Nursing Process Workbook Part a

Topics: Nursing, Critical thinking, Breathing Pages: 6 (855 words) Published: September 11, 2013
Nursing process
The core for nurses to provide holistic and patient orientated care Assessment
Assessment includes not only physiological data, but also psychological, sociocultural, spiritual, economic, and life-style factors as well Holistic health

Evidence-based practice
Practice that is delivered which incorporates the most up to date research and information to provide appropriate care Critical thinking
An essential nursing skill that is involved in practice. This includes purposeful thinking with use of cognitive reasoning. Critical reasoning

Reflective practice
Being about to draw back onto thoughts, feelings and processes in regards to practice and being able to critically comment on performance whilst keeping in mind expectations. Subjective data
Data that is opinion and feeling based which is often hard to determine the intensity. Objective data
Data that is collected through controlled processes and produce a result that can be easily record and analysed

Clinical application:
> subjective data:
- has a cold
- felt unwell
- shortness of breath
- doesn't smoke
> objective data
- vital signs
- shivering

HEALTH INTERVIEW
> open ended questions:
When you want to acquire a more detailed answer from the patient where it falls unto the direction for follow up questions > close ended questions:
when asking only very direct and specific questions

15y/o girl
> how to provide a clear explanation prior to undertaking health assessment interview - buy clearly stating why you are doing the interview and what it is for and briefly what its components are made up of.

factors that may affect the health assessment interview:
tone
posture
speed
SAMPLE
- Does the abdominal pain feel stabbing, burning, throbbing, stinging? etc - Are you allergic to anything?
- Are you currently on any medication?
- Have you been admitted to hospital for anything before?
- When did you last go to the bathroom?
- What were you doing prior to when the pain started?

PQRST
- What causes the pain to become worse or better?
- Does it feel burning, nauseating, shooting? etc
- Where does the pain feel the most painful?
- How is the severity of the pain on a scale of 1 to 10 with 1 being no pain and 10 being extremely excruciating? - When did the pain start?

> Okay thank you for Alexandra, I'll just place your documents in our files safely and come back to you in just a moment.

> That she is only 15 years old and her parents must be notified of any major procedures she is undertaking.

MRS Doulaveras
1. That she speaks very little English and an interpreter may be needed 2. Her previous MI may be a concentration point during her health assessment interview

> Inspection
observations from head to toe of the patient
eg: Looking at the consciousness state of the patient
Palpation
Uses the sense of touch to gather data about temp, texture and moisture eg: taking a pulse reading
Percussion
Striking or tapping the body with an object to produce and evaluate sound eg: Percussion of abdomen for assessing abnormalities e.g. swelling Ausculatation
Listening to the sounds the body makes with a stethoscope
eg: lung sounds to note any wheezing, or crackles

DETECT
Airway
- Look for any obstructions
- For any troubles breathing
- Any movement of air
Breathing
- Rise and fall of the chest
- Breathing in and out from mouth or nose
- Position of the trachea
Circulation
- Coloration of their skin for presence of blood
- Listen for blood pressure and heart sounds
- Feel for temperature of skin
Disability
- Look at the level of consciousness
- Listen to response to external stimuli
- Feel for muscle power
Exposure
- For any wounds
- Listen for air leaks
- Feel the abdomen
Fluids
- The amount and colour of urine
- Listen for patient complaint of thirst
- Feel the skin turgor
Glucose
- Conscious state of the patient
- For complaints of thirst
- Feel if patient is sweaty...
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