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Nursing Process. Ch 11. What Is It?. Framework = method = formula Systematic approach Dynamic Interpersonal Patient-centered Goal-oriented. Steps (Parts). Assessing Diagnosing Planning Implementing Evaluating. Quote . . .
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Nursing Process Ch 11
What Is It? • Framework = method = formula • Systematic approach • Dynamic • Interpersonal • Patient-centered • Goal-oriented
Steps (Parts) • Assessing • Diagnosing • Planning • Implementing • Evaluating
Quote . . . • Nurses are responsible for a unique dimension of healthcare – “ the diagnosis and treatment of human responses to actual or potential health problems”
Evolution • In 1960s nursing recognized as distinct entity • 1973 the ANA Congress developed Standards of Practice • Ongoing reassessments and revisions
Trends • Initially plans of care were long and handwritten • Today’s care plans are • Standardized • Computerized • Focus on similarities between illnesses, etc
Problem Solving • Combination of • Trial-and-error • Scientific process • Intuition
Purpose • Provide patient care that is • Scientific • Holistic • Creative
Critical Thinking • Ability to • identify a problem • analyze it • develop a response • follow through • Based on • experience • Knowledge • Intuition
Critical Thinking, cont’d. • “…active, organized, cognitive process used to carefully examine one’s thinking and the thinking of others.” • Involves use of MIND • Form conclusions • Make decisions • Draw inferences • reflect
C. T. Characteristics • Independent thinker • Fair-minded • Intellectually humble • Intellectually courageous • Good faith & integrity • Curious & persevering • Disciplined • Creative • Confident
Assessing Ch 12
4 Types • Initial • Shortly after contact with patient • Most facilities have specific time-frames • Establishes database for development of plan
Focused • Gathers data about specific problem • May be part of initial assessment, but more often is not • Emergency • Identifies life-threatening problems • Time-Lapse • Compares current to previous data
Data Collection • Consider • time • needs of patient • developmental stage • physical surroundings • past and present coping patterns
Data Characteristics • Complete • Factual • Accurate • Relevant
Data Sources • Subjective • Patient • Primary source • Usually BEST source • Family & significant others • When patient is a child or impaired adult • Spouses • Consider confidentiality when including friends
Data Sources, cont’d • Objective • Observed data (What is not spoken) • Findings from physical exam • Results from diagnostic or lab tests • Information from pertinent nursing or medical literature
Objective Sources cont’d. • Patient record • H & P • Laboratory • Consultations • X-ray, CT, PT/OT, other ancillary departments
Data Collection • Demographics • Medical history • Habits • Meds, allergies • Environmental/familial factors • Potential for injury • Ability to participate in plan of care
Data Collection • Physical assessment • Usually by Review of Systems • Overview of symptoms • Diet • Each body system
Interview • Planned • Consider schedule of tests • Patient preferences • Family or visitor presence
Interview Phases • Preparatory • Introduction • Working • Termination
Interview Phases • Preparatory • Nurse collects background info from previous charts • Ensure environment is conducive • Arrange seating • 3 – 4 ft apart • Interviewer at 45° angle to patient • Allow adequate time
Phases cont’d. • Introduction • Nurse introduces self • Identifies purpose of interview • Ensure confidentiality of information • Provide for patient needs before starting
Phases cont’d. • Working • Nurse gathers info for subjective data • Excellent communication skills are needed • Active listening • Eye contact • Open-ended questions
Phases cont’d. • Termination • Inform patient when nearing end of interview • Ensure patient knows what will happen with info • Offer patient chance to add anything
Data Validation • Verifies understanding of information • Comparison with another source • patient or family member • record • health team member
Data Documentation • Clear and concise • Appropriate terminology • Usually on a designated form • Physical assessment • Usually by Review of Systems • Overview of symptoms • Diet • Each body system
Documentation • Record in permanent record ASAP • Use patient’s own words in subjective data – enclose in “ ___” (quotation marks) • Avoid generalizations – be specific • Don’t make summative statements – describe - e.g. patient is being ornery should be patient resists instruction or patient states “Don’t talk to me, I don’t care about that”