The Nursing Process

Definition of Nursing Process Systematic patient centered method for Structuring the delivery of nursing care

Five Phases of Nursing Process 1- Assessment 2- Planning 3- Diagnosing 4- Implementing 5- Evaluating

Phase one: Assessment Steps: 1- Collecting Data 2- Organizing 3- Validating 4- Documenting

Step one: Data Collection Data Bases which are used to collect data about client include: 1- History 2- Physical exam findings 3- lab results 4- diagnostic results 5- data from other health professionals

Types of collected data 1- Subjective data = Symptoms 2- Objective data = Signs

Sources of Collected Data 1- Primary source : client only 2- Secondary source : file, records, family, nursing literature,etc Examples of records: medication sheets, lab sheets, medical records like consultation sheets, etc.

Data Collection Methods 1- Observation 2- Interview

Observation as data collection method Examples: 1- Respiratory distress symptoms 2- Threats to client safety 3- Functionality of intravenous lines, drips, pumps, machines 4- Immediate environment of the client

Interview as a data collection method Approaches of Interview 1- Directive approach 2- Nondirective approach 3- Combined approach

Types of Questions in Interview 1- Closed Ended Questions 2- Open Ended Questions

Elements when planning an interview 1- Timing 2- Place 3- language 4- seating arrangement 5- distance

Stages of Interview 1- Opening ( rapport and orientation) 2- Body 3- Closing ( offering help, questions, conclusions, etc)

Pay Attention to practice tips at the bottom of page 90 : communication during an interview

Step 2 of Assessment: Organising When a nurse uses written or computerized format that organises the assessment data in a systematic way which could be easily referred to. For example: nursing daily assessment sheets.

Next lecture will be from page 91 to validating data 2- documenting data ◦ 3- diagnosing