NCM 103 Lec Finals

Week 15 Reviewer
Unit 1
Nursing Process
• Nursing as a Science
Nursing Care Plans/Concept Maps
• Utilize the process to construct an individualized plan of care for a patient
based on critical analysis of assessment data.
• Systematic method of giving humanistic care. (Cost effective manner)
Nursing Process
• Evolves, from 3 steps, to 4 (APIE), to 5 (ADPIE), now 6 (ADOPIE).
• Synonymous with problem solving approach for health care needs.
• Through this, nursing was able to build its own body of knowledge.
Nursing Care Plans
• Written guidelines for client care.
• Organized to quickly identify nursing actions.
• Coordinates resources, enhances continuity of care.
• Organizes information for change of shift report.
Theorists
Lydia Hall
• Originated the term Nursing Process.
• 3 steps: Note Observation (assessment), Administration of Care
(implementation), Validation (Evaluation). (1955)
Dorothy Johnson
• 3 steps: Assessment, Decision (planning), Nursing Action (implementation).
(1959)
Ida Orlando
• 3 steps: Client’s Behavior (assessment), Nurse’s Reaction (planning), Nurse
Actions (implementation). (1961)
Yura An Walsh
• 4 components: Assessing, Planning, Implementing, Evaluating. (1967)
Knowles
• 4 steps: Discover, Delve, Decide, Do Discriminate. (1967)
American Nurses Association (ANA)
• Innovations: distinguished Diagnosis as a separate step of the NP. (1973)
• Diagnosis of actual and potential Health Problems. (1980)
• Outcome Identification is also differentiated as distinct step, thus 6 Steps.

