Nursing Process and Assessment Techniques

Nursing Process

• Definition: The nursing process is the foundation of professional nursing practice, offering a framework for nurses to deliver organized and effective patient care.
• Requires: Critical thinking.

Characteristics of the Nursing Process

1. Analytical: Combines reasoning and decision-making.
2. Dynamic: Adapts to changing patient needs.
3. Organized: Systematic approach to care delivery.
4. Outcome oriented: Focused on achieving desired patient outcomes.
5. Collaborative: Involves teamwork among healthcare professionals.
6. Adaptable: Can be modified based on patient situations.

Steps of the Nursing Process

1. Assessment

   • Description: Ongoing and organized appraisal of a patient's well-being.
   • Data Collection:
     • Primary Data: Information from patient interviews.
     • Secondary Data: Information from family members or healthcare team.
     • Subjective Data: Symptoms, health history.
     • Objective Data: Signs, physical examination, lab, and diagnostic results.
   • Methods:
     • Observation (sight, hearing, smell).
     • Patient interviews (includes orientation phase, working phase, and termination phase).

2. Diagnosis

   • Analysis of Data: Recognize and analyze cues.
   • Nursing Diagnosis: Identify problems such as ineffective airway clearance or risk for unstable blood glucose.
   • Types of Diagnoses:
     • Problem-Focused.
     • Risk.
     • Health Promotion.

3. Planning

   • Prioritize Hypotheses: Order of nursing diagnoses based on urgency.
   • Goal Setting: Develop short and long-term goals using SMART criteria.
   • Care Plans: Individualized strategies to meet patient needs.

4. Implementation

   • Take Action: Execute interventions that correspond to the care plan.
   • Types of Interventions:
     • Independent (nurse-initiated).
     • Dependent (physician-initiated).
     • Collaborative (team approach).

5. Evaluation

   • Assess Response: Determine if the patient met the goals set in the planning phase.
   • Cyclic Nature: Continuously reassess and update care strategies as needed.

Documentation and Care Plans

• Documentation: Record findings, interventions, and patient responses.
• Care Plans: Use nursing interventions classification (NIC) and outcome identification classification (NOC).

Assessment Techniques

• Inspection: Visual examination of the whole person and body systems.
• Palpation: Touch to assess texture, temperature, moisture, and tenderness.
• Percussion: Tapping to determine the condition of internal organs.
• Auscultation: Listening to internal sounds (heartbeats, breath sounds).

General Survey Components

• Physical Attributes: Age, race, gender identity, personal hygiene.
• Behavioral Factors: Affect, mood, safety considerations, substance use.
• Vital Signs: Tracking height, weight, body mass index (BMI).

Physical Examination Components

• Skin, Hair, and Nails: Inspect for abnormalities and lesions. Observe for signs of dehydration (skin turgor).
• Head and Neck: Palpate and inspect cranial structures, thyroid, and lymph nodes.
• Respiratory: Assess chest shape, breathing patterns, auscultate lung sounds for abnormalities.
• Cardiac and Peripheral Vascular: Evaluate heart tones, pulse quality, and check for circulatory issues.

Maslow’s Hierarchy of Needs in Nursing

1. Physiologic Needs: Basic survival needs (e.g., oxygen, water, food).
2. Safety and Security: Protection from harm and emotional security.
3. Love and Belonging: Need for social connections and support.
4. Self-Esteem: Desire for self-respect and personal worth.
5. Self-Actualization: Achieving one's full potential and personal growth.

Examples in Nursing Practice

• Addressing the highest priorities based on Maslow's model during patient care scenarios.
• Recognizing critical conditions through the emergency severity index (ESI) for prioritizing nursing interventions (levels 1 to 5).

Evaluation of Nursing Interventions

• Continuous assessment of patient outcomes post-implementation.
• Adjustment of care plans based on the dynamic responses from patients.