nursing process (adpie) recopied from the original author of this ppt jeena.aejy
DESCRIPTION
The Nursing Process (ADPIE).TRANSCRIPT
NURSING
PROCESS
Presented by: Dave Jay S. Manriquez RN.
THE NURSING PROCESS
A systematic problem-solving approach used to identify, prevent and treat actual or potential health problems and promote wellness.
Nursing process
A systematic way to plan, implement and evaluate care for individuals, families, groups and communities.
Characteristics of the Nursing Process Dynamic Client-centered Planned Interpersonal and collaborative Universally applicable Can focus on problems or
strengths
Open, flexible
Humanistic and individualized
Cyclical
Outcome focused ( results oriented)
Emphasizes feedback and validation
STEPS IN NURSING PROCESS
AssessmentNursing DiagnosisPlanningImplementationEvaluation
AssessmentAssessmentAssessmentAssessment
Nursing Nursing DiagnosiDiagnosiss
Nursing Nursing DiagnosiDiagnosiss
PlanningPlanningPlanningPlanningImplementatiImplementationonImplementatiImplementationon
EvaluationEvaluationEvaluationEvaluation
Nursing ProcessNursing Process Nursing ProcessNursing Process
Benefits of using the nursing process
Continuity of care Prevention of duplication Individualized care Standards of care Increased client participation Collaboration of care
EVALUATION
IMPLIMENTATION
PLANNING
ASSESSMENT
DIAGNOSIS
INTER RELATIONSHIP BETWEEN THE STEPS OF NURSING PROCESS
ASSESSMENT
Assessment Assessing is a continuous process
carried out during all phases of nursing process. All phases of the nursing process depend on the accurate and complete collection of data.
Assessing is the systematic and continuous collection, organization, validation and documentation of data.
- Potter and Perry( 2006)
Assessment is the deliberate and systematic collection of data to determine a clients current and past health status and to determine the clients present and past coping patterns
- Carpenito 2000 Assessment is the systematic and
continuous collection, validation and communication of patient data. - Carol Taylor
Types of Assessment 1. Initial Assessment: Performed within specified time after
admission to a health care agency Eg. Nursing Admission Assessment 2. Problem Focused Assessment: Ongoing process integrated with
nursing care to determine specific problem identified in an earlier assessment and to identify new or overlooked problems.
E.g.. Assessment of clients ability to perform self-care while
assisting client to bathe. 3. Emergency Assessment: Done during psychiatric or physiological
crisis of the client to identify life threatening problems Eg. Rapid assessment of airway, breathing and circulation
during cardiac arrest 4. Time lapsed-Reassessment: Done several months after initial
assessment to compare the clients status to baseline data previously obtained.
Assessment
ASESSMENT
Collect dataOrganize dataValidates DataDocument data
DIAGNOSIS
PLANNING
IMPLIMENTATION
EVALUATION
1.COLLECTION OF DATA
Data Collection is the process of gathering information about a clients health status.
Collection of Data:
Data base: A data base is all information about a client. It includes the nursing health history, physical assessment, the physician’s history, physical examination, results of laboratory and diagnostic tests and material contributed by other health personnel.
Medical vs. Nursing Assessments
Medical assessments Target data pointing to pathologic
conditions
Nursing assessments Focus on the patient’s response to
health problems
Types of Data:
SUBJECTIVE DATA: Also referred to as symptoms or covert data are apparent only to the person affected and can be described or verified only by that person
Eg. Itching, Pain, Feelings of worryOBJECTIVE DATA: Also referred to as signs or overt
data. These are detectable by an observer or can be measured or tested against an accepted standard.
They can be seen, heard, felt or smelled and they
are obtained by observation or physical examination Eg. A Blood Pressure Data Discolouration of the Skin
Objective Data vs. Subjective Data Objective data
Observable and measurable data that can be seen, heard, or felt by someone other than the person experiencing them
E.g., elevated temperature, skin moisture, vomiting
Subjective data Information perceived only by the affected person E.g., pain experience, feeling dizzy, feeling
anxious
Sources of Data:
Primary Source (Direct Source
client: Usually BEST source
Secondary Source (Indirect Source) Family Members
Client’s records 1. Medical Records Eg. Medical History, Physical Examination, Operation notes, Progress notes, Consultation done by Physicians 2. Records of therapies done by other health professionals
Eg. Social Workers, Dieticians, Physical Therapist 3. Laboratory Records Other health care professionals Verbal reports
Literature
Data Collection
Consider time needs of patient developmental stage physical surroundings past and present coping patterns
Data Characteristics
Complete
Factual
Accurate
Relevant
Data collection methods
OBSERVATION
INTERVIEWING
PHYSICAL ASSESSMENT
Observation To gather data using senses
Eg: laboured breathing, pallor or flushing,pain
a lowered side rail ,functioning of an equipment , pt environment and people in it etc…
Interviewing An interview is
a planned communication or a conversation with a purposeTypes of questions and SettingRapport are important
Collection of Health History
Four Phases of a Nursing Interview
Preparatory phase
Introduction
Working phase
Termination
Interview Phases
Preparatory Nurse collects background info
from previous charts Ensure environment is conducive Arrange seating
3 – 4 ft apartInterviewer at 45° angle to patient
Allow adequate time
Phases cont’d.
IntroductionNurse introduces selfIdentifies purpose of interviewEnsure confidentiality of information
Provide for patient needs before starting
Phases cont’d.
WorkingNurse gathers info for subjective
dataExcellent communication skills
are neededActive listeningEye contactOpen-ended questions
Phases cont’d.
TerminationInform patient when nearing end of interview
Ensure patient knows what will happen with info
Offer patient chance to add anything
Physical assessment Appraisal of health
status
Usually by Review of Systems
Overview of symptoms
Observable, measurable data
Objective data Possible approaches—body systems,
head to toe, or functional health patterns
Methods of physical assessment Inspection Percussion Palpation Auscultation
Problems Related to Data Collection Inappropriate organization of the
database Omission of pertinent data Inclusion of irrelevant or duplicate data,
erroneous or misinterpreted data Failure to establish rapport and
partnership Recording an interpretation of data
rather than observed behavior Failure to update the database
2.ORGANISING DATA
Nurses uses a written or computerized format for arranging he data systematically
3.VALIDATING DATA
VALIDATING -THE ACT OF DOUBLE CHECKING
Verifies understanding of information
Comparison with another source -patient or family member -record -health team member
4. DOCUMENTING DATA
Record in permanent record ASAPUse patient’s own words in
subjective data – enclose in “ ___” (quotation marks)
Avoid generalizations – be specific
Don’t make summative statements
Thank you