Essay on Nursing Process

2391 Words Oct 8th, 2010 10 Pages
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
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TECHNIQUES:
a. Offer to answer questions. Do u have any questions?
b. Conclude by saying “Well, ….” , that generally signals that the need of interactions
c. Thank the client.
d. Express concern for person’s welfare and future. “Take care of urself….”
e. Plan for the next meeting, if there’s a need.
f. Provide summary to verify accuracy and agreement.
3. EXAMING – a physical exam/ assessment is the systematic data-collection method used observation (the senses) to detect health problems. APPROACHES:
a. CEPAHALOCAUDAL / HEAD-TO-TOE APPROACHES – begins the examination at the head, progresses to the neck, thorax, abdomen, and extremities, and ends at the toes.
b. BODY SYSTEMS APPROACH – investigates each systems individually. That is, respiratory, circulatory, nervous systems, and so on.
c. SCREENING EXAMINATION/ REVIEW OF SYSTEMS – is a brief review of a screening examination measured against norms/standards, such as ideal wt & ht for body tem / BP.

B. ORGANIZING DATA – the nurse uses a written/computerized format that organizes the assessment data systematically.
OTHER TERM: Nursing Health History, Nursing Assessment, Nursing Database Form
NURSING CONCEPTUAL MODELS
1. Gordon (2000) –provides a framework of 11 functional health patterns. It collects data about dysfunctional as well as functional behavior.
2. Orem, Taylor, and Renpenning (2000) – delineate 8 universal self care requisites of humans.
3. Roy and Andrews (1998) – classify

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