
⢠The Nursing process is a systematic method of
planning and providing individualized nursing care
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Purposes of nursing process
â˘To identify a clientâs health status and actual or
potential health care problems or needs.
â˘To establish plan to meet the identified need
â˘To deliver specific nursing interventions to meet those
needs
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Characteristics of Nursing Process:
â˘Cyclic
â˘Dynamic nature
â˘Client entredonnes
â˘Focus on problem solving and decision making
â˘Interpersonal and collaborative style
â˘Universal applicability
â˘Use of critical thinking and clinical reasoning.
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Definition:
Assessment is the systematic and continuons collection,
organization, validation, and documentation of data
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ď Types of assessment
The four different types of assessment are:
1) Initial nursing assessment
2) Problem-focused assessment
3) Emergency assessment
4) Time-lapsed reassessment
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1. Initial nursing assessment:
performed within specified time after admission.
To establish a complete database for problem
identification.
Example: Nursing admission assessment
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ď 2.Problem-focused assessment,
To determine the status of specific problem identification in
earlier assessment
Example: hourly checking of vital signs of fever patient.
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3.Emergency assessment:
During emergency situation to identify any life
threatening situation.
Example: rapid assessment of individualâs airway,
breathing status, and circulation during .a cardiac
arrest
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4. Time-lapsed reassessment: several months after initial
assessment to compare the clientâs current health status with
the data previously obtained.
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Collection of data
Data collection is the process of gathering information
about a clientâs health status. It includes the health history,
physical examination, results of laboratory and dignostic
tests, and material contributed by other health personnel.
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â˘Types of data
two types: subjective data and objective
SUBJECTIVE: Base on what the patient says
OBJECTIVE : Base on your observation, laboratory data
and vitals signs
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â˘Subjective, also referred to as symptoms or covert data, are
clear only to the person affected and can be describe only by
that person.
Itching, pain, and feeling of worry are examples of subjective
data
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Objective data, also referred to as signs or overt data, are
detectable by an observer or can be measured or tested
against an accepted standard.
They can be seen, heard, felt, or smelled, and they are
obtained by observation or physical examination.
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Sources of data
sources of data are primary or secondary.
Primary: it is the direct source of information.
The client is the primary source of data
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Secondary: it is the indirect source of information:
all sources other than the client are considered
secondary sources. Family members , health
professionals, records, laboratory and diagnostic
results are secondary sources
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ď METHODS OF DATA COLLECTION
The methods use to collect data are :
observation, interview and examination.
Observation: it is the gathering data by using the senses.
Vision, smell and hearing are used
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Interview: an interview is a planned
communication or a conversation with a
purpose.There are two approaches to interviewing:
directive and nondirective.
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The direct interview is highly structured and directly ask the
questions and the nurse controls the interview.
A nondirective interview, or rapport building interview and the
nurse client to control the interview
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Stages of an interview
An interview has three major stages:
1. The opening or introduction
2. The body of development
3. The closing
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Examination : the physical examination is a systematic
data collection method to delect health problem. To conduct
the examination, the nurse uses techniques of inspection,
palpation, percussion and auscultation.
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Organization of data
The nurse uses a format that organizes the assessment
data systematically. This is often referred to as nursing
health history or nursing assessment form
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Validation of data
The information gathered during the assessment is
ÂŤ double-checkd Âť or verified to confirm that it is
accurate and complete
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Documentation of data
To complete the assessment phase, the nurse records client
data. Accurate documentation is essential and should include
all data collected about the clientâs health status.
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NURSING DIAGNOSIS is:
âa clinical judgment concerning a human response to health
condition/life processes, or vulnerability for that response, by
an individual, family, group, or communityâ
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5 kinds of nursing diagnosis
Actual
Risk potential nursing diagnoses
Possible nursing diagnosis
Wellness diagnoses
Syndrome diagnoses
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Actual diagnoses
The person data base contains evidence of signs and
symptoms or defining characteristics of the diagnoses
3 part statement
PES( Problem+ Etiology+Signs and symptoms)
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Problem: Nanda ( North American nursing Diagnosis
Association), approve Nursing Diagnosis
Etiology: written as related to = is often part of medical
diagnosis
Signs and symptoms: written as: âas evidenced
byâ=should include your assessment data of how decided on
that particular diagnosis
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Example of actual nursing diagnosis:
Nursing diagnosis/Related to/as manifested by.
Ineffective airway clearance/Related to
physiologic effect of pneumonia/ as evidence
by increased sputum, coughing, abnormal
breath sounds, tachypnea and dyspnea.
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⢠RISK Diagnosis
The persons data base contains evidence
of related (risk factors of diagnosis, but no
evidence of defining characteristics
Problem+ Etiology
Risk for impaired skin integrity/related to
obesity excessive diaphoresis and confinement
to bed
No signs and symptoms
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â˘Possible diagnoses
The personâs data base doesnât
demonstrate the defining characteristics or
related factors of diagnosis, but your own
intuition tells you the diagnosis may be present.
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Possible nursing diagnoses are statements
describing a suspected problem for which additional
data are needed to confirm or rule out the
suspected problem.
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⢠One part statement and simply name the
possible problem
Example:
possible ineffective individual coping
Possible Chronic Low Self-Esteem
Possible Social Isolation.
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Wellness diagnoses
Being able to diagnose wellness diagnoses is based on
recognizing when healthy client indicate desire to achive a higher
level of functioning area.
Use part statement use the Word potential for enhanced.
Peter says i wish i were a better parents
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ď Health promotion diagnosis (also known as
wellness diagnosis) is a clinical judgment
about motivation and desire to increase well-
being. Health promotion diagnosis is
concerned in the individual, family, or
community transition from a specific level of
wellness to a higher level of wellness.
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Nursing diagnosis: potential for enhanced
parenting.
â˘Syndrome diagnosis
A syndrome diagnosis is a clinical judgment
concerning with a cluster of problem or risk nursing
diagnoses that are predicted to present because of a
certain situation or event.
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Identify what kind of nursing diagnosis
âImpaired communication /related to language barrier as
evidence by inability to speak or understand English and
use of Spanish
EXERCICE
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Identify if the statement is correct. If not correct
the statement.
Risk for injury related to lack of side rails on bed
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â˘A social relationship is primarily initiated for the
purpose of friendship, socializations and
companionship
â˘The communication is usually centered around
sharing ideas, feelings and experiences and meets
the basic needs of people.
â˘In Therapeutic Nurse patient relationship, the
social relationship must be limited
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⢠A healthy intimate relationship involves two people
who are emotionally committed to each other and
both concerned about having their needs met and
helping each other.
â˘The relationship may include sexual or emotional
intimacy as well as sharing of mutual goals
⢠It has no place in the nurse patient relationship.
57. THERAPEUTIC RELATIONSHIP
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â˘It focuses on the needs, experiences, feelings and
ideas of the client.
â˘The areas to be worked on are agreed on and the
outcomes are continually evaluated.
â˘The nurse uses communication skills, personal
strengths and understanding of human behaviour to
interact with the client
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1. Help to understand his/her problems.
2. Cope with present problems.
3. Identify emerging problems.
4. Find out new alternatives to problems
5. Communicate
6. Try out new patterns of behaviour
7. Socialize
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â˘Self awareness includes self concept, beliefs and
values.
If a nurse has a positive self concept about herself she
will be confident in caring for the patient. But if she has
developed a negative self concept, she will not be able
to help the patient
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Ability of developing the rapport
â˘It is defined as a relationship of mutual sympathy and
understanding especially between patient and
therapist.
â˘The essential qualities for developing rapport are
warmth, genuineness and empathy
