“ Nursing Process somine nuess variety of situations. In every clinical situation iis important fora nurse ta think eitcally and make sound omens. so that the client ultimately receives the best nursing care. The nursing process i a variation of scientific reasoning ‘Movs Purses organize and systematize nursing practice. The nurse makes inferences about the meaning of a client’ lth problems or generalizes abut the client’ functional state of health. A pattern will begin to form and the A aninaes to collect more information elaborating tanto a nursing process using, her/his critical thinking skills, Critical Musgisan active, organized, cognitive process used to carefully examine one’s thinking and the thinking of others. Reis more jsyos yroblem solving, i is an attempt to continually improve, how to apply onesel when faced with problems in client care sep es Plustorcat re Sung process can he seen throughout the history of nursing. During the time of Hippocrates. when the profession of medicine rcned the profession of nursing evolved simultaneously hecause every ill person needed someone to care. Initially, it was famiy member later replaced by men and women from various religious orders, Thus, trial and error method was the most «xenon fem of early problem solving in client care, Florence Nightingale introduced the concept of formal training for nurses ‘eich equpped the nurses to think entically and approach the problem, Jays narsing process, as we know it, has evolved over many years. In 1955, Hall first described nursing as a process, then ve the next few years the actual steps were identified by different nurses. In 1967, Yura and Walsh identified the four step, asssment, Hanning, implementation and evaluation. During mid 1970s other nurses added a fifth step that of diagnosis. Since thr time nursing process has been clearly recognized as the guiding framework for nursing practice. E Qlorrmtion Tenurang process isa problem-solving approach used by nurses to meet the need of the client. Its a deliberate method that ‘nho onthe use of cognitive, interpersonal and psychomator skills. + Yersand Walsh describe the nursing process as a set of actions to assist the clients in maintaining optimal wellness, ANA defines - the nursing pracess is used to identify, diagnose and treat human responses to health and illness Ht is @ énamie continuous process, which allows a nurse to modily care as the clients need changes. The use of nursing process Tromtes individualized nursing cate and assists the nurse to respond to clients needs in a timely and reasonable manner, CHARACTERISTI S OF NURSING PROCESS Data from cach phase provide input to the next phase. Nursing process is 8 regularly repeated event or sequence of events 2 o¢e| that i continuously changing (dynamic) rather than staying the same (static) * Tyenursing proces is client centred It organizes plan of care according to client problems rather than nursing goals, * tisanadapaion of problem-solving and aystem theory. Is divected towards a client response tollness ‘eeet their needs, Scanned wth CamScannerTextbook of Advanced x As a icable in all clini “The uiniverslly applicable characteristics of nursing Process ae Wis appl allelinica set . s ar ing process. ) 1 Nurses must use ertical thinking skills to carryout NUrSIET he MBS for gy We, Ms EPS Nursing process has five steps: + Assessment + Planning + Evaluation «Nursing diagnosis + Implementation Assessment Assessment is the deliberate and syst status and coping strategies Nursing assessment includes two steps . Calletion ‘and verification of data from a primary source (client) and secondary source (family, health Profes exyatc collection of data to etermine a cent’ current 3nd past hth ey, fe Ma ee, medical records), | y + Analysis ofall the data asa basis for developing nursing diagnosis and an individualized nursing care plan frye leg Purposes of Assessment + Toeestablish a data about the client’ perceived needs, health problems and responses to these problems, + To get data that reveal related experiences, health practices, goals, values, expectations about the healthcare suey nurse apples principles of critical thinking when conducting a client assessment. The assessment must be relevant tical healthy problem. The muse snst be able to differentiate important data rom the data mass. Acveisthe nt, that the nurse uses through the use of 5 senses, Higher level of judgement develops over time and experience " ‘Two Approaches may be Used Use of a Structured Data-base Format + This helps in comprehensive assessment. Nurses, assessment moves from general to specific, focusing on the pretene ing areas, Nurse identifies functional patterns (patient strength) and dysfunctional patterns (nursing diagnosis) Problom-oriented Approach + The nurse focuses on the client's presenting situation, Assessment begins with problem area and spreads out tort areas of client’ if, Whatever the approach uscd, the nurse clusters the data and identifies emerging problems andptsd | problems, Types of Assessment Initial Comprehensive Assessment ‘An initial assessment, also