NURSING PROCESS
• • ASSESSMENT PLANNING IMPLEMENTATION EVALUATION • A. P. I. E.
ASSESSMENT TOUCH • Reassuring hand on hand / security • Feel temperature of skin/ site, size of swelling • Palpate body parts ? Location of pain / dislocation of joints / position of foetus / pressure on bleeding point • Hygiene routines eg bathing /toileting /dress • Carry out procedures eg blood tests/ B. P.
ASSESSMENT • SIGHT / VISION • General appearance/posture of patient, paralysis/mobility /pain /facial expression • Condition of skin eg Colour/ dry/ pale/clammy • Injuries eg Wound/bleeding/gunshot/fracture • Describe condition of body waste eg urine/faeces/mucous/vomit/bleeding • Record of vital signs
• Diagnosis from scans / x-rays • Surgery – use of equipment – microsurgery • Use of distant application of procedure eg Angiogram • General safety – tidy away obstacles, mop up spillages • Observe recovery eg mobility /balance • Monitor feeding practices/amount-record
• HEARING • Voice tone of patient & family • Listen to their concerns/wishes-explain clearly every procedure that may be carried out • Breathing – rate & rhythm, noisy/quiet different types of coughs-dry/wet • Tolerance of pain-moan/cry • Use of equipment – Heart monitor, B. P.
• • SMELL Body hygiene eg sweat / clothing/ incontinent Breath of patient ? Diabetic /dehydration Body waste eg abnormal urine / faeces / vomit Infection –open wound eg leg ulcers Gangrene of skin eg toes Medications eg liquid Food eg suitable for use
TASTE • Temperature of liquids • Texture of food • Medications
PLANNING • Following assessment, initial diagnosis, write up series of investigations eg • Blood tests • Bioposy / swab /sample of tissue • X-rays / Ultrasound scans • Consult other medical opinions • Prescribe medications
IMPLEMENTATION Follow up on • Results of tests/procedures • Inform appropriate medical personnel • Carry out any prescribed procedure • Observe patient’s reaction to treatment • Continue record of vital signs
EVALUATION • Record patient’s condition • Improvement? Continue with prescribed medications / procedures Refer back for consultation OPD / GP • No improvement? Continue with further investigations, review state of patient by using a new assessment