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NURSING PROCESS
Six Phases of the Nursing Process
1.
Assessment. Is collecting, validating, organizing and recording data about the clients health
status (may be an individual, family or community).
Collection of data.
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9. Psychologic data. Includes general survey of appearance and behavior, major stressors,
usual coping pattern, communication style, self-concept and mood.
Functional health Framework. Evaluates the effects of the mind, body and
environment in relation to a person's ability to perform the tasks of daily living. This health
assessment framework organizes data collection in terms of Gordon's 11 functional health
patterns:
2. Head - to - Toe Framework. This system of collecting data starts from the head and proceeds
systematically to the toes.
General: General health state, VS and weight, nutritional status
Head: hair, scalp, eyes, ears, oral cavity, cranial nerves
Neck
Chest
Abdomen
Extremities
Genitals
Rectum
Physical Health Examination
Conducted from the head to the toes (cephalo-caudal technique): skin, hair, nails, head, face,
ears, eyes, nose, sinuses, mouth, throat, neck, breasts, and axillae, thorax/back, heart and
peripheral vessels, upper extremities, abdomen, anus and rectum, genitals, and lower
extremities.
Determine the mental status and LOC or state of awareness at the beginning of physical
examination.
Protect the client's privacy during the entire procedure. Invasive procedures cause feelings of
embarrassment.
Prepare the needed articles and equipment before start of procedure. To conserve time, effort
and prevent fatigue in the client.
Modes of Examination
2. Inspection. Assessing by using the sense of sight.
3. Palpation. Examining the body using the sense of touch. Use the fatpads of the fingers.
4. Percussion. Tapping body parts to produce sounds.
5. Auscultation. Listening to body sounds with the use of stethoscope
Positions
1.
Dorsal recumbent. Back-lying position with the knees flexed and hips
externally rotated.
2. Dorsal/supine. Back-lying position with or without a pillow.
3. Sitting or seated, position. Back unsupported and legs hanging freely.
4. Fowlers
a. Semi-Fowlers. Head of bed elevated at 15-45 degree angle.
b. High Fowlers. Head of bed raised at 80 90 degree angle.
5. Lithotomy. Back-lying position with feet supported in stirrups.
6. Genupectoral/Knee-Chest. Kneeling position with torso at 90 degrees angle to hips.
7. Lateral Side. Lying position.
8. Sim's. Semi -prone position.
9. Prone. Face-lying position, with the head turned to side. Also abdomen-lying position.
During physical examination of the abdomen, it is important to flex the knees to relax
the abdominal muscles, thereby facilitating the examination of abdominal organs.
3.
The sequence of examining the abdomen is as follows: right lower quadrant, right
upper quadrant, left upper quadrant and left lower quadrant. (RLQ, RUQ, LUQ, LLQ)
4.
The best position when examining the chest is sitting/upright position. This permits
examination of both the anterior and posterior chest.
5.
The best position when examining the back is standing position. This enables the
examiner to assess the posture and the gait of the client.
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6.
7.
To palpate the neck for lymphadenopathy or enlargement of the thyroid gland, the
nurse stands behind the client.
If opthalmoscopy is done, darken the room for better illumination.
8.
If instrument vaginal examination is done, pour warm water over the vaginal
speculum before use. To ensure comfort.
9.
General Survey
To assess the general appearance and behavior of an individual age, sex, race
body built, ht., wt. In relation to the client's age, lifestyle and health
posture and gait
hygiene and grooming
body and breath odor
signs of distress
obvious signs
attitude
affect and mood
speech
thought process
Types of Data:
a. Subjective data (symptoms). Those that can be described only by the person
experiencing it.
b. Objective data (signs). Those that can be observed and measured.
Sources of Data:
a. Primary: Patient/ Client.
b. Secondary: Family members, Significant Others, Patient's
Team Members, Related Literature.
Record/Chart, Health
2.
P - problem
R - related to factors
3.
P - problem
E - etiology
S -signs and symptoms
Purposes:
To provide individualized care.
To promote client participation.
To plan care that is realistic and measurable.
