Overview of Nursing Process Week Week 2 Files Column Unit/Module Lec Learning Objectives: After the learning session, the students will be able to Describe the ADPIE as an acronym representing the five phases of the nursing process. Understand the Health Assessment in nursing practice Describe the types of health Assessment. Determine the nurse's role in Health Assessment Nursing Definition The protection, promotion, and optimization of health and abilities, prevention of illness and injury, alleviation of suffering through the diagnosis and treatment of human responses, and advocacy in the care of individuals, families, communities, and populations. (Nursing: Scope and Standards of Nursing practice [ANA], 2010.) Nursing Process A systematic approach to care using the fundamental principles of: Critical Thinking Client-centered approaches Goal-oriented tasks Evidence-based practice (EDP) Nursing intuition Overview of Nursing Process 1 Holistic based in scientific knowledge Nursing Assessment Nursing assessment is a key component of nursing practice Obtaining of information about a patient’s physiological, psychological, sociological, and spiritual status. Nursing assessment is the first step in the nursing process. NPI (Nurse Patient Interaction) Performs the head-to-toe assessment or cephalocaudal method. Failure to do a nursing assessment can’t progress on the treatment. Maliligaw ka sa susunod na procedure. Health Assessments is an essential nursing function which provides foundation for quality nursing care and intervention. It helps to identify the strengths of the clients in promoting health. HA helps to identify client’s needs, clinical problems. Evaluates response of the person to the health problems and intervention. The 5 Steps in the ADPIE Nursing Process Assessment (A) Nurse is expected to perform the following task Gather the biographical information Name, age, gender, height, weight, address History of present health concern Chief complain History of past illness Allergies on medicine Overview of Nursing Process 2 Family history Functional assessment Collecting subjective and objective data Subjective Data Verbal statement directly from the patient or immediate relative. Symptoms Objective Data Observable and measurable data Tangible data (Vital signs, I and O, height and weight) Laboratory Results Use your senses in obtaining objective data Signs Example skin is oily the skin is warm vital signs Comparing Subjective and Objective Data Overview of Nursing Process 3 Diagnosis (D) Nursing Diagnosis is defined as a clinical judgement about responses to actual or potential health problems on the part of the patient, family or community (NANDA) North American Nursing Diagnosis Association (NANDA) provides nurses with an up to date list of nursing diagnoses Analyzing subjective and objective data Maslow’s Hierarchy of Needs Basic Physiological Needs Nutrition (water and food), elimination (toileting), airway (suction), breathing (oxygen), circulation (pulse, cardiac monitor, blood pressure), (ABC’s), sleep, sex, shelter, and exercise Safety and Security Injury prevention (side rails call lights, hand hygiene, isolation, suicide precautions, full precautions, car seats, helmets, seat belts), fostering a climate of trust and safety (therapeutic relationship), patient education (modifiable risk factors for stroke, heart disease) Love and Belonging Overview of Nursing Process 4 Foster supportive relationships, methods to avoid social isolation (bullying), employ active listening techniques, therapeutic communication, sexual intimacy Self-Esteem Acceptance in the community workforce, personal achievement, sense of control or empowerment, accepting one’s physical appearance of both body habitus Self-Actualization Empowering environment, spiritual growth ability to recognize the point of view of others, reaching one’s maximum potential Planning (P) Goals and outcomes are formulated that directly impact patient care Positive outcome Care plans provide a course of direction for personalized care tailored to an individual’s unique needs Enhance by communication, documentation and continuity. Goals should be: S = pecific M = measurable or Meaningful A = attainable or Action-Oriented R = alistic or Results-Oriented T = imely or time-oriented Types of Goal STG also known as short term goal goal within a certain period LTG Overview of Nursing Process 5 long term goal goal within your shift Implementation (I) Implementation is the step which involves action. This phase requires nursing interventions such as applying a cardiac monitor or oxygen, direct or indirect care, medication administration, standard treatment protocols. Types of Interventions Independent Interventions Those activities that nurses