Nursing careLecture №2

Definitions, purposes, characteristics and staging of the nursing process. Nursing examination methods.

Diagnostics procedures in a therapeutic hospital and the role of a nurse in their preparation and implementation.

Vladislav Grishingrishin@ibbm.unn.ru

Health• It is state of complete physical, mental, and social well-being, not

merely the absence of disease or infirmity” (WHO, 1947).• Individuals’ views of health vary among different age-groups,

genders, races, and cultures. • “All people free of disease are not equally healthy.” Pender (1996)

Views of health have broadened to include mental, social, and spiritual well-being and a focus on health at the family and community levels

Illness• It is is a state in which a person’s

physical, emoDonal, intellectual, social, developmental, or spiritual funcDoning is diminished or impaired. • Therefore illness is not

synonymous with disease.

Models of Health and illness

• Health Belief Model • Health PromoDon Model • Maslow’s Hierarchy of Needs • HolisDc Health Models

Health Belief Model

The model helps you understand factors influencing patients’ perceptions, beliefs, and behavior to plan care that will most effectively assist patients in maintaining or restoring health and preventing illness.1. an individual’s perception of susceptibility to an illness2. an individual’s perception of the seriousness of the illness3. the likelihood that a person will take preventive action—results

from a person’s perception of the benefits of and barriers to taking action.

Health Promotion Model

“Complementary counterpart to models of health protection” The model focuses on the following three areas:1. individual characteristics and experiences2. behavior- specific knowledge and affect3. behavioral outcomes

Maslow’s Hierarchy of Needs

Holis9c Health Models

• The holistic health model of nursing attempts to create conditions that promote optimal health.

The nursing process

• It is the framework for providing professional, quality nursing care. It directs nursing activities for health promotion, health protection, and disease prevention and is used by nurses in every practice setting and specialty.

1. Assessment

Assessment is the first step in the nursing process and includes collection, verification, organization, interpretation, and documentation of data. Assessment involves several steps:

• Collecting data from a variety of sources • Validating the data• Organizing data • Categorizing or identifying patterns in the data • Making initial inferences or impressions • Recording or reporting data

Types of data

• The patient should be considered the primary source of data (the major provider of information about self). Sources of data other than the patient are considered secondary sources and include family members, other health care providers, and medical records. • Subjective data are gathered by interacting with the patient and

include the patient’s feelings, perceptions, and concerns. Objective data are observable and measurable and are obtained through physical examination and diagnostic tests.

2. Diagnosis

• The second step in the nursing process involves further analysis(breaking the whole down into parts that can be examined) and synthesis (putting data together in a new way) of the data that have been collected.

Types of nursing diagnosis

3. Planning

Planning involves developing a proposed course of action in regard to the patient’s health status. The planning phase involves several tasks: • Prioritizing the list of nursing diagnoses • Identifying and writing client-centered long- and shortterm goals

and outcomes • Developing specific interventions • Recording the plan of care

Nursing interventions

• A nursing intervention is the activity that the nurse will perform to promote accomplishment of the goals. For each nursing diagnosis, there may be a number of nursing interventions.

4. Implementation

• ImplementaDon involves the execuDon of the nursing plan of care derived during the planning phase. It consists of performing nursing acDviDes that have been planned to meet client outcomes.

5. Evaluation

It involves determining whether client goals have been met, parDally met, or not met. There are a number of possible reasons that goals are not met or are only parDally met, including: • The iniDal assessment data were incomplete. • The goals and expected outcomes were unrealisDc. • The Dme frame was too opDmisDc. • The goals and nursing intervenDons planned were not appropriate

for the specific client.

General assessment of the patient’s condition

• position in bed • state of consciousness • anthropometry• general condition

The severity of the patient's condition

Mild condition Moderate condition Severe condition Extremely severe

condition

Consciousness Clear consciousness Clear or stunned

consciousness

Clear or stunned

consciousness, sopor

(sometimes delirium)

Sopor or coma

Position in bed Active position Forced or active

position

(self-service ability

maintained)

Passive or forced

position

(inability to self-

service; the patient

needs constant care;

sometimes

psychomotor

agitation)

Passive position

(in some cases –

motor agitation,

general convulsion)

AnthropometryThe anthropometry is a complex of ways and methods to measure a human body.

• Weighing• Measurement of height• Measurement of circumference

Thermometry

Pulse

• Electrical impulses originaDng from the sinoatrial (SA) node travel through heart muscle to sDmulate cardiac contracDon. When a pulse wave reaches a peripheral artery, you can feel it by palpaDng the artery lightly against underlying bone or muscle. The pulse is the palpable bounding of the blood flow in the peripheral artery. The number of pulsing sensaDons occurring in 1 minute is the pulse rate.

Assessment of pulse

• You can assess any artery for pulse rate, but you typically use the radial artery because it is easy to palpate. The carotid site is recommended for quickly finding a pulse.

• Rate (N = 60-80 BPM)• Rhythm• Strength• Equality• Tension • Value • Shape

Character of the Pulse

Radial pulse

Caro9d pulse

Apical pulseCLINICAL DECISION: If heart rate is irregular or pa0ent is receiving cardiovascular medica0on, count for 1 minute (60 seconds). Irregular rate is more accurately assessed when measured over a longer interval.

Blood pressure

• It is the force exerted on the walls of an artery by the pulsing blood under pressure from the heart. The peak of maximum pressure when ejection occurs is the systolic pressure. Diastolic pressure is the minimal pressure exerted against the arterial walls at all times. • The standard unit for measuring BP is millimeters of mercury (mm

Hg). The measurement indicates the height to which the BP raises a column of mercury. Record BP with the systolic reading before the diastolic reading (e.g., 120/80). The difference between systolic and diastolic pressure is the pulse pressure.

Physiology of Arterial Blood Pressure

• Cardiac Output• Peripheral Resistance• Blood Volume • Viscosity • Elasticity

Alterations in blood pressure

• hypertension• hypotension• OrthostaDc hypotension

Measurement of blood pressure

Measurement of blood pressure

Korotkoff’s sounds

Technique of measuring blood pressure

Common Errors in Blood Pressure Assessment

• Bladder or cuff too wide OR too narrow OR too short • Cuff wrapped too loosely OR unevenly • Deflating cuff too slowly OR too quickly • Arm below OR above heart level • Arm not supported • Stethoscope that fits poorly or impairment of examiner’s hearing, causing

sounds to be muffled • Stethoscope applied too firmly against antecubital fossa • Inflating too slowly • Repeating assessments too quickly • Inadequate inflation level • Multiple examiners using different Korotkoff sounds for diastolic readings

Thanks for your attention!