Copyright © 2011 Wolters Kluwer Health | Lippincott Williams & Wilkins Introduction to Nursing Process and Assessing

Copyright © 2011 Wolters Kluwer Health | Lippincott Williams & Wilkins Five Steps of the Nursing Process Assessing—collecting, validating, and communicating of patient data Diagnosing—analyzing patient data to identify patient strengths and problems Planning—specifying patient outcomes and related nursing interventions Implementing—carrying out the plan of care Evaluating—measuring extent to which patient achieved outcomes

Copyright © 2011 Wolters Kluwer Health | Lippincott Williams & Wilkins The Steps of the Nursing Process

Copyright © 2011 Wolters Kluwer Health | Lippincott Williams & Wilkins Characteristics of the Nursing Process Systematic—part of an ordered sequence of activities Dynamic—great interaction and overlapping among the five steps Interpersonal—human being is always at the heart of nursing Outcome oriented—nurses and patients work together to identify outcomes Universally applicable—a framework for all nursing activities

Copyright © 2011 Wolters Kluwer Health | Lippincott Williams & Wilkins Problem Solving and the Nursing Process Trial-and-error problem solving Scientific problem solving Intuitive thinking Critical thinking

Copyright © 2011 Wolters Kluwer Health | Lippincott Williams & Wilkins Benefits of the Nursing Process Patient –Scientifically based, holistic individualized patient care –Continuity of care –Clear, efficient, cost-effective plan of action Nurse –Opportunity to work collaboratively with other healthcare workers –Satisfaction of making a difference in lives of patients –Opportunity to grow professionally

Copyright © 2011 Wolters Kluwer Health | Lippincott Williams & Wilkins Four Blended Skills Cognitive skills—using critical thinking; a systematic way to form and shape one’s thinking Technical skills—manipulating equipment skillfully to produce desired outcome Interpersonal skills—promoting the dignity and respect of patients and establishing caring relationships Ethical/legal skills—establishing a personal moral code and professional role responsibilities

Copyright © 2011 Wolters Kluwer Health | Lippincott Williams & Wilkins Cognitively Skilled Nurses Offer scientific rationale for patient plan of care. Select nursing interventions most likely to yield desired outcomes. Use critical thinking to solve problems creatively. Display purpose of thinking and adequacy of knowledge. Work through potential problems and use helpful resources. Critique judgments/decisions.

Copyright © 2011 Wolters Kluwer Health | Lippincott Williams & Wilkins Technically Skilled Nurses Use technical equipment with competence and ease to achieve goals with minimal distress to patients. Creatively adapt equipment and technical procedures to needs of patients in diverse circumstances.

Copyright © 2011 Wolters Kluwer Health | Lippincott Williams & Wilkins Interpersonally Skilled Nurses Use interactions with patients and significant others and colleagues to promote human dignity and respect. Elicit personal strengths and abilities of patients to achieve health goals and establish caring relationships. Provide the healthcare team with knowledge about patient goals and expectations. Work collaboratively with healthcare team as respected and credible colleagues.

Copyright © 2011 Wolters Kluwer Health | Lippincott Williams & Wilkins Ethically and Legally Skilled Nurses Are trusted to act in ways that advance interests of patients Are accountable for the practice Act as effective patient advocates Mediate ethical conflict among patient, significant others, and healthcare team

Copyright © 2011 Wolters Kluwer Health | Lippincott Williams & Wilkins Four Types of Nursing Assessments Initial comprehensive Focused Emergency Time-lapsed

Copyright © 2011 Wolters Kluwer Health | Lippincott Williams & Wilkins Assessing: The Primary Source of Information Is the Patient

Copyright © 2011 Wolters Kluwer Health | Lippincott Williams & Wilkins Initial Comprehensive Assessment Performed shortly after admittance to hospital Performed to establish a complete database for problem identification and care planning Performed by the nurse to collect data on all aspects of patient’s health

