Nursing Process.pptx

Nursing Process

_{Specific to the nursing profession}

Nursing Process

 _{Organized framework to guide practice}  _{Problem solving method - client focused}  _{Systematic- sequential steps}

 _{Goal oriented- outcome criteria}

Advantages of Nursing Process

 _Provides

individualized care

 _{Client is an active}

participant

 _{Promotes continuity}

of care

 _{Provides more}

effective

communication among nurses and healthcare

professionals

 _{Develops a clear}

and efficient plan of care

 _{Provides personal}

satisfaction as you see client achieve goals

 _{Professional growth}

5

Steps in the Nursing Process



_Assessment



_Nursing

Diagnosis



_Planning

Assessment

 _{First step of the Nursing Process}  _{Gather Information/Collect Data}

 Primary Source - Client / Family

 Secondary Source - physical exam, nursing

history, team members, lab reports, diagnostic tests…..

 Subjective -from the client (symptom)

• _{“I have a headache”}

 Objective - observable data (sign)

• _{Blood Pressure 130/80}

Assessment-collecting data

 _{Nursing Interview (history)}

 _{Health Assessment -Review of Systems}  _{Physical Exam}

Assessment-collecting data



_{Make sure information is complete &}

accurate



_{Validate prn}



_{Interpret and analyze data}

Compare to “standard norms”

Example of Assessment

 Obtain info from nursing assessment,

history and physical (H&P) etc…...

 _{Client diagnosed with hypertension}  B/P 160/90

 2 Gm Na diet and antihypertensive

medications were prescribed

 _{Client statement “ I really don’t watch my}

Nursing Diagnosis

 Second step of the Nursing Process

 _{Interpret & analyze clustered data}

 _{Identify client’s problems and strengths}

 Formulate Nursing Diagnosis (NANDA :

North American Nursing Diagnosis

Association)-Statement of how the client is RESPONDING to an actual or potential

Nsg Dx vs MD Dx

 _{Within the scope of nursing practice}

 _{Identify responses to health and illness}  _{Can change from day to day}

 _{Within the scope of medical practice}  _{Focuses on curing pathology}

 _{Stays the same as long as the disease is}

Formulating a Nursing Diagnosis

 _{Composed of 3 parts:}

 _{Problem statement- the client’s response}

to a problem

 _{Etiology- what’s causing/contributing to}

the client’s problem

 _{Defining Characteristics- what’s the}

Nursing Diagnosis

 Problem( Diagnostic Label)-based on your

assessment of client…(gathered

information), pick a problem from the NANDA list...

 _{Etiology- determine what the problem is}

caused by or related to (R/T)...

 _{Defining characteristics- then state as}

Example of Nursing Dx

 Ineffective therapeutic regimen

management

R/T difficulty maintaining lifestyle changes and lack of knowledge

AEB B/P= 160/90, dietary sodium

Types of Nursing Diagnoses

_Actual

Imbalanced nutrition; less than body requirements RT chronic diarrhea, nausea, and pain AEB height 5’5” weight 105 lbs.

 _Risk

Risk for falls RT altered gait and generalized weakness

 _Wellness

Collaborative Problems

 _{Require both nursing interventions and medical}

interventions

EXAMPLE: Client admitted with medical dx of pneumonia

Planning

Third step of the Nursing Process

 _{This is when the nurse organizes a nursing care}

plan based on the nursing diagnoses.

 _{Nurse and client formulate goals to help the}

client with their problems

 _{Expected outcomes are identified}

 _{Interventions (nursing orders) are selected to aid}

Planning – Begin by

prioritizing client problems

 Prioritize list of

client’s nursing diagnoses using Maslow

 Rank as high,

intermediate or low

 Client specific

Planning- Types of goals



_{Short term goals}



_{Long term goals}



_{Cognitive goals}

Goals are patient-centered and

SMART

Specific

Measurable

Attainable

Relevant

Time Bound

Planning-select interventions

 Interventions are selected and written.  _{The nurse uses clinical judgment and}

professional knowledge to select

appropriate interventions that will aid the client in reaching their goal.

 Interventions should be examined for

feasibility and acceptability to the client

 Interventions should be written clearly and

Interventions –

 _{Independent ( Nurse initiated )- any}

action the nurse can initiate without direct supervision

 _{Dependent ( Physician initiated )-nursing}

actions requiring MD orders

 _{Collaborative- nursing actions performed}

Implemention

“Doing” step

 _{Carrying out nursing intervention}  _s

 _{This includes monitoring, teaching, further}

assessing, reviewing NCP, incorporating physicians orders and monitoring cost

Evaluation-

 _{A comparison of client behavior and/or response}

to the established outcome criteria

Evaluation Errors

Factors that impede goal attainment:

 _{Incomplete database}

 _{Unrealistic client outcomes}  _{Nonspecific nsg interventions}

 _{Inadequate time for clients to achieve}