Nursing made incredible easy - med surg chapter 2

Chapter 2: Nursing Process

Overview

  • Focus on five critical aspects of the nursing process:

    • Five steps of the nursing process

    • Effective communication tools during health history collection

    • Components of a comprehensive health history

    • Techniques for performing inspection, palpation, percussion, and auscultation

    • Application of the nursing process in practice

The Nursing Process

  • Developed by Ida Jean Orlando over 50 years ago.

  • Provides a systematic and holistic structure for nursing care.

  • Incorporates:

    • Critical thinking

    • Patient-centered care

    • Goal-oriented actions

    • Evidence-based practice

    • Nursing intuition

  • Similar in structure to the scientific method, it helps:

    • Determine patient needs

    • Create prioritized plans

    • Implement those plans

    • Evaluate effectiveness

Five Steps of the Nursing Process

  • Dynamic and interconnected steps that resemble problem-solving steps in various professions:

    1. Assessment

    2. Diagnosis/Identifying Patient Needs

    3. Goals/Planning

    4. Implementation

    5. Evaluation

Benefits of the Nursing Process

  • Focus shifts to the patient's specific needs rather than solely on the disease.

  • Encourages patient participation, independence, and compliance, enhancing outcomes.

  • Improves communication among healthcare teams.

  • Provides a professional framework, promoting accountability and quality improvement.

Assessment Phase

  • Data Collection:

    • Nurses gather data utilizing critical thinking focused on patients' specific needs.

    • Assess multifaceted aspects:

      • Physiological

      • Psychosocial

      • Spiritual

      • Cultural

      • Life factors

  • Utilize various tools for data collection:

    • Health history

    • Physical assessment

    • Review of medical and laboratory information (ANA, 2020).

Health History Collection

  • Purpose:

    • Gather subjective data regarding the patient's current condition.

    • Identify health status and risks.

  • Components:

    • General questions about physical and emotional health.

    • Specific inquiries into body systems and structures.

  • Sources of Information:

    • Patient, caregivers, or other health professionals.

  • Establish good rapport through effective communication and sensitivity.

Techniques for Effective Interviews

  • Ensure patient comfort and understanding of the process.

  • Employ effective interviewing techniques:

    • Allow time for patient reflection

    • Encourage talking and elaboration

    • Show active listening through paraphrasing, clarifying, and summarizing (Burke, 2020).

Interview Techniques to Avoid

  • Avoid methods that can hamper communication:

    • Rushing or interrupting

    • Asking leading or probing questions

    • Using complex language

    • Giving unsolicited advice or false reassurance

    • Sharing personal anecdotes

    • Making judgments or presumptions

Structuring the Interview

  • Create a supportive environment:

    • Minimize interruptions by closing doors.

    • Position yourself to face the patient comfortably.

  • Ensure note-taking does not obstruct personal connection and communication.

Types of Questions in Health History

  • Question Formats:

    • Open-ended Questions:

      • Allow for extended responses, fostering detailed engagement.

    • Closed-ended Questions:

      • Require simple yes/no or factual responses, useful for brevity.

Sections of Health History Data

  1. Biographic Data:

    • Collect personal demographics (age, sex, marital status, etc.).

  2. Health and Illness Patterns:

    • Chief complaints, current and past health history, family health history.

  3. Health Promotion and Protection Patterns:

    • Lifestyle, health beliefs.

  4. Role and Relationship Patterns:

    • Evaluate psychosocial health aspecten.

  5. Summary of Health History:

    • Conclude with the main findings and plan.

Physical Assessment

  • Steps involve:

    • Hand hygiene before interactions.

    • Employing classic techniques in sequence:

      1. Inspection

      2. Palpation

      3. Percussion

      4. Auscultation

  • Adapt the sequence for abdominal assessments as needed.

Techniques of Physical Assessment

  • Inspection:

    • Observational technique assessing appearance, color, size, symmetry, etc.

  • Palpation:

    • Touch to evaluate texture, size, masses, temperature, moisture, and tenderness.

  • Percussion:

    • Tapping to identify organ borders and conditions by sound differences.

  • Auscultation:

    • Listening to body sounds with a stethoscope, ensuring equipment hygiene post-use.

Nursing Process in Action

  • Gather comprehensive patient profiles through nursing history, assessments, and diagnostics.

  • Continually analyze and prioritize patient needs using the Lippincott Advisor Problem-Based taxonomy.

  • A systematic approach to develop patient-centered care plans.

Evaluation Phase and Re-assessment

  • Assess effectiveness of interventions and their alignment with patient goals.

  • Adapt the care plan as needed based on patient progress and response.

  • Emphasize SMART goals throughout to ensure focused and measurable outcomes.

Conclusion

  • Successful navigation through the nursing process enhances patient care and ensures holistic health outcomes.