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The Nursing Process.

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Presentation on theme: "The Nursing Process."— Presentation transcript:

1 The Nursing Process

2 Outline Background & Hx. of nursing process Definitions
Benefits of nursing process Purposes of using nursing process Characteristics Components of nursing process: - Assessment - Planning & nursing diagnosis - Implementation - Evaluation


4 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. The nursing process is an essential part of the nursing care plan.

5 The Nursing Process An organizational framework for the practice of nursing Orderly, systematic Central to all nursing care Encompasses all steps taken by the nurse in caring for a patient

6 Definition of the Nursing Process
A systematic problem-solving approach used to identify, prevent and treat actual or potential health problems and promote wellness. A systematic way to plan, implement and evaluate care for individuals, families, groups and communities.

7 Holistic Physical- Emotional- Psychosocial- Developmental-
Spiritual Being Medical Diagnosis Nursing Diagnosis Rheumatoid Arthritis Self-care deficit: bathing, related to joint stiffness

8 Benefits of Nursing Process
Provides an orderly & systematic method for planning & providing care Enhances nursing efficiency by standardizing nursing practice Facilitates documentation of care Provides a unity of language for the nursing profession Is economical Stresses the independent function of nurses Increases care quality through the use of deliberate actions

9 Purposes of using nursing process
Continuity of care Prevention of duplication Individualized care Standards of care Increased client participation Collaboration of care

10 Characteristics: a. Planned, organized, &Systematic b. Dynamic
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 people, young or old, in any type of practice setting

11 5 components of the Nursing Process:
Assessment Diagnosis Planning Implementing Evaluating

12 1st Component of the Nursing Process- ASSESSMENT:
Two methods of Assessment 1. Subjective – client’s perspective Examples: Report of fainting, complaint of dizziness, nausea, headache 2. Objective – observable & measurable Examples: Vomiting, unsteady gait, pale skin,rapid breathing Data Collection: By Observation, interview, & Examination

13 During Assessment, the care provider:
Establishes A Data Base: comprehensive information you gather on initial contact with the person to assess all aspects of health status. Focus assessment – the data you gather to determine the status of a specific condition. Continuously Updates The Data Base. Validates Data: - Measurable data - Double check personal observations - Double check equipment - Check with experts and team members - Compare objective and subjective data & Clarify statements Communicates Data

14 Types of Data To Collect:
Objective data-observable and measurable facts (Signs) Subjective data-information that only the client feels and can describe (Symptoms) Resources Sources of Data Client Other individuals Previous records Consultations Diagnostics studies Relevant literature Primary source: Client Secondary source: Client’s family, reports, test results, information in current and past medical records, & discussions with other health care workers

15 2nd component of the Nursing Process- Diagnosis:
A clinical judgment about individual, family, or community responses to actual or potential health problems. A nursing diagnosis provides the basis for selection of nursing interventions to achieve outcomes for which the nurse is accountable.


17 Development of the Nursing Diagnosis
Two-part Statement 1. Problem statement – describes the client’s response to an actual or potential health problem (diagnostic label) 2. Etiology – cause of the problem 3. The diagnostic label & etiology are linked by the terminology Related to (R/T) Example: Ineffective breathing pattern R/T neuromuscular impairment.

18 Cont. Development of the Nursing Diagnosis
Three-part-statement Problem statement – describes the client’s response to an actual or potential health problem (diagnostic label) 2. Etiology – cause of the problem 3. The diagnostic label & etiology are linked by the terminology Related to (R/T) 4. Defining characteristics Example:

19 Types of nursing diagnosis:
Actual nursing diagnosis – a problem exists. Composed of the problem statement, related factors and signs & symptoms Risk nursing diagnosis – indicates the problem doesn’t exist but has special risk factors Wellness nursing diagnosis – indicates the client’s desire to attain a higher level of wellness in some area of function.

20 NANDA – North American Nursing Diagnosis Association
NANDA-International is recognized as the leader in development and classification of nursing diagnoses Identifies nursing functions Creates classification system Establishes diagnostic labels Example: Risk of infection related to compromised nutritional state Potential complication of seizure disorder related to medication compliance

21 3rd 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 improve his health status or better cope with his illness.

22 During Planning, the provider:
A. Establishes Priorities B. Writes Client Goals/Outcomes And Develops An Evaluative Strategy C. Selects Nursing Interventions D. Communicates The Plan Note: In planning we establish the goals, interventions and outcomes

23 General Guidelines for Setting Priorities
Take care of immediate life-threatening issues. Safety issues. Patient-identified issues. Hierarchy of needs models. Nurse-identified priorities based on the overall picture, the patient as a whole person, and availability of time and resources.


25 Identification of Outcomes
Provides guidelines for individualized nursing interventions Establishes goals & evaluation criteria to measure effectiveness of the nursing care plan - Short-term goals – 1 week - Long-term goals – weeks to months

26 Nursing Interventions
An action performed by the nurse that helps the client achieve the results specified by the goals and expected outcomes. Evidence based nursing. Monitor health status. Minimize risks. Resolve or control a problem. Promote optimum health and independence. 3 types: independent, interdependent, dependent

27 Interventions Direct interventions: actions performed through interaction with clients. Indirect interventions: actions performed away from the client, on behalf of a client or group of clients.

28 Documenting the Plan of Care
To ensure continuity of care, the plan must be written and shared with all health care personnel caring for the client. Consists of: Prioritized nursing diagnostic statements. Outcomes. Interventions.

29 Documentation Clear and concise Appropriate terminology
Usually on a designated form Physical assessment Usually by Review of Systems Overview of symptoms Diet Each body system

30 4th Component of the Nursing Process- Implementing:
The provider carries out the plan of care

31 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 Documents Care

32 5th 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 from the entire health care team, including the patient.

33 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 Indicated

34 Determining Outcome Achievement
Must be aware of outcomes set for the client. Must be sure patient is ready for evaluation. Is patient able to meet outcome criteria? Is it: Completely met? Partially met? Not met at all? Record in progress in notes. Update care plan.

35 Short-Term Goals Outcomes achievable in a few days or 1 week
Developed form the problem portion of the diagnostic statement Client-centered Measurable Realistic Accompanied by a target date

36 Long-Term Goals Desirable outcomes that take weeks or months to accomplish for client’s with chronic health problems

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