1 data analysis

Nursing Process

Maria Carmela L. Domocmat, RN, MSN

Nursing Process
• Is the framework for professional nursing
practice.
• Nursing Process and Maslow are the main
frameworks for the local board and the
NCLEX Exams.


• Remember ONLY the RN can assess,
develop a plan of care, evaluate and
educate clients.
• Promotes humanistic, outcome-focused,
cost-effective care


• Pushes nurses to continually examine
what they are doing and to study how it
can be done better.


• Nursing Process consists of five
interrelated steps
– Assessment
– Diagnosis
– Planning
– Implementing
– Evaluating


Why learn about it?
• The nursing process provides the basis for
the board exams –you need to be
thoroughly familiar with it to think your way
to through the questions.
• It helps you think critically in the clinical
setting—you must master the principles
behind the nursing process.


• Using the nursing process complements
what other health care professionals do by
focusing on both the medical problems
and human response –how the person
responds to medical problems, treatment
plans, and changes in activities of daily
life.


• Advantages to the nurse who becomes
skilled in the use of the nursing process:


COMPARISON OF
PHYSICIAN’S DATA &
NURSE’S DATA

Physician’s data
• Disease focus
• Mrs. Garcia has pain and swelling in all
joints. Diagnostic studies indicate that she
has rheumatoid arthritis. We will start her
in a course of anti-inflammatories to treat
the rheumatoid arthritis.
• (Focus is on treating the arthritis)


Nurse’s data
• Wholistic focus –considering their
problems and their effect on the person’s
ability to function independently.
• Mrs. Garcia has pain and swelling in all
joints, making it difficult to dress herself.
She has voiced that it’s difficult to feel
worthwhile when she can’t even feed
herself. She states that she is depressed
because she misses seeing her two small
grandchildren. Carmela L. Domocmat, RN, MSN
Maria

• We need to develop a plan to help her
pain, to assist with her feeding and
dressing, to work through feelings of low
self-esteem, and for special visitations with
the grandchildren.
• (Focus is on Mrs. Garcia)


• Meet the standards of nursing clinical practice
• Graduation from an accredited school of nursing
• Confidence
• Job satisfaction
• Professional growth
• Aid in staff assignments
• Employment in a nationally accredited hospital


WHAT IS CRITICAL
THINKING IN NURSING?

Critical thinking in nursing:
• Entails purposeful, outcome-oriented
(results-oriented) thinking.
• Is driven by patient, family, and community
needs.
• Is based on principles of nursing process
and scientific method


• Requires knowledge, skills and experience
• Is guided by professional standards and
ethics codes.


• Requires strategies that maximize human
potential (e.g., using individual strengths)
and compensate for problems created by
human nature (e.g., the powerful influence
of personal perspectives, values and
beliefs.)
• Is constantly re-evaluating, self-correcting,
and striving to improve.

Critical Thinkers are:
• Aware of their strengths and
capabilities
• Sensitive to their own limitations
and predispositions
• Open minded
• Humble
• Creative


Critical Thinkers are:
• Proactive
• Flexible
• Aware that errors are stepping-
stones to new ideas
• Willing to persevere
• Cognizant to the fact that we don’t
live in a perfect world
• Introspective

DATA COLLECTION,
ANALYSIS, AND
DOCUMENTATION


Assessment
• the collection of data about an individual’s
health state
• first and most critical phase of the nursing
process


Assessment
• ongoing and continuous throughout all the
phases of the nursing process
• is systematic and continuous collection,
validation and communication of client
data as compared to what is
standard/norm


Purpose:
To establish a data base (all the information
about the client) to determine the client’s
overall level of functioning in order to make a
professional clinical judgment
To supplement, confirm, or question data
obtained in the nursing history
To obtain data that will help the nurse
establish nursing diagnoses and plan patient
care


To evaluate the appropriateness of the
nursing interventions in resolving the patient's
identified pathophysiology problems
collect data of patient’s health status, to
identify deviations from normal, to discover
the patient’s strengths and coping resources,
to point actual problems, and factors that
place the patient at risk for health problems


• Wholistic data collection.
• Nurse collects physiologic, psychological,
sociocultural, developmental, and spiritual
data about the client


nurse focuses on how client’s health
status affects his activities of daily living
(ADL) and how the client’s ADL affect is
health
Ex: client with asthma


assess how client interact within their
family, cultures, and community and how
the client’s health status affects the family
and community
Ex: client with DM who has amputation; single
parent mother of a 6 year-old child


• Data from nursing assessment can be
classified as subjective and objective.


Data include:
nursing health history
physical assessment
the physician’s history & physical
examination
results of laboratory & diagnostic
tests
material from other health personnel


Assessment
– The first step in determining the health status
of the client
– Because the entire plan of care is based on
the data collected during this phase, you need
to make every effort to ensure that your
information is correct, complete, and
organized in a way that helps you begin to get
a sense of patterns of health or illness.


Types of Assessment


Types of Assessment
• Initial comprehensive assessment
• Ongoing or partial assessment
• Focused or problem-oriented assessment
• Emergency assessment
• Time-lapsed assessment


Initial comprehensive
assessment
• assessment performed within a specified
time on admission


assessment
• Involves collection of subjective data about the
– client’s perception of his/her health of all body parts or
systems,
– past health history,
– family history, and
– lifestyle and health practices (which includes
information related to the client’s overall function) as
well as objective data gathered during a step-by-step
physical examination


assessment
When performed?
• On the initial contact with the client
• where: hospital, community, clinic or home
setting
• purpose: to have a baseline
comprehensive data about the client
• Ex: nursing admission assessment


Ongoing or partial assessment


• consists of data collection that occurs after
the comprehensive database is
established
• consists of mini-overview of the client’s
body systems and holistic health patterns
as a follow-up on his health status


• When performed?
• usually performed whenever the nurse or
another health care professional has an
encounter with the client


• purposes:
• Any problems that were initially detected in
the client’s body system or holistic health
patterns are reassessed in less depth to
determine any major changes
(deterioration or improvement) from the
baseline data.
• Brief reassessment of the client’s normal
body system or wholistic health patterns is
performed to detect new problems

Focused or problem-oriented
assessment
• consists of a thorough assessment of a
particular health problem and does not
cover areas not related to the problem
• purpose: to have a thorough assessment
on the special health concern of the client
identified in an earlier assessment


Focused or problem-oriented
assessment
• When performed?
• performed when a comprehensive
database exists for a client and he/she
comes to the health care agency with a
special health concern


Emergency assessment
• a very rapid assessment performed in a
life-threatening situations
• rapid assessment done during any
physiologic/physiologic crisis of the client
to identify life threatening problems


Emergency assessment
• purpose: to determine the status of the
client’s life-sustaining physical functions


Time-lapsed assessment
• reassessment of client’s functional health
pattern done several months after initial
assessment to compare the client’s
current status to baseline data previously
obtained.


Sources of Data


Sources of Data
• Primary source:
– data directly gathered from the client using interview and
physical examination.

• Secondary source:
– data gathered from client’s family members, significant
others, client’s medical records/chart, other members of
health team, and related care literature/journals.


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