Nursing Process (3)

8/8/2019 Nursing Process (3)

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Fundamentals of Nursing (NUR 101)

Prepared by

Nabeel Al-Mawajdeh RN.Mcs.

King Saud University- Aflaj College


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Chapter 1Nursing Process


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Nursing Process

An organized sequence of problem-solvingsteps used to identify and to manage the health

problems of clients. Steps of the Nursing Process

1. Assessing.

2. Diagnosing.

3. Planning.4. Implementing.

5. Evaluating.


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Assessment

Assessment: Collecting data to determine theneeds and health problems of patient.


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Data Collection

Types of Data:

1. Subjective data (symptoms)

Are information perceived such as (feelingnervous, nauseated, chilly or experiencing pain)


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Data Collection (Contd)

2. Objective data (signs)

Are observable and measurable data that can

be seen, heard and felt, and its observed byone person can be verified by another personobserving the same patients. Such as (increasetemperature, lab. results, moist skin, refusal tolook at or eat food)


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Sources ofData

Primary source: Client.

Secondary source: Clients family, reports,

test results, information in current and pastmedical records, and discussions with otherhealth care workers ( physicians , socialworkers , dietitians , physiotherapists andlaboratory technicians )


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Data Collection Methods

1. Observation.

Is the conscious and deliberate use of the five

senses to gather data (sighting, smelling andhearing)2. Interview.

Is the planned communication, during theassessment step of the nursing process toobtain and establish a successful workingpartnership with the patient , then to obtainthe necessary patient data .


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Data Collection Methods (contd)

3. Techniques of Physical Assessment.

Is the examination of the patient for objective

data that may better define the patientscondition and help the nurse in planning care,include:

inspection , palpation , percussion , and

auscultation .


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Problems Related to Data Collection

1. Inappropriate organization of the database.

2. Omission of pertinent data.

3. Inclusion of irrelevant or duplicate data.

4. Misinterpreted data.

5. Failure to establish rapport and partnership.


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Diagnosis

Health issue that can be prevented, reduced,resolved, or enhanced through independent

nursing measures.


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Nursing Diagnosis Categories

1. Actual.

2. Risk.

3. Possible.

4. Syndrome.

5. Wellness.


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Diagnostic Statements

Name of the health-related issue or problem asidentified in the NANDA (North American

Nursing Diagnosis Association) list. Etiology (its cause)

Signs and Symptoms.

The name of the nursing diagnosis is linked tothe etiology with the phrase related to, andthe signs and symptoms are identified with thephrase as manifested (or evidenced) by.


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Formulating and Validating Nursing

Diagnosis

Parts of Nursing Dxs.1. Problem.

The purpose of the problem statement is todescribe the health state or health problem ofthe patient as possible.Identifies what is unhealthy about the patient,indicating the need for change

2. Etiology.

Identifies the factors that are maintaining theunhealthy state or response (causative factor )

3. Defining characteristics.The subjective and objective data that signalthe existence of the problem identify.


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Diagnosis Examples

Example 1 :

Hygiene self-care deficit ( problem )

related to

fear of falling in the obesity (etiology )

as manifested by

strong body and urine odder (characteristics )


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Diagnosis Examples (Contd)

Example 2 :

Chest pain ( problem )

related todecrease coronary blood flow (etiology)as manifested by

facial expression (characteristics )


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Diagnosis Examples (Contd)

Example 3 :

Ineffective individual coping (problem)

related toloss of job ( etiology )

as manifested by

increase daily use of alcohol (characteristics )


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Planning

The process of prioritizing nursing diagnoses andcollaborative problems, identifying measurable

goals or outcomes, selecting appropriateinterventions, and documenting the plan of care.

The nurse works in partnership with the patientand family.


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Elements of Planning

Establishing priorities.

Writing goals / outcomes that determine the

evaluative strategy . Selecting appropriate nursing interventions.

Communicating the plan of nursing care.


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Priorities of Planning

Determine problems that require immediateaction.

