Nursing Process

2373 Words Sep 20th, 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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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