Purposes of Nursing Process

• Identify health status to actual/potential HC problems & needs.
• Establish plans to meet identified needs.
• Deliver specific nursing interventions to meet needs.
Characteristics of Nursing Process
• Cyclic
• Dynamic nature
• Client- centered
• Focused on problem- solving and decision making
• Interpersonal and collaborative style
• Universal
• Use of critical thinking and clinical reasoning
Why use the Nursing Process for Care Plans
• Requirement set by national practice standards (ANA, TJC).
• Basis for NCLEX.
• Based on principles and rules that promote critical thinking in nursing.
STEPS OF THE NURSING PROCESS
1. Assessment
• The first step in determining health status.
• Gathering of information (put pieces of health puzzle together).
• Entirety of plan is based on the data collected, so it needs to be
complete and accurate.
• Collect, verify, organize data, identify patterns, report and record data.
• Report significant abnormalities immediately.
What data is Collected?
• Nurse is expected to first perform an assessment when encountering a
patient, to identify health problems, and physiological, psychological,
and emotional state.
• Most common approach in gathering information is Interview.
• Physical examinations, Referencing patient’s health history, Obtaining
patient’s family history, and General observation are also used to collect
assessment data.
Assessment (another juju definition)
• Deliberate & systematic collection of data to determine client’s current
and past health status, functional status, and to determine client’s present
& coping pattern.
• Focus upon client's response to health problems.
“Assessment is a part of each activity the nurse does for and with the
patient” -Atkinson & Murray, 1991
• To be most useful, data collected should be relevant to particular health
problem. Therefore, nurse should think critically about what to assess.
“Nursing assessment should include client’s perceived needs, health
problems related experience, health practices values & lifestyles” -Bandman
& Bandman, 1995
Health Assessment
• Essential nursing function that provides foundation for quality nursing care
and intervention.
• Helps to identify strengths of client in promoting health and needs &
clinical problems.
• Evaluates responses of person to health problems & interventions.
A Health Assessment Includes:
• Health History: Physical Assessment
• Additional necessary factors assessed: Psychological, sociocultural,
spiritual, economic, lifestyle.
• Nursing process begins with complete and accurate HA.
The Nurse and HA
• Accurate and thorough HA reflects Knowledge and Skills of Professional
Nurse.
Purposes of Assessment
1. Collect data pertinent to patient’s health status. – Subjective/Objective
2. Identify deviations from normal.
3. Discover strengths, limitations, and coping resources.
4. Pinpoint actual problems.
5. Spot factors that place patients at risk of health problems
6. Build rapport with patients and families.
Critical Thinking
• Purposeful, outcome directed (result) thinking.
• Driven by patient, family, community needs.
• Based on nursing process, evidence-based thinking, scientific method.
• Requires specific knowledge, skills, experience.
• Guided by professional standards, and codes of ethics.
• Continually reevaluating, self-correcting, striving for improvement.
Diagnostic Reasoning
• Gathering and Clustering data to draw inference and propose diagnoses,
is based on nurses’ critical thinking.
• Seven step process used in context of HA:
1. Identify abnormal data, strengths.
2. Cluster data.
3. Draw inferences.
4. Propose nursing diagnoses.
5. Check for presence of defining characteristics.
6. Confirm or rule out nursing diagnosis.
7. Document conclusions.
• Collaborative problems.
Critical Thinking Approach To Assessment
• Assessment involves collecting information from the patient and from
secondary sources (e.g., family members), along with interpreting and
validating the information to form a complete database.
• Two stages of assessment:
o Collection and verification of data
o Analysis of data
5 Activities Needed to Perform a Systematic Assessment
• Collect data
• Verify data
• Organize data
• Identify Patterns
• Report & Record data
PURPOSE: To Establish A Database
• Activities during assessment.
• Collection of data- gathering information about the client considering the
physical, psychological, emotional, sociocultural, and spiritual factors that
may affect his/her health status.
Comprehensive Data Collection
• Begins before you actually see the patient. (Nurse report from ER, Chart
reviews)
• Continue with the admission interview and physical assessment once you
meet the patient.
• Other information resources include: family, significant others, nursing
records, old medical records, diagnostic studies, relevant nursing
literature.
• Consider age, growth & development.
What's Important Data?
• Name, age, gender, admitting diagnosis
• Medical/surgical history, chronic illnesses
• Advanced Directives
• Laboratory Data/Diagnostic tests
• Medications
• Allergies
• Support Services
• Psychosocial/Cultural Assessment
• Emotional state
• Comprehensive Physical Assessment
Comprehensive Physical Assessment
• Vital signs
• Height & weight
• Review of systems (neurological/mental status, musculoskeletal,
cardiovascular, respiratory, GI, GU, skin and wounds.
• Standardized risk assessments: Pressure ulcers, falls, DVT
TYPES OF DATA
Subjective data (Covert)
• What patient says about self during history taking- patient is the primary
source.
• Patient's verbal descriptions of their health problems.
Objective data (Overt)
• What you observe during physical examination using techniques-
measurable information- vital signs, auscultation, visual appearance, lab
values.
• Observations or measurements of a patient's health status.
Developing the Nurse-Patient Relationship for Data Collection
Sources of Data
Primary:
• Patient Interview, observations, physical examinations. (best source)
Secondary:
• Family and significant others. (Obtained patient agreement first)
• Health Care Team
• Medical Records
• Scientific Literature
Types of Assessment
1. Initial Assessment
• Done within specified time after admission to Hospital.
• Purpose: To establish a complete data base for problem
identification, reference, and future comparison.
Example: Admission Assessment
2. Focus/Ongoing Assessment
• Purpose: Determines the status of a specific problem identified in the
earlier assessment & to identify new or overlooked problem.
Example: Hourly Fluid Intake Output Assessment
3. Emergency Assessment
• During any physiologic and psychologic crisis of the patient.
• Purpose: To identify life threatening problems.
Examples: ABC Assessment in Cardiac Arrest
Assessment of Suicidal Attempts on Violence
4. Time Lapsed Assessment
• Several months after the initial assessment.
• Purpose: To compare current status to baseline data obtained.
Example: Reassessment of clients’ functional health patterns in home
care.

2. Diagnosis
3. Outcomes
4. Planning
5. Implementation
6. Evaluation