The collection of data about an individual’s health state IV. Assessment: Data Collection a. History: subjective data b. Physical exam: objective data c. Samples of objective vs.. Subjective data I. Sore shoulder ii. Unconscious . Blood in the urine iv. Dizziness v. Sore throat vi. Weight gain Elevated temperature vii. V. Nursing Process a. Definition: a systematic problem solving process that guides all nursing actions b. Purpose: to help the nurse provide goal directed. Client centered care c. Assessment I. Collect data 1. Review of the clinical record 2. Interview/ Health history 3.
Physical exam 4. Functional assessment 5. Consultation 6. Review of the literature (evidence based practice) Nursing Process: Diagnosis I. Interpret data 1. Identify cluster of cues d. 2. Make inferences ii. Validate inferences (conclusion drawn from the evidence or reasoning characteristics iii. Compare clusters of cues with definitions and defining iv. Identify related factors v. Document the diagnosis e. Outcome Identification I. Identify expected outcomes ii. Individualize to patient iii. Ensure outcomes are realistic and measurable time frame f. Planning I.
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Prioritize nursing diagnoses (Measles Hierarchy) and write outcomes and goal iii. Develop specific interventions iv. Record plan v. Communicate to other members of health care team Interventions/lamentation (client focused) iv. Include a ii. Identify g. Executing/ carry out the plan ii. Necessary skills iii. Continual assessment iv. Psychosomatic v. Interpersonal vi. Critical thinking Communication: writing, reporting, revising I. Evaluate the goals 1. Met, not met, partially met? Ii. Reassess iii. Make necessary changes lb. Always a continual process VI. Benefits of the nursing process: client a.
Continuity of care b. Prevention Of omission and duplication c. Individualized care d. Increase client participation VII. Benefits of the nursing process: nurse, profession a. Nurses I. Job satisfaction ii. Continual learning iii. Increased self confidence iv. Staffing assignments v. Standards of practice b. Profession I. Promotes collaboration h. Evaluation ii. Helps people to understand what nurses do VIII. Data Base a. What is it? I. Data base: organization of assessment data varies depending on conceptual model used 1. Models provide a framework for: a. Determining what to observe b.
Organizing observations or data c. Interpreting and using the information ii. Nursing diagnoses are clinical judgments about a person’s response to an actual or potential health state b. Databases I. Complete (or total health) data base 1. Includes complete health history and full physical examination 2. Describes current and past health state and forms baseline to measure all future changes 3. Yield first diagnoses ii. Follow-up data base 1 . Status of all identified problems should be evaluated at regular and appropriate intervals 2. Note changes that have occurred 3.
Evaluate whether problem is getting better or worse 4. Identify coping strategies being used iii. Episodic data base 1. For limited or short-term problems 2. Collection of mini database, a smaller scope and more focused hat complete data base complex, or one body system direction of presenting concern 3. Concerns mainly one problem, one cue 4. History and examination follow a. Acute or chronic onset, associated with fever, local or generalized issues base iv. Emergency data 1. Rapid collection of data, often complied concurrently with lifesaving measures 2. Diagnosing must be swift and sure a.
Person is question simultaneously while his or her airway, breathing, circulation, level of consciousness, and disability are being assessed k Why perform a health assessment? A. Purpose is to Make a judgment or diagnosing b. During an assessment, a clinician is able to collect all important data that allows to make nursing judgment and diagnoses Developmental Tasks and Health Promotion Across the Life Cycle l. Developmental Stages (p. 13-31 ); Erikson Psychosocial Stages of development: person have to meet certain developmental skills in order to move forward a. Infancy (birth to 1 year) b.
Early childhood: Toddler (1-3 years) c. Early childhood: Preschooler (3-5/6 years) d. School child (6-10/12 years) e. Preadolescence (10-12/13 years) f. Adolescent (12/13- 19) g. Early adult (20-40) h. Middle adult (40-64) I. Late adult (65+) II. Physical: growth, physiological development Ill. Psychosocial: Erikson IV. Cognitive: Pigged: reasoning, learning, thinking, remembering imagining etc. V. Behavioral: Growth motor skills, fine motor skills, language, personal social skills VI. Developmental Screening Tests a. The Denver II I. Age range: birth to 6 years old ii. Detects developmental delays: 1.
Gross Motor, Language, Fine Motor, Social Skills not determine intelligence iv. Screening tool, not diagnostic b. Adult Life Stress Measures I. Hassles and uplift Scale ii. Age range: Adults iii. Assesses day to day stresses iii. Does iv. Minor but frequent stresses (Hassles) are r/t negative health Transactional Considerations in Assessment l. Basic Characteristics of Culture a. Learned: from birth through the process of language, acquisition, and colonization b. Shared: all member of the same cultural group c. Adapted: two specific conditions that are related to environment and technological factors and ability of natural resources d.
Dynamic: ever changing: systematic appraisal of an individual’s belief, values and practices II. Ethnicity a. Social group w/ common traits Geographic origin Religion Race Language Shared values Traditions Symbols Food preferences Ill. Religious Beliefs and Practices a. Integral component of the individual’s culture b. Religion plays a huge role in the way people practice their health care c. May be used to explain: -cause(s) of illness -perception of its severity -choice of healers IV. Religious beliefs and practices a. Religion I. Organized system of beliefs ii.
Concerns the cause, purpose and nature of the universe Belief in or worship of God or gods iv. More than 1500 religions in the US v. Religion and culture are interconnected b. Spirituality I. Based on each person’s unique life experiences and effort to find purpose and meaning in life V. Steps in Understanding Beliefs from a Cultural Perspective a. Identify your own culture (bias, beliefs, practices, attitudes, values) b. Identify the client& beliefs VI. Illness and Culture a. Causes of Illness I. Biomedical: germ theory( certain microorganisms causes illness ii.
Naturalistic: forces of nature that must be kept at balance and harmony iii. Magic-Religious: supernatural forces: voodoo and witchcraft VII. Transactional Expressions of Illness a. Transactional expression of pain I. Expectations, manifestations, and management of pain are embedded in a cultural context ii. Pain has been found to be a highly arsenal experience, depending on cultural learning the meaning of the situation, and other factors unique to the person iii. Silent suffering has been identified as the most valued response to pain by health care professionals VIII. Steps to Cultural Competence a.
Understand one’s own heritage-based values, beliefs, attitudes and practices b. Identify the meaning of “health” to patient c. Understand how health care system works d. Acquire knowledge about social backgrounds of patients Become familiar with languages, interpretive services, and community resources available to nurses and patients The Interview . What is the interview? 1. Meeting between care provider and client 2. Goal is to record a complete health history 3. First and most important part of data collection 4. A means to identify health strengths and problems bridge to the physical exam II.