The Nursing process unit-V BSC NURSING 1st year

 UNIT-V

THE NURSING PROCESS

SHORT ESSAYS

1. Explain ASSESMENT as first step of nursing process

Ans. ASSESSMENT

Definition Assessment is the systematic and continuous collection, organization,

validation, and documentation of data (information).

Types of assessment: The four different types of assessments are;

1. Initial nursing assessment

2. Problem-focused assessment

3. Emergency assessment

4. Time-lapsed reassessment

1. Initial nursing assessment: Performed within specified time after admission.To

establish a complete database for problem identification. Eg: Nursing admission

assessment

2. Problem-focused assessment: To determine the status of a specific problem

identified in an earlier assessment. Eg: hourly checking of vital signs of fever patient

3. Emergency assessment: During emergency situation to identify any life

threatening situation. Eg: Rapid assessment of an individual's airway, breathing

status, and circulation during a cardiac arrest.

4. Time-lapsed reassessment: Several months after initial assessment. To compare

the client's current health status with the data previously obtained.

2. Explain the types and sources of Data collection

Ans. Data collection is the process of gathering information about a client's health

status. It includes the health history, physical examination, results of laboratory and

diagnostic tests, and material contributed by other health personnel.

Types of Data Two types: subjective data and objective data.

1. Subjective data, also referred to as symptoms or covert data, are clear only to the

person affected and can be described only by that person. Itching, pain, and feelings

of worry are examples of subjective data.

2. Objective data, also referred to as signs or overt data, are detectable by an

observer or can be measured or tested against an accepted standard. They can be

seen, heard, felt, or smelled, and they are obtained by observation or physical

examination. For example, a discoloration of the skin or a blood pressure reading is

objective data.

Sources of Data collection: Sources of data are primary or secondary.

1. Primary: It is the direct source of information. The client is the primary source of

data.

2. Secondary: It is the indirect source of information. All sources other than the client

are considered secondary sources. Family members, health professionals, records

and reports, laboratory and diagnostic results are secondary sources.

3. Describe various methods of the data collection

Ans. Methods of the data collection: The methods used to collect data are

observation, interview and examination.

Interview method: An interview is a planned communication or a conversation with

a purpose.

There are two approaches to interviewing: directive and nondirective.

The directive interview is highly structured and directly ask the questions. And the

nurse controls the interview.

A nondirective interview, or rapport building interview and the nurse allows the client

to control the interview.

STAGES OF AN INTERVIEW: An interview has three major stages:

1. The ope3. The closing

Observation Method: It is gathering data by using the senses. Vision, Smell and

Hearing are used.

Examination Method: The physical examination is a systematic data collection

method to detect health problems. To conduct the examination, the nurse uses

techniques of inspection, palpation, percussion and auscultation.

4. Differentiate between medical and nursing diagnosis with examples.

Ans. Difference between Nursing Diagnosis from Medical Diagnosis

Nursing diagnosis

Medical diagnosis

A nursing diagnosis is a statement of A medical diagnosis is made by a

nursing judgment that made by nurse, by physician.

their

experience,

education,

and

expertise, are licensed to treat

Nursing diagnoses describe the human Medical diagnoses refer to disease

response to an illness or a health | processes.

problem.

Nursing diagnoses may change as the | A client's medical diagnosis remains the

client's responses change.

same for as long as the disease is

present

EX: Ineffective breathing pattern

Ex: Asthma

Activity intolerance

Cerebrovascular accident

Acute pain

Appendicitis

Disturbed body image

Amputation

5. Explain the steps of nursing care plan for the client with suitable exampless

Ans. The are 5 3. Planning

4. Implementation

5. Evaluation

EX. 1 the patient with fever planed the nursing care plan

Planning9

assessment Nursing

Implementation

Evaluation

diagnosis

Subjective Hyperthermia data: the related

Assessed the Body

the

AssessS

vital signs of

vital signs of temperature

to

reduced after

client

illness

the client.

the cltent.

as

evidenced by

complained

Provide

Provided

implementing

that he feels body

hygienic

hygienic care. all measures.

and temperature

Administered

warm

care.

recording.

Administer

producing

the medication

tab. Pct 650

heat out

medications

like

from body.

mg.

Objective

Given

antipyrutics.

Cold

Give

data:

cold

compression

for 15 min.

Body

compression

for 15 min

Provided

temperature

highly

Provide

plenty of fluids

of Educated on

recorded by

plenty

fluids.

nutritious diet

measuring

Educate on

temperature

and personal

nutritious

hygiene

>Encouraged too

and

diet

take rest and

personal

sleep

hygiene.

Encourage

>Reassessed

the vital signs

rest

and

sleep

and recorded.

stepsuraged too

and

diet

take rest and

personal

sleep

hygiene.

Encourage

>Reassessed

the vital signs

rest

and

sleep

and recorded.

steps of nursing care plan:

1. Assessment

2. Nursing diagnosis

ning or introduction

2. The body or development

>Reassess

vital

the

Signs.

6. Explain the steps in planning as a part of nursing process

Ans. The planning process 1. Setting priorities 2. Establishing client goals /desired outcome 3. Selecting nursing interventions 4. Writing individualized interventions on care plan

Setting priorities The nurse begin planning by deciding which nursing diagnosis requires attention

first, which second, and so on.

Nurses frequently use Maslow's hierarchy of needs when setting priorities.

