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1

Nursing Process

Assessment/Data Collection
Nursing Diagnosis
Planning
goals/outcomes
care/ interventions
Implementation
Evaluation

2

Nursing Process: Assessment

Collect data
Review of the clinical record
Interview
Health history
Functional assessment
Physical exam
Consultation
Review of the literature

Subjective: History

Objective: Exam

3

DATA BASE

Subjective Findings

Objective Findings

Lab/Diagnostic Results

4

DIAGNOSTIC REASONING

Analyze data and draw conclusions.
Formulate hypothesis (“hunch”).
Develop “list”…
Cluster data in groups
Validate data

5

Nursing Process: Diagnosis

Interpret data
Identify clusters of cues – compare clusters
Make inferences
Validate inferences
Identify related factors
Document the diagnosis

Clinical judgment about client’s response to “actual” or “potential” health state

6

TYPES OF NURSING DIAGNOSES

ACTUAL DIAGNOSES

RISK DIAGNOSES

WELLNESS DIAGNOSES

7

Nursing Process: Planning

Establish priorities
Identify interventions
Document the plan of care

8

Nursing Process:

Outcome Identification

Identify expected outcomes
Individualize to the person
Realistic and measurable
Include a time frame

9

Nursing Process:

Implementation

Review planned interventions
Schedule and coordinate total health care
Collaborate with other team members
Supervise implementation of care plan
Counsel person and significant others - teaching
Involve person in health care plan
Refer for continuing care
Document care provided

10

Nursing Process:

Evaluation

Refer to expected “outcomes”
Evaluate individual’s condition and compare actual outcomes with expected outcomes
Identify reasons for failure to achieve “expected” outcomes
Take corrective action to modify plan of care
Document evaluation in plan of care

11

Evidence Based Practice (EBP)

SYSTEMIC APPROACH TO PRACTICE

EMPHASIZES “BEST EVIDENCE”
(RESEARCH BASED EVIDENCE)

COMBINES “BEST EVIDENCE” WITH…
MEDICAL DIAGNOSES
NURSING DIAGNOSES

12

Nursing diagnoses

are clinical judgments about a person’s response to an actual or potential health state

13

Biomedical model

Health as absence of disease

Health and disease are opposite extremes on linear continuum

Disease is caused by specific agents or pathogens

A natural progression to health promotion and disease prevention rounds out our concept of health

Guidelines to prevention emphasize link between health and personal behavior

14

WELLNESS MODEL

Dynamic processes

Continually moving toward “wellness”

15

HOLISTIC MODEL

MIND, BODY, SPIRIT = ONE ENTITY

Each part affects the others

16

HEALTH PROMOTION/DISEASE PREVENTION MODEL

Health and behavior are connected and inter-related”

17

NURSING MODEL “MIXTURE”

HOLISTIC MODEL

HEALTH PROMOTION/DISEASE PREVENTION

INCLUDES CULTURE, VALUES, FAMILY, SOCIAL ROLES, SELF-CARE BEHAVIORS, ETC.

18

Data Bases - 4 Types

1. Complete Data Base (complete history and physical examination)

2. Episodic or Acute Problem-Centered Data Base (focused assessment)

3. Follow-up Data Base (re-check)

4. Emergency Data Base (emergency assessment)

19

What is Culture

Culture is composed of all verbal and behavioral systems that transmit meaning

Culture is learned

Culture is shared

Culture is the result of adaptation to the environment

Culture is universal

Culture is dynamic

20

Becoming Culturally Competent

Cultural Sensitive
Cultural Awareness
Cultural Knowledge
Cultural Skill
Cultural Encounter
Cultural Desire

21

Cultural Assessment

Health Beliefs/Practices
Religious Beliefs/Practices
Language/Communication
Family Structure
Other Support Systems
Dietary Practices/Nutrition
Educational Level

22

Principles of setting priorities

1. Airway problems
2. Breathing problems
3. Cardiac and circulation problems
4. Vital sign concerns (high fever)

23

Guide for cultural care

Preparing:
1. discover and understand your own heritage, cultural values, biases, and traditional health beliefs and practices.
2. Aquire basic knowledge of cultural values and health/health beliefs and practices for patient groups that you serve

RESPECT

24

Internal factors

Internal factors are those particular to the examiner, what you bring to the interview.

1. Liking Others
2. Empathy
3. The ability to listen

25

External Factors

Prepare the physical setting.

1. Ensure privacy
2. Refuse interruptions
3. Dress
4. Note taking

26

PURPOSE OF CLIENT/PATIENT INTERVIEW

Obtain a health history
Begin a relationship with the patient
Teaching and learning
One of the most important parts of health care process.

27

MEASURES TO RELIEVE ANXIETY AND CREATE CLIMATE OF TRUST

Behavior of interviewer important
Non-judgmental attitude
Establish verbal contract
Emphasize therapeutic goals/purpose
Confidential
Concentrate on “what the patient is saying”

28

INTERVIEW COMPONENTS

INTRODUCTION

WORKING PHASE
Data gathering phase. Use of open and
closed ended questions.

CLOSURE

29

Responses of the interviewer

Facilitation- Encourage the patient to say more such as nodding, saying go-on, continue, mmmk uh-huh.

Silence- use after open ended questions

Reflection- repeating what the patient said so that it shows that you were listening.

Empathy- an empathetic response recognises a feeling and puts it into words.

Clarification- Use this when a patients word choice is ambiguous or confusing. Example, tell me what you mean by...

Confrontation- this shifts the interview from the patients perspective to yours. (confrontation, interpretation, explanation, and summary)

30

10 COMMON TRAPS

False reassurance
Giving unwanted advise
Using authority
Using avoidance language
Distancing
Using professional jargon
Using biased or leading questions
Talking too much
Interrupting
Why questions