Application Of Nursing Process In Basic Assessment Of Adult Individuals By Dr. Hanan Said Ali

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Application Of Nursing Process In Basic
Assessment Of Adult IndividualsByDr. Hanan Said
Ali
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Learning Objectives Identify component of
nursing process. Gather a health history
Develop Nursing Diagnosis and Care Plan Manage
client problems Evaluate Nursing care
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Introduction Nursing process are used in
identifying the client health problems and his
functional state of health. It can be used in
assessing health status through using the
following steps 1- Gathering a health
history. 2- Developing nursing diagnosis and
care plan. 3- Managing client problems. 4-
Evaluating nursing care.
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1-How To Gather a Health History ?ObjectiveTo
find out what is central to their concerns and to
help find solutions.What is needed from the
nurse ? The nurse must pay attention to
client's worries and to direct an interview and
examination so that a clear picture is created of
their condition. Patience and dedication is
required to thoroughness and detail.
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The nurse must form a partnership with the
client during interview, so that the interview
is oriented to the client and not a disease.
The nurse must know her idiosyncrasies , e.g.
-- Wanting to be liked. -- Fear of harming the
client or catching a disease. -- Do not allow
the resultant feelings to the
relationship with the client.
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2-How To Develop Nursing Diagnosis and Set
Care Plan ? - The nursing history allows the
nurse to gather a complete and detailed data base
about the clients health status. - After
collecting a history a- the nurse conducts a
physical assessment to refute, confirm , or
supplement the existing assessment data base.
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b- The nurse critically thinks about the
information provided by the client, applies
knowledge from previous clinical care. c-
Methodically conducts an examination to create a
clear picture of the clients status. e.g. A
client may complain of back pain 1- The nurse
asks several questions to clarify the nature of
the pain .
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2- During the examination the nurse carefully
looks for the source of the pain for example
-- Discomfort when changing position or a bruise
across the clients back , to rule out a variety
of potential ailments.
- one assessment finding cannot
conclusively reveal the nature of an
abnormality. - A Complete assessment is
needed to form a definitive diagnosis.
Important
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- The nurse group significant findings into
patterns of data that reveal actual or high- risk
nursing diagnosis. - Each abnormal finding
directs the nurse to gather additional
information. - Information gathered during
an initial physical assessment provides a
baseline of a clients functional abilities.
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- The baseline of the client serve as a
comparison for future assessment findings . e.g.
During a subsequent assessment , the nurse can
determine whether the clients condition has
changed.
The accuracy of data base allows the nurse to
develop individualized nursing diagnosis
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Assessment Method Finding Patterns Nursing Diagnosis
Inspection of the skin Skin along sacral area is intact. There is 3-cm area of redness Skin blanches on palpation. No skin lesions are observed. There is pressure area around coccyx. Risk for impaired integrity
Palpation of the skin Skin is moist fr0m diaphoresis. There is tenderness to palpation around the sacral area. There is good skin turgor. Skin moisture promote s maceration.
Historical data Client suffered fractured left leg . Client is immobilized due to left leg traction. Continued pressure is exerted over sacrum
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Physical assessment findings help determine the
etiology of diagnosis The nurse
can select the correct type of interventions
for the care plan
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Physical assessment is 0n going , and thus the
care plan changes with the client
condition. The nurse monitors the clients
progress and responses to therapies to review
existing diagnosis and identify new problems
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3- How To Manage client problems ? - When
caring for the client the nurse makes many
observations and performs a variety of therapies
. - The nurses success in giving care
depends on the ability to recognize change in
status and to modify therapies so that the
clients gain the most desirable outcome. -
Physical assessment skills allow the nurse to
judge the status of the clients health and
direct the management of care.
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e.g. The nurse inspects the skin during a
routine bath and finds it excessively dry
she does not use soap and applies body
lotion to the skin she revises
the written care plan
other nurses know the type of the skin care
to provide .
Instruction is also given to the client about
the skin care.
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Performing the mechanics of physical assessment
is relatively simple. The more difficult
challenge lies in using findings to make decisions
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4-What is The Benifits From Evaluating Nursing
care ? Nurses become accountable for their
nursing care by evaluating the results of nursing
interventions. Physical assessment skills
enhance the evaluation of nursing measures
through monitoring physiological and behavioural
outcomes of care .
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The same physical assessment skills used to
assess a condition (e.g., palpation of the
clients pulse) can be used as an evaluation
measure after care is administered (e.g., an
evaluation of a clients tolerance to an exercise
plan)
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- Nurses make accurate , detailed , objectives
measurements through physical assessment .-
The measurements determine whether the expected
outcomes of care are met.- The nurse does not
rely solely on intuition when physical assessment
can be used to evaluate effectiveness of care.
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Thank You