process Nursing
Nursing process is to provide a systematic method for nurses to plan and implement
client care to achieve desired outcomes.
of nursing process Important
Systematically collect patient data
Clearly identify patient strengths and actual and potential problems (diagnosing)
Develop a holistic plan of individualized care that specifies the desired patient goals
and related outcomes and the nursing interventions most likely to assist the patient to
meet those expected outcomes (planning)
Execute the plan of care (implementing)
Evaluate the effectiveness of plan of care in terms of patient goal achievement
(evaluating)
of the Nursing Process Steps
Assessment
Diagnosis (nursing) or analysis
Planning
Implementation
Evaluation
of the nursing process Characteristics
Systematic
Dynamic
Interpersonal
Outcome oriented
Assessment
Assessment is the first step of the nursing process when client information is gathered
and examined in preparation for the second step diagnosis.
:phase include the following activities Assessment
Collecting data: Gathering information about the patient or client
1.
The following summarizes the resources for gathering data
Patient/ client (primary source)
Family/ significant others
Nursing records
Medical records
Record of diagnostic studies.
Patient interview.
examination By Physical
Inspection: Examination by careful and critical observation.
Auscultation: Examination by listening with stethoscope.
Palpation: Examination by touching and felling.
Percussion: Examination by touching, tapping, and listening.
Validating data: Making sure that you know which data is actually fact and which
data are questionable.
Organizing Data; clustering the data into groups of information that will help you to
identify patterns of health or disease.
Identifying Patterns: making an initial impression about patterns of information, and
gathering additional data impression about patterns of information, and gathering
additional data to fill in the gaps to describe more clearly what the data mean.
Communicating /Recording data: reporting significant data to expedite treatment,
and completing the data base
for data collection Preparing
Establishing Assessment Priorities
Before beginning to collect data on any patient, the nurse should have a good sense of
the type of data needed to develop a satisfactory plan of care. For example, pediatric
nurses are careful to establish the developmental age and milestones obtained by
children admitted to a pediatric unit.
Another example, A school nurse who suspects child abuse pays careful attention to
the child's statement about living conditions at home and relationships with family
members and caregivers.
Health Orientation
Assess patient knowledge and believe about illness and wellness
Developmental stage
Nursing assessments are modified according to the developmental needs of patients.
For example, when assessing an infant, special attention is given to weight gain and
physical growth, feeding and elimination problems, sleep-activity cycles, and the
parenting skills of caregivers.
for nursing Need
When assessing patients is to gather only data that are helpful when planning and
delivering care. It would be inappropriate, for example, to collect a detailed sexual
history on a patient admitted to the hospital overnight after a slight concussion.
Practical considerations
Data already collected from the patient and in the patient record should not be
repeatedly sought from the patient unless there is a need to validate them.
Data Collection
Types of data
and objective Subjective
Subjective
Subjective data are information perceived only by the affected person; these data
cannot be perceived or verified by another person. Examples of subjective data are
feeling nervous, nauseated, or chilly and experiencing pain.
Objective
Objective data are observable and measurable data that can be seen, heard, or felt by
someone other than the person experiencing them. Example, elevated body
temperature
of data Characteristics
Complete
As much as possible, all the patient data needed to understand a patient health
problem and develop a plan of care to maximize health and well-being should be
identified. For example, knowing that a patient has lost weight is not fully meaningful
until the nurse discovers (1) if the weight loss was intentional or unintentional, (2) If it
was related to a change in eating or exercise patterns. (3) how the patient views and is
responding to the weight loss.
Accurate
Both the patient and the nurse may intentionally or unintentionally misrepresent
patient information. For example, a patient who values being thin may describe a
weight gain of several pounds as the onset of obesity.
Relevant
Diagnosis Nursing
Nursing Diagnosis: An actual or potential health problem that is focuses upon the
human response of an individual or group, and that nurses are responsible and
accountable for identifying and treating independently.
Diagnostic Statements for Actual Nursing Diagnoses Writing
When you write a diagnostic statement for actual nursing diagnoses, you should use
the PES (problem, etiology, signs and symptoms) system to describe the diagnosis.
That is, you write a three-part statement, which includes the following:
The problem(P)
1.
Its cause or etiology(E)
2.
The signs and symptoms(defining characteristics) that are evident in the
3.
patient(S)
Rule: to write a diagnostic statement for an actual nursing diagnoses, link the problem
and its etiology by using‘’’related to’’. Add ‘’ as manifested by’’ or ‘’as evidenced by
Diagnostic statement: Ineffective Airway Clearance related to weak cough and
incisional pain, as manifested by poor or no cough effort and statements that incision
hurts too much when he coughs.
Diagnostic Statements for Potential Problem Writing
Potential and Possible Nursing Diagnosis (two-part statement):
Problem +Etiology
Potential Ineffective Airway Clearance Related to Smoking
Planning
the goals, interventions and outcomes Establish
Guidelines for Setting Priorities General
.issues life-threatening
Take care of immediate
.Safety issues
.Patient-identified issues
overall picture, the patient as a whole person, Nurse-identified priorities based on the
.resources and availability of time and
Identified Priorities Nurse
.s strengths and health concerns’Composite of all patient
.Moral and ethical issues
.Time, resources, and setting
.Hierarchy of needs
.Interdisciplinary planning
Implementation
Implementation refers to the action phase of the nursing process in which nursing
care is provided. It is the actual initiation of the plan and recording of nursing actions.
Its purpose is to provide technical and therapeutic nursing care required to help the
client achieve an optimal level of health.
Evaluation
Evaluation, the sixth phase of the nursing process, follows implementation of the plan
of care. Evaluation is defined as the judgment of the effectiveness of nursing care to
meet client goals based on the client's behavioral responses. This phase involves a
thorough, systematic review of the effectiveness of nursing interventions and a
determination of client goal achievement.