Is the systematic and continuous collection organization validation and documentation of data?

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Nursing process,,,Assessment

NURSING PROCESS INTRODUCTION AND PHASE 1 ASSESSMENT

NURSING PROCESS INTRODUCTION AND PHASE 1 ASSESSMENT

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Nursing process,,,Assessment

1. 1. NURSING PROCESS INTRODUCTION
2. 2. INTRODUCTION • Defined by “hall” in 1955 • 1967 Yura And Walsh proposed four elements of nursing process – Assessment – Planning – Implementation and – Evaluation
3. 3. PURPOSES • To identify a client health status and actual or potential health care problems or needs • To establish plans to meet the identified needs and to deliver specific nursing interventions to meet those needs
4. 4. DEFINITION The nursing process is a systematic, rational method of planning and providing nursing care. • The nursing process is cyclical ,that is its components follow a logical sequence , but more than one components may be involved at one time.
5. 5. COMPONENTS • Assessment • Nursing diagnosis • Planning • Implementing and • Evaluating
6. 6. CHARACTERISTICS • Dynamic • Client centered • Planned • Interpersonal and collaborative • Universally applicable • Can focus on problems and strength
7. 7. CHARACTERISTICS • Open and flexible • Humanistic and individualized • Cyclical • Outcome focused • Emphasizes feedback and validation
8. 8. BENEFITS • Continuity of care • Prevention of duplication • Individualized care • Standards of care • Increased client participation • Collaboration of care
9. 9. STEPS OF NURSING PROCESS
10. 10. ASSESSMENT
11. 11. Assessment • Assessing is the systematic and continuous collection , organization , validation and documentation of data (information) as compared to what is standard norm. • It is continuous process. • All phases of nursing process depend on the accurate and complete collection of data.
12. 12. Purposes of assessment • To establish a data base • To identify health‐promoting behaviors • To identify actual and/or potential health problems
13. 13. Types of assessment • Initial assessment • Problem focused assessment • Emergency assessment • Time lapsed assessment
14. 14. • INITIAL ASSESSMENT:- It is done within specified time after admission to Hospital • Purpose: To establish a complete data base for problem identification, reference and future comparison Eg: Admission assessment • PROBLEM FOCUSED ASSESSMENT :- Ongoing process integrated with nursing care • Purpose : To determine the status of specific problem identified in an earlier assessment Eg: Hry assessment of clients fluid intake and urinary output in an ICU
15. 15. • EMERGENCY ASSESSMENT:- During any physiologic or psychologic crisis of the client • Purpose: To identify the threatening problem and to identify new or overlooked problem Eg: Rapid assessment of person’s airway and breathing status and circulation during a cardiac arrest • TIME LAPSED REASSESSMENT:- Several months after initial assessment • Purpose : To compare the clients current status to baseline data previously obtained Eg: Reassessment of the clients functional health patterns in a home care or outpatient setting or in a hospital at shift change.
16. 16. Steps of assessment/activities in assessment phase 1. Collect data 2. Organize data 3. Validate data 4. Document data
17. 17. 1. Collection of data It is the process of gathering information a client’s health status • Systematic and continuous • Reflect the clients changing health status • Needs client and nurse active participation
18. 18. Data can be………
19. 19. Types of data Subjective data Objective data •Described by only the person who affected •Included client sensations ,feelings, beliefs ,attitudes and perception of health status Eg:- Itching Pain Feelings of worry •Referred to as signs or overt data •Related on observer •Can be measured or tested Eg:- Discoloration of skin Blood pressure
20. 20. Sources of data Client Support people Client’s records Health care professionals Literature
21. 21. Methods of data collection Observing Interviewing Examining
22. 22. Observing Observation is conscious, deliberate skill that is developed through effort and with an organized approach.  Eg:- Using the senses to observe client data • Methods observation : – Vision – Smell – Hearing – Touch • Aspects of data : – Noticing data – Selecting, organizing and interpreting the data
23. 23. Interviewing An interview is a planned communication or a conversation with a purpose Eg: Nursing health history • Approaches of an interview: – Direct interview – Indirect interview • Types of interview questions: – Closed questions (Are you having pain now?) – Open ended question (what brought you to hospital?) – Neutral questions (how do you feel about that?) – Leading questions (you are stressed about surgery tomorrow aren't you?)
24. 24. Interviewing • Planning the interview and setting: – Time – Place – Seating arrangement – Distance – Language • Stages of an interview – The opening and introduction – The body or development – The closing
25. 25. Examination • Techniques – Inspection – Palpation – Percussion – Auscultation • Physical examination can be, – Cephalocaudal approach – Screening examination – Review of systems
26. 26. 2. Organizing data The nurses use a written (or computerized) format that organizes the assessment data systematically  Conceptual models or frame works Nursing models or frame work Gordon's functional health pattern Orem’s self care model Roy’s adaptation model Wellness model Non nursing models Body system model Maslow’s hierarchy of needs Developmental theories
27. 27. Orem’s self care model……
28. 28. Body system model………….
29. 29. Maslow’s hierarchy of needs……….
30. 30. 3. Validating data Validation is the act of “double checking "or verifying the data to confirm that it is accurate and factual.
31. 31. 4. Documenting data Assessment data must be recorded and reported. Accurate and complete record communicates information to health care team.
32. 32. Thank you

What are the 3 methods of data collection in nursing?

Is the collecting validating organizing and recording of data about patient's health status?

Which phase of nursing process is collecting and organizing data?

What are the methods used for data collection when assessing a client?