Unit 1 (c) Nursing Process.ppt

LEARNING OUTCOMES

 Discuss the concepts and theories that underpin the

process of nursing.

 Formulate nursing diagnosis on actual and potential

patient’s problems.

 Plan and document appropriate patient’s goals and

interventions with the collaboration of patient, family and the multidisciplinary team.

 Implement the Nursing Care Plan.

 Evaluate and reassess each component of the Nursing

Care Plan appropriately.

 Educate patients and their families during their stay at

hospital and at the time of discharge.

 Demonstrate appropriate communication skills and

THE NURSING PROCESS IS:

 A systematic, rational method of planning and providing

individualized nursing care.

 An organized, systematic method of giving individualized

nursing care that focuses on identifying and treating unique responses of individuals or groups to actual-(Alfaro)

 Nursing is the protection, promotion, and

CHARACTERISTICS OF NP

• A problem-solving method

• Systematic, goal-directed, flexible, rational approach

• Ensures consistent, continuous, quality nursing care

• Provides a basis for professional accountability

CHARACTERISTICS:

a) Systematic

 _{The nursing process has an ordered sequence of activities and each}

activity depends on the accuracy of the activity that precedes it and influences the activity following it.

b) Dynamic

 _{The nursing process has great interaction and overlapping among the}

activities and each activity is fluid and flows into the next activity

c) Interpersonal

 _{The nursing process ensures that nurses are client-centered rather than}

task-centered and encourages them to work to enhance client’s strengths and meet human needs

d) Goal-directed

 _{The nursing process is a means for nurses and clients to work together}

to identify specific goals (wellness promotion, disease and illness prevention, health restoration, coping and altered functioning) that are most important to the client, and to match them with the appropriate nursing actions

e) Universally applicable

 _{The nursing process allows nurses to practice nursing with well or ill}

BACK

GROUND



The nursing process is based on a nursing theory

developed by Ida Jean Orlando.

 She developed this theory in the late 1950's as she

observed nurses in action.

 _{She saw "good" nursing and "bad" nursing.}



From her observations she learned that the patient

must be the central character.

 _{Nursing care needs to be directed at improving outcomes for}

the patient, and not about nursing goals.

 The nursing process is an essential part of the nursing care

BACK GROUND OF NURSING

PROCESS

 The original concept of the nursing process was introduced in

the 1950s as a three-step process of

 Assessment, Planning, and Evaluation

 Based on the scientific method of

 Observing, Measuring, Gathering data, and Analyzing the findings.

 Over time, became part of the;

 Conceptual framework of all nursing curricula and

 Included in the legal definition of nursing in the nurse practice acts of most states.

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 as

5

STEPS IN THE NURSING

PROCESS



Assessment



Nursing

Diagnosis



Planning



Implementing

1

COMPONENT OF THE NURSING

PROCESS-

ASSESSMENT:

 The first step, or phase, of the nursing process is

assessment.

 During this phase, you are collecting data (factual

information) from several sources.

 The collection and organization of these data allow to:

 Determine the patient’s current health status.

 Determine the patient’s strengths and problem areas

(both actual and potential).

1

COMPONENT OF THE NURSING

PROCESS-

ASSESSMENT:



Data Collection

 Assessment involves taking vital signs (TPR

BP & Pain assessment).

 Performing a head to toe assessment

 Listening to the patient's comments and

questions about his health status

 Observing his reactions and interactions with

DURING

ASSESSMENT

, THE CARE

PROVIDER

A.

Establishes A Data Base

B.

Continuously Updates

The Data Base

C.

Validates Data

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



Inspection



Palpation



Percussion

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 salt” “

2

COMPONENT OF THE NURSING

PROCESS-

DIAGNOSIS

:



Diagnosis

means reaching a definite

conclusion regarding the patient’s strengths

and human responses.



This diagnostic process is complex and utilizes

aspects of intelligence, thinking, and critical

thinking.



The diagnosis of human responses is a

NURSING DIAGNOSIS

 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

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

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 evidence of

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 evidenced

EXAMPLE OF NURSING DX

 Ineffective therapeutic regimen

management

R/T difficulty maintaining lifestyle changes and lack of knowledge

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/Potential

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

3

COMPONENT OF THE NURSING

PROCESS-

PLANNING

:



The establishment of client goals/outcomes

_{Working with the client, to prevent, reduce, or}

resolve problems



To determine related nursing interventions (actions)

that are most likely to assist client in achieving goals



This is about improving the quality of life for your

patient.



_{This is about what your patient needs to do to}

DURING

PLANNING

, THE PROVIDER:



A.

Establishes Priorities



B.

Writes Client Goals/Outcomes And

Develops An Evaluative Strategy



C.

Selects Nursing Interventions

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 the

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



Psychomotor goals

GOALS ARE

PATIENT-CENTERED AND

SMART

S

pecific

M

easurable

A

ttainable

R

elevant

T

ime Bound

3RD COMPONENT OF THE NURSING

PROCESS-

IMPLEMENTING

:

DURING

IMPLEMENTING

, THE CARE

PROVIDER:

 Carries Out The Plan Of Nursing Care or Setting your

plans in motion and delegating responsibilities for each step.

 Continues Data Collection And Modifies The Plan Of

Care As Needed

IMPLEMENTION

“Doing” step

 Carrying out nursing intervention  s

 This includes monitoring, teaching, further

assessing, reviewing NCP, incorporating physicians orders and monitoring cost effectiveness of

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 jointly

4TH COMPONENT OF THE NURSING

PROCESS-

EVALUATING

:



The measuring of the extent to which

client goals have been met



Evaluation involves not only analyzing

the success of the goals and

interventions, but examining the need

for adjustments and changes as well.



The evaluation incorporates all input

DURING

EVALUATING

, THE CARE

PROVIDER:



Measures The Clients Achievement

Of Desired Goals/Outcomes



Identifies Factors That Contribute To

The Client’s Success Or Failure



Modifies The Plan Of Care, If

EVALUATION-



A comparison of client behavior and/or

response to the established outcome criteria



Continuous review of the nursing care plan

Examines if nursing interventions are

EVALUATION ERRORS

Factors that impede goal attainment:

 Incomplete database

 Unrealistic client outcomes  Nonspecific nsg interventions

PURPOSE OF THE NURSING PROCESS:



To Achieve Scientifically-

Based, Holistic, Individualized

Care For The Client



To Achieve The Opportunity To

Work Collaboratively With

Clients, Others

THE WHOLE PATIENT



The nursing process involves looking at the whole

patient at all times. It personalizes the patient. He is

not "the CVA in 214B."



It also forces the health care team to observe and

HOLISTIC



Spiritual Being

Medical

Diagnosis

Nursing

Diagnosis

Rheumatoid Arthritis _{Self-care deficit:}