NRS 204 Lecture

The Nursing Process

Overview

  • The nursing process is a systematic method utilized by nurses for providing patient care, commonly represented by the acronym ADPIE:

    • Assessment

    • Diagnosis

    • Planning

    • Implementation

    • Evaluation

1. Assessment

  • Gather Information: Collect both subjective and objective data:

    • Subjective Data: Information provided by the patient (what they tell you).

    • Objective Data: Information gathered through physical examination and observations by the nurse.

  • Methods of Data Collection:

    • Observation

    • Health interviews (conversations between nurse and patient)

    • Physical examination

  • Review and verify data for clarity and accuracy.

2. Diagnosis

  • Interpretation of the collected data:

    • Identify and prioritize problems through a NANDA-approved nursing diagnosis:

      • Example: "Pain related to pressure in ear as evidenced by crying."

  • Types of Diagnoses:

    • Medical Diagnosis: Identifies a disease (e.g., flu).

    • Nursing Diagnosis: Addresses patient needs and responses (e.g., trouble breathing due to stuffy nose).

Components of Nursing Diagnosis (PES Format)

  1. Problem: Approved nursing diagnosis.

  2. Etiology: Cause of the problem.

  3. Signs/Symptoms: Evidence of the problem.

3. Planning

  • Set SMART Goals:

    • Specific, Measurable, Achievable, Relevant, Time-bound.

  • Types of Planning:

    • Initial Planning: Conducted after admission assessment.

    • Ongoing Planning: Continuous adjustments based on patient’s needs.

    • Discharge Planning: Preparing patient and family for discharge.

4. Implementation

  • Put the Plan into Action:

    • Execute nursing interventions as outlined in the care plan.

    • Ensure interventions are appropriate for the specific client and focus on achievable outcomes.

  • Ongoing Assessment:

    • Monitor patient's response to care and adjust the plan as necessary.

5. Evaluation

  • Determine the outcomes of nursing interventions:

    • Evaluate patient compliance and document the client’s responses.

    • Assess whether goals were met and if the care plan needs revision.

Clinical Judgement

  • Essential for nurses to:

    • Notice: Recognize situations and patient cues.

    • Interpret: Analyze data and cues.

    • Respond: Implement necessary interventions.

    • Reflect: Assess the efficacy of interventions and modify as needed.

Health Assessment

  • Definition: Collecting data to assess health status, risks, and needs.

  • Attributes:

    • Subjective: Patient-reported information.

    • Objective: Observed and measurable data.

  • Holistic Assessment: Involves physical, psychological, spiritual, and functional well-being.

  • Clinical Judgement: Assessment of patient needs leading to proper care decisions.

Categories for Organizing Data

  • Systems: Organ systems in the body.

  • Functional Health Patterns: Activities of daily living.

  • Emergency Assessment: Immediate and critical evaluations for urgent issues.

Physical Assessment Techniques

  • Inspection: Visual examination.

  • Palpation: Touch to assess underlying structures.

  • Auscultation: Listening to body sounds (heart/lung sounds).

  • Percussion: Tapping to evaluate underlying structure.

Vital Signs Assessment

Key Vital Signs

  • Temperature

  • Pulse

  • Respiration

  • Blood Pressure (BP)

  • Often includes Oxygen Saturation (SpO2)

Blood Pressure Assessment

  • Normal Levels:

    • Systolic: <120

    • Diastolic: <80

  • Hypertension Stages:

    • Stage 1: 130-139 / 80-89

    • Stage 2: >=140 / >=90

Temperature Assessment

  • Methods: Oral, Rectal, Axillary, Temporal, Tympanic.

  • Influencing Factors:

    • Environment, physical activity, hormonal changes.

Respiratory Rate Assessment

  • Normal Rate for Adults: 12-20 breaths per minute.

  • Measured visually or through observation.

Cardiovascular Assessment

  • Evaluating Heart Function:

    • Pulse locations: Radial, Carotid, Apical.

    • Documenting: Rate, rhythm, strength of pulse.

  • Common Findings:

    • Cold extremities, prolonged capillary refill are signs of circulation issues.

Implications of Immobility

  • Systemic Effects:

    • Muscles: Atrophy and weakness

    • Skin: Pressure sores due to decreased blood flow.

    • Cardiovascular Complications: Risk of thrombus.

    • Gastrointestinal Motility: Decreases, leading to constipation.

Nursing Interventions for Mobility

  • Encourage early mobilization post-surgery.

  • Use passive or active range of motion exercises.

  • Collaborate with physical therapists for mobility enhancement strategies.

Conclusion

  • Effective patient care utilizes the nursing process for structured and systematic assessment, ensuring comprehensive diagnosis, planning, implementation, and evaluation of patient care.