The Nursing Process Week 3
Way of looking at something/client & helping them to maintain their health
or improve it but..
First you have to know something about them right?
Once you do some detective work you can find out what works for them and
why and what doesn’t and then you can help them
Systematic Approach
Takes knowledge from:
o Biological, physical and social sciences
Applies to unique client situations
Why?
o To ID, diagnose and treat responses to health & illness
o .
The nursing process is based on a nursing theory developed by Ida Jean
Orlando. She developed this theory in the late 1950's as she observed nurses
in action. She saw "good" nursing and "bad" nursing.
From her observations she learned that the patient must be the central
character.
Nursing care needs to be directed at improving outcomes for the patient, and
not about nursing goals.
The nursing process is an essential part of the nursing care plan.
Allows nurses to organize practice: gather data, make inferences, see patterns,
think critically & make sound decisions
Applies to: individual, family & community
Differentiates nursing practice from other HC providers practice
Dynamic and continuous
Assessment
Evaluation Diagnosis
Implementation Planning
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1st component of the Nursing Process- ASSESSMENT
Data Collection
Assessment involves taking vital signs (TPR BP & Pain assessment).
Performing a head to toe assessment
Listening to the patient's comments and questions about his health status
Observing his reactions and interactions with others. It involves asking pertinent
questions about his signs (observable) and symptoms (non-observable), and
listening carefully to the answers.
During Assessment, the nurse:
Establishes a Data Base
Continuously updates the data base
Validates data
Communicates data
ASSESMENT: FIRST STEP OF THE NURSING PROCESS
Gather Information/collect Data
Primary Source – client/Family
Secondary Source – physical exam, nursing history, team members, lab reports,
diagnostic tests
Subjective -from the client (symptom)
“I have a headache”
Objective - observable data (sign)
Blood Pressure 130/80
(no age of consent for healthcare in Canada)
Sources of Data
Client
Family and significant other
Healthcare team
Medical records
Literature (research)
Nurse’s experience
Methods of Data Collection
Interview
Nursing health history
Family history
Physical exam
Observation of client behaviour
Diagnostic and lab data
Nursing Health History
Identifying data
Reason for health interview
Current state of health
Spiritual variables
Developmental variables
Psychological variables
Sociocultural variables
History of past illnesses and injuries
Review of symptoms
Cultural Competence
Culture influences a client’s behaviour.
Consider health beliefs, use of alternative therapies, nutritional habits, relationship
with family, & personal comfort zone
Avoid stereotyping
Avoid gender bias
Comfort with the nurse’s physical closeness and contact during the exam
Assessment-collecting data
Nursing Interview (history)
Health Assessment – review of Systems
Physical Exam
INSPECTION
PALPATION- BODY FEELING
PERCUSSION
AUSCULTATION - LISTENING
Integration of Physical Assessment with Nursing Care
Integrate examination during routine nursing care:
Vital signs
Bathing
Range of motion
Activities of daily living
Analyzing Signs and Symptoms
Sign
Action or physical manifestation of something that can be observed by others
Symptom
Sensation or emotion that is perceived or experienced and reported by the client;
not observable to others
Physical Examination: Inspection
General inspection
Uses vision, hearing, and smell
Recognizes normal and abnormal
Is the simplest of five assessment skills
Vital signs
Height, weight, and waist circumference
Local inspection
CAGE questions
Palpations
Use hands to touch body parts.
Use different parts of hands to distinguish texture, temperature and
movement.
Hands should be warm, fingernails should be short.
Start with light palpation and end with deep palpation.
Percussion
Not too common
Auscultation
Involves listening to sounds
Learn normal sounds first before identifying abnormal or variations.
Requires a good stethoscope
Requires concentration and practice
} Chris is a 1st yr college student, away from
home for the first time. Chris comes to the
college health centre stating he has difficulty
sleeping, fatigue, & GI problems (abd cramps,
followed by diarrhea).
} Chris tells you:
“ the adjustment to college has been hard. I wasn’t prepared for all
the work. This is such a change from high school. I have failed 2
MTs and I have never failed an exam before. I feel so lonely and
miss my family and friends.”
} What examples of data are present in this case?
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Chris makes statements about school
Behaviours- whats causing
Stimuli- stress going through
