Introduction To Health Presentation NURSING 251

The nursing process is

A common thread among all nurses

Nursing process

A systemic problem solving approach to identifying and treating human responses to actual health problems

Assessment

The first phase in the nursing process

The nursing process is

A continual assessment

Revise plan as necessary

Nursing diagnosis

Clinical judgment about clients, family, community responses to “actual” or “potential” health problems

Nursing diagnosis

Analyze and synthesize assessment data to determine nursing concerns

Example of assessment

Reddened area on patients sacral area

Example of Nursing diagnosis

Potential of impaired skin integrity related to prolonged bedrest

Example of plan/goal

Patient will maintain intact skin while in hospital

Example of implementation

Would be to carry out that action or plan

Example of evaluation

Did this plan work? Has it made things worse or better?

Definition of assessment

An identification by a nurse of the needs, preferences, and ability of a patient. The collection of data and information relevant to the care of patients there problems and needs.

Definition of purpose

To establish a data base

Physical systems

Functioning in a normal way

Emotional ability

To maintain a positive perspective

Social supports

Such as family, loving relationships, significant others

Spiritual sources

strength

identify weaknesses

Physical system problems interfere with regaining previous level of functioning

Lack of emotional support

Integrate previous responses

To health problems with current status

Evaluate overall health status

Exercise, stress, nutrition

Identify cultural influence

On health status

Data is

Descriptive, concise, and complete

Data

DOES NOT include interpretive or judgmental statements

There is two types of data

Subjective and objective

Four types of assessment

1. Initial

2. Ongoing/partial

3. Focused/problem

4. Emergency

The Initial comprehensive assessment

First presents the client and gives an overall picture of health with both subjective and objective data

The Ongoing/partial assessment

Occurs after comprehensive database is established and includes a reassessment

The focused/problem assessment is a

Specific health concern and is followed up by a comprehensive assessment

The emergency assessment

Occurs rapidly when life saving action needs to be taken an immediate diagnosis is needed

Examples of emergency assessment

Airway/breathing

Severe bleeding

Shock

Steps of a health assessment

1. Subjective data

2. Objective data

3. Primary vs. secondary data

4. Validation of data

Subjective data is

Information stated by the patient including symptoms

Objective data is

Directly observed by examiner (signs)

Examples of objective data

Physical characteristics

Body functions

Appearance and behavior

Results of measurements

Lab results

Primary source is

The patient

Secondary sources are

Family

Medical records

Physician

Nurse

Validation of data is a

Crucial part of assessment ensures all data is accurate and matches up

Validation of data

Fills in missing pieces to get the whole picture

With documentation of data you must

Document all findings it forms a database and allows health care team to see the picture

Process of data analysis

Identify

Cluster data

Nursing diagnosis

Define characteristics

Confirm or rule out diagnosis

Document conclusion