To allow involvement of support people.
Activities During Outcome Identification:
Establish priorities.
A priority is something that takes precedence in position, deemed the most important
among several items. Priority setting is a decision - making process that ranks the order of
nursing diagnoses in terms of importance to the client.
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c. use Maslow's hierarchy of needs; Physiologic needs are given priority over
psychosocial needs.
d. consider something that is very important to the client.
e. clients with unstable condition should be given priority over those
with stable conditions.
f. consider the amount of time, materials, equipment
to care for clients.
required
High - priority nursing diagnoses are those that are potentially life - threatening and require
immediate action. Examples include Impaired Gas Exchange, Ineffective Breathing Pattern,
Self - Directed Risk for Violence.
Medium - priority nursing diagnoses are those that could result in unhealthy consequences,
such as physical or emotional impairment, but are not life - threatening. Examples include
Fatigue, Activity Intolerance, Ineffective Coping, Dysfunctional Grieving.
Low - priority nursing diagnoses involve problems that usually can be resolved easily with
minimal interventions and are unlikely to cause significant dysfunction. Examples include
sensation of hunger in a client who is on NPO (nothing by mouth), in preparation for a
diagnostic procedure; minimal pain on the third postoperative day, related to ambulation.
Establish clients goals and outcome criteria.
A client goal is an educated guess, made as a broad statement, about what the clients
state will be after the nursing intervention is carried out.
Behavioral goals are written to indicate a desired state. They contain an action verb and a
qualifier that indicate the level of performance that needs to be achieved.
Examples of behavioral verbs used in client goals are as follows:
calculate
distinguish
participate
classify
draw
practice
communicate
explain
recall
compare
express
recite
define
identify
record
demonstrate
list
state
describe
name
use
construct
maintain
verbalize
contrast
perform
Goals may be short term or long term. Short term goal (STG) can be met in
a relatively short period (within days or less than a week). A long term (LTG) requires
more time (several weeks or months).
4. Planning. Involves determining beforehand the strategies or course of actions to be taken before
implementation of nursing care. To be effective, involve the client and his family in planning.
Purposes:
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The plan of care is a step - by - step process. This is
Purpose: To carry out planned nursing interventions to help the client attain goals and achieve
optimal level of health.
Activities:
Reassessing. To ensure prompt attention to emerging problems.
Set priorities. To determine the order in which nursing interventions are carried out.
Perform nursing interventions. These may be independent, dependent, or
collaborative measures.
Record actions. To complete nursing interventions, relevant documentation should be
done.
CRITICAL TO REMEMBER:
SOMETHING THAT IS NOT WRITTEN IS CONSIDERED AS NOT DONE.
Requirements of Implementation
1. Knowledge. Include intellectual skills like problem - solving, decision - making and teaching.
2. Technical Skills. To carry out treatments and procedures.
3. Communication Skills. Use of verbal and non - verbal communication to carry out planned
nursing interventions.
4. Therapeutic Use of Self. It is being willing and being able to care.
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6. Evaluation. Is assessing the client's response to nursing interventions and then comparing the
response to predetermined standards or outcome criteria.
Purpose: To appraise the extent to which goals and outcome criteria of nursing care have
been achieved.
Activities:
Collect data about the client's response.
Compare the client's response to goals and outcome criteria.
The four possible judgments that may be made are as follows:
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A. Manual
Technical Skills
B. Intellectual
Critical Thinking
Careful deliberate,
goal directed to solve
problems/
Make decisions
Keeping an open
mind
C. Interpersonal
To establish
positive
interpersonal
relationships, with
clients, co-workers
(requires
communication
skills)
Willingness to Care
Keep the focus on what is best for the patient.
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1.
2.
3.
4.
5.
6.
7.
8.
9.
Caring Behaviors
Inspiring someone / instilling hope and faith.
Demonstrating patience, compassion and willingness to persevere.
Offering companionship.
Helping someone stay in touch with positive aspect of his life.
Demonstrating thoughtfulness.
Bending the rules when it really counts.
Doing the little things
Keeping someone informed.
Showing your human side by sharing stories