Establishing client goals/desired outcomes After establishing priorities, the nurse set goals for each nursing diagnosis. Goals may be short term or long term.

Nursing interventions A nursing intervention is any treatment, that a nurse performs to improve patient's

health.

TYPES OF NURSING INTERVENTIONS

1. Independent interventions are those activities that nurses are licensed to initiate on the basis of their knowledge and skills. 2. Dependent interventions are activities carried out under the orders or supervision of a licensed physician.

3. Collaborative interventions are actions the nurse carries out in collaboration with

other health team members

Writing Individualized Nursing Interventions After choosing the appropriate nursing interventions, the nurse writes them on the care plan. Nursing care plan is a written or computerized information about the client's care.

Ans.

Definition The official NANDA definition of a nursing diagnosis is: "a clinical

judgment concerning a human response to health conditions/life processes, or a

vulnerability for that response, by an individual, family. group, or community."

Status of the Nursing Diagnosis: The status of nursing diagnosis are actual, health

promotion and risk.

1. An actual diagnosis is a client problem that is present at the time of the nursing

assessment.

2. A health promotion diagnosis relates to clients' preparedness to improve their health

condition.

A risk nursing diagnosis is a linical judgement that a problem does not exist, but the

presence of risk factors indicates that a problem may develop if adequate care is not

given

Components of a NANDA Nursing Diagnosis

A nursing diagnosis has three components:

(1) The problem and its definition

(2) The etiology

(3) The defining characteristics.

1. The problem statement describes the client's health problem.

2. The etiology component of a nursing diagnosis identifies causes of the health

problem.

3. Defining characteristics are the cluster of signs and symptoms that indicate the

presence of health problem.

Formulating Diagnostic Statements

The basic three-part nursing diagnosis statement is called the PES format and

includes the following

1. Problem (P): statement of the client's health problem (NANDA label)

2. Etiology (E): causes of the health problem

3. Signs and symptoms (S): defining characteristics manifested by the client.

Example: Acute pain related to abdominal surgery as evidenced by patient discomfort

and pain scale.

8. Define nursing process. Explain the purpose and importance of nursing

process

Ans. Definition: Nursing process is a critical thinking process that professional nurses

use to apply the best available evidence to care giving and promoting human functions

and responses to health and illness.

Purposes of nursing process

&To identify a client's health status and actual or potential health care problems

or needs.

To establish plans to meet the identified needs.

To deliver specific nursing interventions to meet those needs.

Importance of nursing process:

The nursing process is important to ensure quality care and to get the preferred

outcome.

In the nursing process, critical thinking is used to recognize the issue and come

up with a logical solution to solving it.

One important aspect of the nursing process is that the plan is not set in stone;

it is meant to be manipulated in order to better suit the patient.

Nurses must be able to think critically in order to recognize the issue, develop a

way to correct it, and be able to communicate the issue to others

Throughout the nursing process, critical thinking is used to determine the best

plan of care for a patient based on their diagnosis.

9. Define nursing intervention and discuss the types of nursing intervention

Ans.

Health system nursing interventions are actions nurses take as part of a

healthcare team to provide a safe medical facility for all patients, such as following

procedures to reduce the risk of infection for patients during hospital stays.

i)Types of Nurse Intervention:

Intensive: is reserved for catastrophic cases where medical recovery is

expected to extend over long or indefinite periods of time

Moderate: combines both phone calls and face-to-face interaction (Field

Nurses).

Limited: consists of telephone interaction only (COP Nurses).

i)Types of nursing interventions

I. Independent interventions Activities nurses are licensed to initiate (i.e., physical

care, ongoing assessment)

II. Dependent interventions Activities carried out under primary care provider's orders

or supervision, or according to specified routines

II. Collaborative interventions Actions nurse carries out in collaboration with other

health team members.

10. Explain the steps of evaluation in nursing process

Ans. Evaluation is defined as the judgment of the effectiveness of nursing care to meet

client goals; in this phase nurse compare the client behavioral responses with

predetermined client goals and outcome criteria.

1. Collecting the data related to the desired outcomes

2. Comparing the data with outcomes

3. Relating nursing activities to outcomes

4. Drawing conclusion about problem status

5. Continuing, modifying, or terminating the nursing care plan

Collecting the data: The nurse collects the data so that conclusion can be drawn

about whether goals have been met. It is usually necessary to collect both subjective

& objective data. Data must be recorded concisely and accurately to facilitate the next

part of the evaluating process.

Comparing the data with outcomes: If the first part of the evaluation prOcess has

been carried out effectively, it is relatively simple to determine whether a desired

outcome has been met. Both the nurse and client play an active role in comparing the

client's actual responses with the desired outcomes.

Relating nursing activities to outcomes The third aspect of the evaluating process

is determined whether the nurDrawing conclusion about problem status: The nurse uses the judgement about

goal achievement to determine whether the care plan was effective in resolving.

reducing or preventing client problems. When goals have been met the nurse can draw

one the following cornclusions about the status of the client's problem.

Continuing, modifying , or terminating the nursing care plan: After drawing

conclusion about the status of the client's problems, the nurse modifies the care plan

as indicated. Whether or not goals were met, a number of decision need to be made

about continuing, modifying or terminating nursing care for each problem.

Before making individual modification, the nurse must first determine why the plan as

a whole was not completely effective. This require a review of the entire plan.

sing activities had any relation to the outcome.

7. Define nursing diagnosis and discuss the types of nursing diagnosis with examples