Nursing Process

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NURSING NOTES 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…show more content…
c. Seating arrangement. • Two parties are seated on two chairs placed at right angles to a desk or table / few feet apart without table between. • A horseshoe or circular chair arrangements • When a client in bed, sit at a 45 degrees angle to bed, not standing and looking down the client who is in bed. d. Distance. Maintaining a distance of 2 to 3 feet. PROXEMICS – term for the study of human use and perception of social and personal space. • INTIMATE ZONE (0-18 inches) –use for comforting, protecting, counseling and preserved for people who feel close. • PERSONAL ZONE (18 inches to 3 feet) – maintained with friends or in some counseling interactions • SOCIAL/PUBLIC ZONE (3 – 6 feet) – used when impersonal business is conducted or with people who are working together. e. Language. Failure to communicate is a form of discrimination. • Translate medical terminologies into common English understandable to both client and family members. STAGES OF INTERVIEW 1. The Opening – most important part. Purpose: to establish rapport (process of creating a goodwill and trust) and orient the interviewee. • begin with a greeting, self intro accompanied by smile or handshake • Explain the purpose and nature of interview • Tell the client how the info will be used and usually states the client’s right not to provide the info. 2. The Body – the client communicates what he feels or thinks. Knows, and perceives in response to questions from the nurse. 3. The

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