Nursing process Rawhia Salah 2015/2016 Adult Health Nursing 351

Definition of nursing process Purposes of nursing process Steps of nursing process Outline

The Nursing Process is: A systematic method of planning that providing individualized nursing care. A G O S H approach (goal-oriented, organized, systematic and humanistic care) for efficient and effective provision of nursing care. Definition of Nursing process

It provides a basis for problem solving, clinical decisions, and individualized patient care It uses to evaluate the needs of patients and their families It provides an organized and universal method of communication for nurses in education, practice, and research Purpose of nursing process

Steps of nursing process

5. EVALUATION a.Collect data related to outcomesCollect data related to outcomes b.Compare data with outcomesCompare data with outcomes c.Relate nursing actions to client goals/outcomesRelate nursing actions to client goals/outcomes d.Draw conclusions about problem statusDraw conclusions about problem status e.Continue, modify, or terminate the client’s care planContinue, modify, or terminate the client’s care plan 4. IMPLEMENTATION a.Reassess the clientReassess the client b.Determine the nurse’s need for assistanceDetermine the nurse’s need for assistance c.Implement the nursing interventionsImplement the nursing interventions d.Document nursing activitiesDocument nursing activities 3. PLANNING a.Prioritize problems/diagnosesPrioritize problems/diagnoses b.Formulate goals/desired outcomeFormulate goals/desired outcome c.Select nursing interventionsSelect nursing interventions d.Write nursing ordersWrite nursing orders 2. DIAGNOSING a.Analyze dataAnalyze data b.Identify health problems, risk, and strengthsIdentify health problems, risk, and strengths c.Formulate diagnostic statementsFormulate diagnostic statements 1. ASSESSING a.Collect dataCollect data b.Organize dataOrganize data c.Validate dataValidate data d.Analyze dataAnalyze data e.Document dataDocument data OVERVIEWOVERVIEW

Assessment is the first step in nursing process It Includes systematic collecting, organizing validating, and documenting client data. To establish a database about the client/patient through observation, interview, physical examination, and medical record Assessment

Second step of the Nursing Process It is the identification of actual or potential health problems as indicated by the assessment data Nursing diagnosis

Nursing Diagnosis Has Three Components: 1.P = problem (diagnostic label) 2.E = etiology (cause) or the related cause contributor to the problem 3.L = link (related to, due to)

Third step of the Nursing Process During this phase the nurse organizes a nursing care plan based on the nursing diagnoses. Planning

It consists of 4 steps 1.Set priorities 2.Establish expected outcomes. 3.Select nursing intervention. 4.Write a nursing care plan. Planning

The fourth step in the Nursing Process This is the “Doing” step Carrying out nursing interventions (orders) selected during the planning step Implementation

Final step of the Nursing Process It is the measurement of the effectiveness of assessing, diagnosing, planning, and implementing Evaluation