Textbook of Medical-Surgical Nursing 3e

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Unit 1 Contemporary concepts in nursing

Health history The health history is conducted to determine the individual’s state of wellness or illness and is best accomplished as part of a planned interview. The nurse’s approach to the patient will largely determine the amount and quality of the information that is received. Achieving a relationship of mutual trust and respect requires the ability to communicate a sincere interest in the patient. Examples of effective therapeutic communica- tion techniques that can be used to achieve this goal are found in Table 2-1. The use of a health history guide may help in obtaining pertinent information and in directing the course of the inter- view. A variety of health history formats designed to guide the interview are available, but they must be adapted to the responses, problems and needs of the person. See Chapter 4 for further information about the health history. Physical assessment A physical assessment may be carried out before, during, or after the health history, depending on the patient’s physical and emotional state and the immediate priorities of the situation. The purpose of the health assessment is to identify those aspects of the patient’s physical, psychological, and emotional state that indicate a need for nursing care. It requires the use of sight, hearing, touch, and smell as well as the appropriate inter- view skills and techniques. Physical examination techniques as 5. Develop the written plan of nursing care. a. Include nursing diagnoses, goals, nursing interventions, expected outcomes and critical times. b. Ensure that all nursing diagnoses identified are addressed in the critical pathway for the patient. c. Write all entries precisely, concisely and systematically. d. Keep the plan current and flexible to meet the patient’s changing problems and needs. 6. Involve the patient, family or significant others, nursing team members and other health team members in all aspects of planning. Implementation 1. Put the plan of nursing care into action. 2. Coordinate the activities of the patient, family or significant others, nursing team members and other health team members. 3. Record the patient’s responses to the nursing actions. Evaluation 1. Collect data. 2. Compare the patient’s actual outcomes with the expected outcomes. Determine the extent to which the expected outcomes were achieved. 3. Include the patient, family or significant others, nursing team members and other healthcare team members in the evaluation. 4. Identify alterations that need to be made in the nursing diagnoses, collaborative problems, goals, nursing interventions and expected outcomes. 5. Continue all steps of the nursing process: assessment, diagnosis, planning, implementation and evaluation.

P l a n o f n u r s i n g c a r e D o c u m e n t a t i o n O u t c o m e ( s )

O u t c o m e s a c h i e v e d o r r e v i s e d

H e a l t h h i s t o r y

C o l l a b o r a t i v e a c t i v i t i e s

E x p e c t e d o u t c o m e s

G o a l s a n d p r i o r i t i e s

C o l l a b o r a t i v e p r o b l e m s

I n t e r v e n t i o n s

N u r s i n g d i a g n o s e s

NURSING ASSESSMENT

P h y s i c a l a s s e s s m e n t D I A G N O S I S P L A N N I N G I M P L E M E N T A T I O N E V A L U A T I O N

Figure 2-4  The nursing process is depicted schematically in this circle. Starting from the innermost circle, (nursing assessment), the process moves outward through the formulation of nursing diagnoses and collaborative problems; planning, with setting of goals and priorities in the nursing plan of care; implementation and documentation; and finally, the ongoing process of evaluation and outcomes

CHART 2-7

Steps of the nursing process

Assessment 1. Conduct the health history. 2. Perform the physical assessment. 3. Interview the patient’s family or significant others. 4. Study the health record. 5. Organise, analyse, synthesise, and summarise the collected data. Diagnosis 1. Identify the patient’s nursing problems. 2. Identify the defining characteristics of the nursing problems. 3. Identify the aetiology of the nursing problems. 4. State nursing diagnoses concisely and precisely. Collaborative problems 1. Identify potential problems or complications that require collaborative interventions. 2. Identify health team members with whom collaboration is essential. Planning 1. Assign priority to the nursing diagnoses. 2. Specify the goals. a. Develop immediate, medium and long-term goals. b. State the goals in realistic and measurable terms. 3. Identify nursing interventions appropriate for goal attainment. 4. Establish expected outcomes. a. Make sure that the outcomes are realistic and measurable. b. Identify critical times for the attainment of outcomes.