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Published byStephany Barrett Modified over 9 years ago
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The Nursing Process
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Definition of Nursing Process Systematic patient centered method for Structuring the delivery of nursing care
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Five Phases of Nursing Process 1- Assessment 2- Planning 3- Diagnosing 4- Implementing 5- Evaluating
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Phase one: Assessment Steps: 1- Collecting Data 2- Organizing 3- Validating 4- Documenting
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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
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Types of collected data 1- Subjective data = Symptoms 2- Objective data = Signs
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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.
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Data Collection Methods 1- Observation 2- Interview
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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
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Interview as a data collection method Approaches of Interview 1- Directive approach 2- Nondirective approach 3- Combined approach
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Types of Questions in Interview 1- Closed Ended Questions 2- Open Ended Questions
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Elements when planning an interview 1- Timing 2- Place 3- language 4- seating arrangement 5- distance
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Stages of Interview 1- Opening ( rapport and orientation) 2- Body 3- Closing ( offering help, questions, conclusions, etc)
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Pay Attention to practice tips at the bottom of page 90 : communication during an interview
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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.
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Next lecture will be from page 91 to 95 1- validating data 2- documenting data ◦ 3- diagnosing
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