Maslows Hierarchy ofHuman Needs

1. Physiologic needs.

2. Safety.

3. Love and belonging needs.

4. Self-esteem needs.

5. Self- actualization needs.


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Writing Goals / Outcomes

Short-Term Goals

Outcomes achievable in a few days or 1 week.

Long-Term Goals

Desirable outcomes that take weeks or monthsto accomplish for clients with chronic healthproblems.


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Guidelines For Goal/Outcome Writing

One of the most important consideration ingoal/outcome writing is to encourage the patientand family to be as involved in goal

development as their abilities and interestpermit . Each patient goal/outcome must have

1- a subject : which is the patient.2- a verb : which indicates the action.

The patient will perform , and criteria whichdescribe in observable such as ( define , identify, list , select , apply , explain , prepare etc


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Problems Related to Planning

1. Insufficient data collection.

2. Nursing Dxs developed from inaccurate data.

3. Goals /outcomes that are stated too broadly .4. Goals/outcomes that are derived from poorly

developed nursing Dxs.


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Implementation (Intervention)

Execute the plan of care (action phase)

The nurse implements medical orders and

nursing orders. Implementation involves the client and one or

more health care team.

The information in the chart shows a correlationbetween the plan and the care that has been

provided. Nurses are accountable for carrying out nursing

orders and physician orders.


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Types of Nursing Intervention

1. Dependent nursing action.Which involve carrying physician prescribedorders.

2. Independent nursing action.Carrying out nurse- prescribed interventionswritten on the nursing plan of care as well asany other actions that nurses initiate withoutthe direction of anther health care professional

and that result from their assessment ofpatient needs .3. Interdependent nursing action.

Which performed jointly by nurses and othermembers of the health care team .


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Carrying Out The Plan of Care

When carrying out the plan of care , nurses usespecialized abilities to

1. Determine the patients continuing need for nursingassistance.

2. Promote self-care .

3. Assist the patient to achieve health goals.


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Evaluation

Evaluate the effectiveness of the plan of care interms of patient goal achievements.

The nurse and patient together measure how wellthe patient has achieved the goals/outcomes

specified in the plan of care , and the purpose ofevaluation is to allow the patients achievement ofexpected outcomes to direct future nurse patientinteractions , based on the patients responses tothe plan of care .


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Measuring Patient Goal/Outcomes

Achievement

1. Collecting evaluative data.The data collected to determine whither theidentified health problems have been resolvedthrough goal achievement.

2. Documenting evaluation.After the data have been collected the nursewrites an evaluative statement to summarizethe findings. And the nurse has three decision

options for how goals have been (met ..Partially met .. not met...)


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Factors That Influence Goal/Outcome

Achievement

1. Numerous patient:( cognitive , cooperate .etc )

2. Nurse: excellent , frustrate , bored.

3. Health care system : inadequate staffing .relationships. etc


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Documenting , Reporting and

Conferring

Documenting care.

Is the written , legal record of all pertinent

interaction with the patient assessing ,diagnosing , planning , implementing andevaluation to facilitate patient care .

Patient record.

Is a compilation of patients health information


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Purposes of Patient Records

1. Communication : between health careprofessionals

2. Care planning : patient responding to treatmentfrom day to day .

3. Education : for the manifestations andtreatment

4. Decision analysis.

5. Research .

6. Legal documentation.


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Methods ofDocumentation

1. Source oriented records : one in which eachhealth care group keeps data on its ownseparate form .

2. Problem- oriented medical records:POMR is organized around a patients problemsrather than a round sources of information .

3. Charting by exception:Is a shorthand documentation method thatmakes use of well-defined standards of practice

4. Computerized records.


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Common Methods of Communication

Among Health Care Professionals

Face to face meeting.

Telephone conversation.

Written message.

Computer message .


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Nursing Care Rounds

Its procedures in which a group of nursesvisit selected patients individually at each

patients bed side to:1. Evaluate the nursing care for the patient has

received.

2. Gather information to help plan nursing care.


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Nursing Process (3)

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