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