Prepared by Mrs.Hamdia Mohammed. 1-Define nursing process 2-Define nursing care plan 3- List the...
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Transcript of Prepared by Mrs.Hamdia Mohammed. 1-Define nursing process 2-Define nursing care plan 3- List the...
![Page 1: Prepared by Mrs.Hamdia Mohammed. 1-Define nursing process 2-Define nursing care plan 3- List the basic components of the Nursing Process. 3-Enumerate.](https://reader036.fdocuments.in/reader036/viewer/2022062409/56649eb45503460f94bbbe04/html5/thumbnails/1.jpg)
prepared byMrs.Hamdia Mohammed
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1-Define nursing process 2-Define nursing care plan
3 -List the basic components of the Nursing Process.
3-Enumerate items of planning process.4 -Apply nursing process on situation.
5 -Explain 2 different example from nursing care plan .
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The Nursing Process is:A systematic, rational method of planning and providing individualized nursing care.
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A written guide, organizing client data into a formal statements of strategies to assist the client achieve optimal health
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Assessment
Diagnosis
Planning
Implementing
Evaluating
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The Planning process:- In the process of developing client care plans ,
the nurse engages in the following activities: 1- Setting Priorities. 2- Establishing client goals /desire outcomes 3- Selecting nursing interventions 4- Writing individualized nursing interventions
on care plans.
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Mrs. Mona Ali have 43 years old, admitted to
hospital in 17-3-1431H. She complain from sharp
chest pain when coughing and dyspnea on exertion.
States unable to carry out regular daily exercise for
past week .Nausea & vomiting associated with
coughing . Assesses own supports as good (e.g.
relationship with husband) is worried about daughter .
States husband will be out of town until tomorrow.
Concerned too about her work and worry about it .
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Nursing diagnosi
s
Goal/Desired outcomes
Intervention
Evaluation
1-Ineffective airway clearance Related to viscous secretions as evidenced by pain and fatigue.
Long term goal-:
Respiratory status : Gas exchange.Short term goal-:
-Absence of pallor and cyanosis
-Pt will be able to use of correct breathing /coughing technique
-Productive cough -Lung clear
1- Assess airway for patency.2-Auscultate lungs for presence of normal or abnormal breathing sounds3-Assess changes in V.S4-Assess cough for effectiveness & productivity( color, amount odor& consistency).
The ptDo coughing & breathing exerciseAnd breaths effectively
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5-Assist pt in performing coughing & breathing exercise( chest physiotherapy ).
6-Put pt in sitting position ( optimal position)& use of abdominal muscles for more forceful cough .
7-Encourage oral intake of fluids.8- Administer medications( e.g antibiotic,
bronchodilators, expectorants) as ordered.9- Give pt nebulizer treatment if indicated.
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Nursing diagnosis
Goal/Desired outcomes
Intervention
Evaluation
2-Deficient fluid volume: intake insufficient to replace fluid loss R/Tvomiting
aeb poor skin turgor
Long term goal-:
Fluid balance.Short term
goal-:-Good skin
turgor-Moist mucous
membranes.-Stating the need
for oral fluid intake.
1 -Assess characteristic of vomiting
)amount , odor, color.(...,
2 -Evaluate fluid status in relation to dietary intake.
3 -Check V.S4-Assess skin
turgor for signs of dehydration .
Pt demonstrateThat he is increase oral fluid intake & return to normal skin turgor .
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5-Assess intake & output.6- Monitor serum electrolytes & report abnormal
value.7-Administer antiemetic drug as order. 8- Give pt I.V fluid as replacement therapy if
indicateas doctor ordered.
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Nursing diagnosis
Goal/Desired outcomes
InterventionEvaluation
3-Anxiety R/T family and work problems aeb concerns about work and parenting roles.
Long term goal-:
Anxiety control.Short term goal-:
Freely expressing concerns and possible solutions about work and parenting roles.
1 -Reassure the pt.
2 -Maintain a calm manner while interacting with pt.
3 -Provide a quite environment.
4 -Encourage her to talk about
anxious feeling
Pt verbalize that she or he return to normal psycholo-gical status
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5- Assist the pt in developing anxiety- reducing skills ( e.g, relaxation, deep breathing , positive visualization ).
6- Assist pt in developing problem solving abilities.- Emphasize the logical strategies pt can use when
experiencing anxious feelings.
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Nursing diagnosis
Goal/Desired outcomes
Intervention
Evaluation
4-Risk for interrupted family processesR/Tmother's illness and temporary unavailability of father to provide child care, AEB concerns about parenting roles.
Long term goal-:Family coping .
Short term goal-:
Client and husband communicating effectively and working together to solve problems.
1 -Assess for precipitating events ( illness, life transition, crisis).
2 -Assess family member’s perceptions of the problem .
3 -Evaluate strengths, coping skills & current support systems.
Pt verbalize that she or he return to normal psycholo-gical status
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Nursing diagnosis
Patient goal
interventionEvaluation
Self Care Deficit: Bathing /Hygiene R/T lack of motivation secondary to depression AEB Unwilling to wash body parts
Will experience no self care hygiene deficit by 4 days
1-talking with patient2-reassure him3-tell the importance of hygiene …….
Patient list the time of washing arms and legs
Example of writing nursing care plan
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Nursing diagnosis
Patient goal
InterventionsEvaluation
Risk for impaired skin integrity r/t decreased mobility
Pt. will experience no any signs of skin breakdown
1 -change position frequently
2-back rub 3-skin care
4-increase fluid intake
5 -increase protein
intake.……
Pt increase daily exercise & change his position continuous.
Example of writing nursing care plan cont.