NURSING NOTES http://www.nursingnotes.info/
FIVE (5) PHASES OF NURSING CARE
(American Nurses Association (ANA) Standards of Clinical Nursing Practice)
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:
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.
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:
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 – signs or overt (obvious) data. It is detectable by the observer, can be measured or tested against accepted standard. They can be seen, heard and felt, or smelled, can be obtained by observation or physical exam. SOURCES OF DATA:
PRIMARY DATA – from the CLIENT, it is the best source of data unless too ill, young, confused to communicate clearly. 2.
SECONDARY DATA – are SUPPORT PEOPLE(family members, friends, caregivers), CLIENT RECORD, HEALTH CARE PROFESSIONALS(doctors, nurses, physiotherapist, social workers), LITERATURE (standards/norms,cultural and health practices, spiritual beliefs) DATA COLLECTION METHODS
OBSERVATION – is a conscious, deliberate skill that is developed through effort and with an organized approach. 2.
INTERVIEW – is planned communication or a conversation with a purpose. TWO APPROACHES:
DIRECTIVE INTERVIEW. The nurse establishes the purpose and controls the interview. The client responds to questions but may limited opportunity to ask questions or discuss concerns b.
NONDIRECTIVE INTERVIEW – rapport-building interview. The nurse allows the client to control the purpose, subject matter, and pacing. RAPPORT- is the understanding b/w 2 or more people.
TYPES OF INTERVIEW:
CLOSED QUESTION – (directive interview) restrictive and answered by YES/NO, questions begin by WHEN, WHERE, WHO, WHAT, DO or IS. b.
OPEN-ENDED QUESTIONS – (indirective interview) invite clients to discover, explore, elaborate, clarify, or illustrate their thoughts and feelings. It may begin with WHAT/HOW. c.
NEUTRAL QUESTION – (open ended and indirective) is a question a client can answer without direction or pressure from the nurse ( regarding feelings and point of views) d.
LEADING QUESTIONS – (closed and directive) directs the client’s answer. It gives the client less opportunity to decide whether the answer is true or not. (Ex. You’re stressed about the surgery tomorrow, aren’t you?) PLANNING AND SETTING OF INTERVIEW
Time. comfortable and unhurried
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