Nursing Process
NURSING NOTES http://www.nursingnotes.info/
FIVE (5) PHASES OF NURSING CARE
(American Nurses Association (ANA) Standards of Clinical Nursing Practice)
I. ASSESING – is the systematic and continuous collection, organizing, validation, and documentation of data. PURPOSE: To establish a database about client’s response to health concerns or illness and the ability to manage health care needs.
TYPES OF ASSESSMENT:
TYPE TIME PERFORMED PURPOSE EXAMPLE
Initial Assessment Within specified time after admission To establish a complete data base for problem identification, reference and future comparison Nursing admission assessment
Problem-focused assessment Ongoing process integrated with nursing care To determine status of specific problem identified in an earlier assessment
To identify new or overlooked problems I & O q 1 hr in ICU
Assess client’s ability to perform self care while assisting to bathe
Emergency Assessment During any physiologic and psychologic crisis of the client To identify life-threatening problems Rapid assessment of ABC during cardiac arrest
Assessment for suicidal tendencies and potential for violence
Time-lapsed reassessment Several months after initial assessment To compare client’s current status to baseline data previously obtained Reassessment of client’s functional health patterns.
A. DATA COLLECTION – is the process of gathering info about a client’s health status.
DATABASE – is all info about the client; includes nursing health history, physical assessment, doctor’s history and physical exam, results of lab and diagnostic tests, and material contributed by other health personel.
CLIENT DATA – past history and current problems.
TYPES OF DATA:
1. SUBJECTIVE DATA – symptoms or covert (secret) data. It is described or verified only by the affected person.
Examples: itching, pain, worry, sensations, feelings, values, attitudes, perception of personal status and life situation.
2. OBJECTIVE DATA –
FIVE (5) PHASES OF NURSING CARE
(American Nurses Association (ANA) Standards of Clinical Nursing Practice)
I. ASSESING – is the systematic and continuous collection, organizing, validation, and documentation of data. PURPOSE: To establish a database about client’s response to health concerns or illness and the ability to manage health care needs.
TYPES OF ASSESSMENT:
TYPE TIME PERFORMED PURPOSE EXAMPLE
Initial Assessment Within specified time after admission To establish a complete data base for problem identification, reference and future comparison Nursing admission assessment
Problem-focused assessment Ongoing process integrated with nursing care To determine status of specific problem identified in an earlier assessment
To identify new or overlooked problems I & O q 1 hr in ICU
Assess client’s ability to perform self care while assisting to bathe
Emergency Assessment During any physiologic and psychologic crisis of the client To identify life-threatening problems Rapid assessment of ABC during cardiac arrest
Assessment for suicidal tendencies and potential for violence
Time-lapsed reassessment Several months after initial assessment To compare client’s current status to baseline data previously obtained Reassessment of client’s functional health patterns.
A. DATA COLLECTION – is the process of gathering info about a client’s health status.
DATABASE – is all info about the client; includes nursing health history, physical assessment, doctor’s history and physical exam, results of lab and diagnostic tests, and material contributed by other health personel.
CLIENT DATA – past history and current problems.
TYPES OF DATA:
1. SUBJECTIVE DATA – symptoms or covert (secret) data. It is described or verified only by the affected person.
Examples: itching, pain, worry, sensations, feelings, values, attitudes, perception of personal status and life situation.
2. OBJECTIVE DATA –