called an admission assessment, is performed when the client enters a healthcare from abesth#* agency. The purposes ars to evaluate the clients health status, to identify functional health patteens that are problemsit!” provide an in-depth, comprehensive database, which is critical for evaluating changes in the client's health status ins assessments. Problem-focused Assessment ces @ probler that has already been identified. ‘This type of # whe he initial assessment. In focus assessments, nurse determines Problem has changed (i.e. improved, worsened, or resolved) Tis ' OF misdiagnosed problems. In intensive care units, nurse MY problems still exists and whether the status of the also includes the appraisal uf any new, overlooked assessment every few minutes, Scanned wth CamScanneratening situatiot fe isthe top priority, Time iso the risays dient’ difficulties involve insin which the preservation of i -c in life-thre® Mi and intervention for the ‘chent’s health problems. Often the 1 ofa ile ABC). Abrupt changes 19 Hn aap ouicdal thoughts) a roles OF Fee ships ent acts) cart also initiate 4M tmergency. Emergency assessment ecuyes on few essential health ensive x “ nt or Ongoing ssessment uF ki ess valuate any changes in the ment ansher 17 af Aes takes place afer the initial asessment £667 ; ee est Nurses petfordt 1 Tapsed reassessment when substantial periads of time have elapsed between (pes eer peri output patient Mite vsits, home health visits health and development serectings) wie ee -cpgi0 ASSESSMENT cnn of att + Cetin data collection Gpyective data collection 4 anon of 63a * Peanzaton of ae dion of data iingidacumentat Observation of the patient Family and SO + Examinat Binzes OF DATA subjective Data Chet perception abo Res Assessment = out the health problem, Objective Data Okerratons and measurements made by th aes ever Kft tis. Cheat i ‘ ‘evarcefrsojectve data Clients wh a0 ‘smaploms, may nat be able to provide del fanily and Significant Others. “ej arc interviewed for primary te : aithcare Team Members © Be information 7 information about how the client reac Weteal Records i Provides, ‘data about the client's medical hist data collector. [ti based on the accepted st formation when the client is + Interview of patient ofthe patient + Review of medical record a. Cliont says there is pain over the left wrist. ndards. eg. Nurse finds swelling and rented and ean answer can provide mast accurate data. But clients experiencing ailed information. ‘an infant, client is citically-ill, mentally handicapped se to health care professionals to procedures, investigations, respanse 10 vistors tory, tests and treatment’ Scanned with CamScannerTextbook of Aken Ne Other Records Educational, military, employment records give information about clients past health status, tacational, military, emplo mM Literature Review of medical, nursing, pharmacological literatute helps to complete assessment Nurse's Experience ¢ nuurse 10 assess correctly and wisely. Past experience and relevant knowledge helps the nurse 10 asses ly ly. Methods of Data Collection ‘vis an organized conversation with the client to obtain history and current illness. Phas. *Qreain: whi the muses nraduce self and the purpose of interview: This haps ts dean yg i i, client, + Working phase: Actual gathering of information takes place. + Termination phase: Nurse concludes the interview and su be terminated in a positive and friendly manner. eS of iMterview are, marises the data cross-check with cient for eeu, Y Ig collected about the current level of illness, review of body systems, family history Feaction to illness. In the Assessment Phase, obtain a Nur obtain a detailed health record af a client. spiritual, mental an en, sing Health History -» structured interview designed to cle spcieda " irsing Health History + Biographic data ~ name, address age. sex, matrial status, occupation, religion, Reason for vist/chief complarat - Primary reason why client sock History of present illness ~ includes: usual health statu + Past healts histor tultation of hospitalization. ', chronological story, family history, disability assesment nncludes all previous immunizations, experiences with iliness, Family history ~ reveals risk factors for certain diseases (1 + Review of systems ~ review labetes, hypertension, cancer, mental illnes) of al health problems by body systems + Lifestyle includes personal habits, diets, slee + Social data conditions + Psychological data ~ informstion about the cli + Pattern of health care ~ POF test patterns, activities of daily living, recreation or hobbies ~ Includes family relationships, ethnic and educational background. economic status, home and neghso" ents cmational state. ‘cludes all healthcare resources: hospitals, ics, health centers, family doctors. Diagnostic and Laboratory investigation Data ‘The nurse must go through all investigation results and i 'erpret the deviations from normal, Observation NWused to gather data by using the five senses and instruments, Physical Examination Systematic detailed examination ofall systems are carried out Scanned wth CamScanner