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Lecture 4

Nursing 1160A/B Lecture Notes - Lecture 4: Soap Note, Alternative Medicine

Course Code
NURS 1160A/B
Karen Ferguson

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Week 4 – January 23rd, 2016 Virginia Polihronova
Thinking Like a Nurse – Tools used to make Clinical
Lecture Notes
Week 4 – January 23rd, 2016
Virginia Polihronova
Nursing Process
- Developed by Orlando
oTheory of validation
- Used while listening to the patient’s story
oIn order to answer questions
- Must integrate SBC vs. deficit approach
- PCC – health care team must all work in partnership with client to achieve goals
- Helps us organize things to deal with circumstances in a logical way
- Should be flexible
- Cognitive thinking process that is systematic – used in any setting and level of intervention
- Overlapping
oOccurs when there is an assessment/observation that the planned intervention is not
oOccurs when assessment is conducted during an implementation (ex. bathing)
Assessment Phase – Getting the Data
- Collect
oPerforming assessments and interviews with client and family, lab results, etc.
oSpeaking with HC team
oDone during all activities – should always be observing
- Organize
- Validate
- Record data
oEx. SOAP note
oIncludes info about client’s strengths and challenges
oConsiders the “patient’s reality”
Nursing Diagnosis Phase
- What is the patient’s present health status?
- What is contributing to it?
- Sort, cluster, and analyze the data
oIdentify from nursing perspective what actions can be taken to help the client
Based on client’s present health status
- Write a statement
- Prioritize diagnoses
- Plan nursing actions
oNot to be confused with medical diagnosis
Planning Outcomes
- What is the patient’s goal?
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