Copyright © 2011 Wolters Kluwer Health | Lippincott Williams & Wilkins Focused Assessment May be performed during initial assessment or as routine ongoing data collection Performed to gather data about a specific problem already identified, or to identify new or overlooked problems Performed by the nurse to collect data about the specific problem

Copyright © 2011 Wolters Kluwer Health | Lippincott Williams & Wilkins Emergency Assessment Performed when a physiologic or psychological crisis presents Performed to identify life-threatening problems Performed by the nurse to gather data about the life- threatening problem

Copyright © 2011 Wolters Kluwer Health | Lippincott Williams & Wilkins Time-Lapsed Assessment Performed to compare a patient’s current status to baseline data obtained earlier Performed to reassess health status and make necessary revisions in plan of care Performed by the nurse to collect data about current health status of patient

Copyright © 2011 Wolters Kluwer Health | Lippincott Williams & Wilkins Establishing Assessment Priorities Health orientation Developmental stage Need for nursing

Copyright © 2011 Wolters Kluwer Health | Lippincott Williams & Wilkins Medical vs. Nursing Assessments Medical assessments –Target data pointing to pathologic conditions Nursing assessments –Focus on the patient’s response to health problems

Copyright © 2011 Wolters Kluwer Health | Lippincott Williams & Wilkins Objective Data vs. Subjective Data Objective data –Observable and measurable data that can be seen, heard, or felt by someone other than the person experiencing them –For example, elevated temperature, skin moisture, vomiting Subjective data –Information perceived only by the affected person –For example, pain experience, feeling dizzy, feeling anxious

Copyright © 2011 Wolters Kluwer Health | Lippincott Williams & Wilkins Characteristics of Data Purposeful Complete Factual and accurate Relevant

Copyright © 2011 Wolters Kluwer Health | Lippincott Williams & Wilkins Sources of Data Patient Family and significant others Patient record Other healthcare professionals Nursing and other healthcare literature

Copyright © 2011 Wolters Kluwer Health | Lippincott Williams & Wilkins The Skill of Nursing Observation Determines the patient’s current responses (physical and emotional). Determines the patient’s current ability to manage care. Determines the immediate environment and its safety. Determines the larger environment (hospital or community).

Copyright © 2011 Wolters Kluwer Health | Lippincott Williams & Wilkins Four Phases of a Nursing Interview Preparatory phase Introduction Working phase Termination

Copyright © 2011 Wolters Kluwer Health | Lippincott Williams & Wilkins Purpose of a Nursing Physical Assessment Appraisal of health status Identification of health problems Establishment of a database for nursing intervention

Copyright © 2011 Wolters Kluwer Health | Lippincott Williams & Wilkins Problems Related to Data Collection Inappropriate organization of the database Omission of pertinent data Inclusion of irrelevant or duplicate data, erroneous or misinterpreted data Failure to establish rapport and partnership Recording an interpretation of data rather than observed behavior Failure to update the database

Copyright © 2011 Wolters Kluwer Health | Lippincott Williams & Wilkins When to Verify Data When there is a discrepancy between what the person is saying and what the nurse is observing When the data lack objectivity

Copyright © 2011 Wolters Kluwer Health | Lippincott Williams & Wilkins Validating Inferences Performing a physical examination using proper equipment and procedure Using clarifying statements Sharing inferences with other team members Checking findings with research reports Comparing cues to knowledge base of normal function Checking consistency of cues

Copyright © 2011 Wolters Kluwer Health | Lippincott Williams & Wilkins Documentation of Data Immediately give verbal reporting of data whenever a critical change in the patient’s health status is assessed. Enter initial database into computer or record in ink on designated forms the same day patient is admitted. Summarize objective and subjective data in concise, comprehensive, and easily retrievable manner. Use good grammar and standard medical abbreviations. Whenever possible, use patient’s own words. Avoid nonspecific terms subject to individual interpretation or definition.