are licensed to initiate on the basis of their knowledge and skills Physical Care ( ex. Bed bath, assist in ambulation ) On going - assessment ( ex. Hourly I and O ) Emotional support and comfort ( ex. NPI of CA patient ). Health teaching ( ex. Nutrition ) Counseling ( ex. Teenage Pregnancy ) Nursing Diagnosis “Impaired Oral Mucous Membranes” - Nursing action is to provide oral care Dependent Interventions Activities carried out under the orders of supervision of a licensed physician Medication Intraveneous Therapy Diagnostic Tests Treatments Diet Activity Overview of Nursing Process 6 Evaluation (E) This final step of the nursing process is vital to a positive patient outcome Reassess or evaluate to ensure the desired outcome has been met Nurse evaluation statement Goal met Partially met Not met QUESTIONS What occurs during the assessment phase of the nursing process? Collect subjective and objective data Overview of Nursing Process 7 TRUE OR FALSE: A partial assessment is done when the client first enters a health care facility FALSE partial assessment is done after admitting a patient TRUE OR FALSE: Subjective data are sensations or symptoms, perceptions, desires, preferences, beliefs, ideas, values, and personal information that can be elicited and verified only by the client TRUE Types of Assessment Initial comprehensive assessment Collection of subjective data about the: client’s perception of health of all body parts or systems past medical history family history lifestyle and health practices Also known as “Triage” Ongoing or partial assessment To determine the status of a specific problem identified based in the initial assessment Data collection that occurs after the comprehensive database is established Mini-overview of the client’s body systems EXAMPLE: Re assessment of lung sound of a Lung CA patient Overview of Nursing Process 8 REASSESS Focused/problem-oriented assessment Thorough assessment of a particular client problem, which does not cover areas not related to the problem EXAMPLE Patient John experience ear pain. The nurse ask about the onset, relieving and aggravating factors and associated symptoms Physical exam focus on John’s ears, nose, mouth and throat Emergency assessment Very rapid assessment performed in life-threatening situations (choking, cardiac arrest, drowning) Evaluate ABC The ABCs stand for airway, breathing, and circulation. This acronym allows nurses to focus on the top priorities needed to ensure a patient's well-being. During patient care, nurses must make sure the patient's airway is unobstructed and clear (aka having a patent airway). Determine the status of client’s life sustaining physical function Nurse identify the threatening problems Evolution of the Nurse’s Role in Health Assessment PAST Physical assessment integral part of nursing Nurses relied on natural senses Palpataion Movement of health care from acute care setting to community care and proliferation of baccalaureate and graduate education Advanced practice nurses Overview of Nursing Process 9 PRESENT Managed care and internal case management has impact on assessment role of the nurse Acute care nurses Critical care outreach nurses Ambulatory care nurses Home health nurses Public health nurses School and hospice nurses FUTURE Rising educational cost Increasing complexity of acute care Growing aging population with complex comorbidities Increasing impact of children and homeless Intensifying mental health issues Expanding health services network Limited number of medical students pursuing practice in primary care settings Aging of the baby boomer generation Nurses Roles Care givers Teacher Patients advocate Counselor Leader Manager Overview of Nursing Process 10 Independent Summary Nursing health assessment differs in purpose, framework, and end result from all other types of professional health care assessment The role of the nurse in health assessment has expanded dramatically from the days of Florence Nightingale, when the nurse used the senses of sight, touch, and hearing to assess clients Communication and physical assessment techniques are used independently by nurses to arrive to professional clinical judgments concerning the client’s health Advances in technology have expanded the role of assessment and the development of managed care has increased the necessity of assessment skills Expert clinical assessment and informatics skills are absolute necessities for the future as nurses from all countries continue to expand their roles in all health care settings Short Term Goal - goal within a certain period Long Term Period - goal within your shift SENSES Sight (Vision) Hearing (Auditory) Smell (Olfactory) Taste (Gustatory) Touch (Tactile) Vestibular (Movement) Overview of Nursing Process 11
