Summary Developing a Nursing Care Plan

What is Nursing Process: A process: is a series of steps or acts that lead to accomplishment of some goals or purpose. Nursing process: is a problem solving approach to meeting the health care and patient ´s needs. Its purpose is to: 1. Identify, prevent, and treat actual or potential health problems or need and promote wellness. 2. Establish plans to meet patient ´s needs. 3. Provide individualized, holistic, effective client care efficiently to meet those needs. Phases of the nursing process: Phases of the nursing process: AAssessment (ssessment (of patient'of patient's needs). s needs). DDiagnosis (of human response to needs). iagnosis (of human response to needs). PPlanning (of patient's care). lanning (of patient's care). IImplementation (of care). mplementation (of care). EEvaluation (of the implemented care). valuation (of the implemented care). Components of the Nursing Process Components of the Nursing Process 1 1. Assessment: . Assessment:  Assessments vary according to their purpose, Assessments vary according to their purpose, timing, time available, and client status. timing, time available, and client status.  It is also carried out during the implementing It is also carried out during the implementing and evaluating phases. and evaluating phases.  For instance, while actually administering For instance, while actually administering medications (implementing), the nurse medications (implementing), the nurse continuously notes the clientcontinuously notes the client’’s skin color, level of s skin color, level of consciousness, and so on. consciousness, and so on. Type of assessment Type of assessment Type of assessment: Type of assessment: 1 1. Initial (comprehensive) assessment:. Initial (comprehensive) assessment: A. A. Examines the patient Examines the patient’’s overall health status.s overall health status. B. B. Performed within specified time upon admission Performed within specified time upon admission to health care health care agency. C. C. Provide a database for problem identification, Provide a database for problem identification, reference, and future ence, and future comparison. D. D. e.g., nursing admission assessment. e.g., nursing admission assessment. Type of assessment: Type of assessment: 2 2. Problem. Problem--focused assessment:focused assessment: A. A. May be initial or ongoing process integrated May be initial or ongoing process integrated with nursing nursing care. B. B. Performed to determine the status of a specific Performed to determine the status of a specific problem identified in an earlier em identified in an earlier assessment. C. C. e.g., hourly assessment of client e.g., hourly assessment of client’’s fluid intake s fluid intake and urinary output in an ICU.and urinary output in an ICU. Type of assessment: Type of assessment: 3 3. Emergency assessment:. Emergency assessment: A. A. Performed during any physiological or Performed during any physiological or psychological crisis of the client. psychological crisis of the client. B. B. Performed to identify life Performed to identify life--threatening problems, threatening problems, and to identify new to identify new problems. C. C. e.g., rapid assessment of airway, breathing, and e.g., rapid assessment of airway, breathing, and circulation during a cardiac lation during a cardiac arrest. Type of assessment: Type of assessment: 3 3. Time. Time--lapsed reassessment:lapsed reassessment: A. A. Can be performed several months after initial Can be performed several months after initial sment. B. B. To compare the client To compare the client’’s current status to s current status to baseline data previously ine data previously obtained. C. C. Reassessment of a client Reassessment of a client’’s functional health s functional health patterns in a home care or outpatient setting or, patterns in a home care or outpatient setting or, in a hospital, at shift a hospital, at shift change. Data collecting methods: Data collecting methods: The principal methods used to collect data are: The principal methods used to collect data are: A. A. Observing, Observing, B. B. Interviewing involving (closed and open Interviewing involving (closed and open--end end questions), and questions), and C. C. Examining ( Examining (the nurse uses techniques of the nurse uses techniques of inspection, auscultation, palpation, and inspection, auscultation, palpation, and percussionpercussion).). Sources of data collected by assessment methods: Sources of data collected by assessment methods: A. A. Primary sources:Primary sources: 1. 1. Client is the primary source of data. Client is the primary source of data. Using both interview techniques and Using both interview techniques and physical examination skills for gathering physical examination skills for gathering information from the mation from the client. Sources of data collected by assessment methods: Sources of data collected by assessment methods: B. B.Secondary sources:Secondary sources: Data source from other than the client are Data source from other than the client are considered secondary source:considered secondary source: 1. 1. Family members. Family members. 2. 2. Other health care providers, and Other health care providers, and 3. 3. Medical records. Medical records. Types of data collected by assessment methods: Types of data collected by assessment methods: A. A. Subjective data (Subjective data (symptomssymptoms): ): 1) 1) Data from the client Data from the client’’s point of view provided s point of view provided verbally by the patient and include feelings, verbally by the patient and include feelings, perceptions, and ptions, and concerns. 2) 2) Interview is the primarily method of collecting Interview is the primarily method of collecting subjective information. subjective information. Steps of collecting subjective data: Steps of collecting subjective data: Obtain a patient history by asking the patient Obtain a patient history by asking the patient and family questions about:and family questions about: a. a. Patient Patient’’s past and present health problems, s past and present health problems, including specific questions about each including specific questions about each body system,body system, b. b. Family health problems, and risk factors for Family health problems, and risk factors for health problems. health problems. c. c. The patient The patient’’s medical record may also be s medical record may also be consulted for background history consulted for background history information. information. Begin with the patientBegin with the patient’’s chief complain . s chief complain . Types of Data collection by assessment methods: Types of Data collection by assessment methods: Examples of subjective information : Examples of subjective information : A. A. I have had pains in my legs three days ago. I have had pains in my legs three days ago. B. B. I have had headache, nausea, pain, numbness, I have had headache, nausea, pain, numbness, dizziness for three hours ness for three hours ago. Types of Data collection by assessment methods: Types of Data collection by assessment methods: B. B.Objective data (Objective data (signssigns):):  Observable and measurable data. Observable and measurable data.  Obtained through physical examination and the Obtained through physical examination and the result of laboratory and diagnostic tests. result of laboratory and diagnostic tests.  Primary method of collecting objective Primary method of collecting objective information is the physical examination. information is the physical examination.  Inspection, palpation, percussion, and Inspection, palpation, percussion, and auscultation techniques are used to collect auscultation techniques are used to collect objective tive data.