Nursing_Process_More_Detailed_Presentation.pptx

Nursing process, detailed steps in nursing

1. Nursing Process A Systematic Approach to Quality Nursing Care

2. Definition of Nursing Process • A systematic, evidence-based method used by nurses to ensure quality care. • Involves critical thinking, problem-solving, and decision-making. • Enables individualized, holistic, and client-centered care. • Framework supported by ANA (2010) and widely accepted globally.

3. Purpose of Nursing Process • Establish a structured method for assessment and care planning. • Facilitate effective communication among healthcare team. • Involve clients and families in care. • Promote efficient use of time and resources. • Enhance client satisfaction and health outcomes.

4. Characteristics of Nursing Process • Systematic – Follows an ordered sequence of steps. • Dynamic – Continuously evolving as client’s needs change. • Client-centered – Focuses on individual needs. • Interpersonal – Requires communication and collaboration. • Universally applicable – Useful across all settings and conditions. • Goal-directed – Aims at achieving health outcomes.

5. Five Major Steps 1. Assessment – Gathering relevant client information. 2. Diagnosis – Identifying client’s problems. 3. Planning – Setting goals and determining interventions. 4. Implementation – Executing the planned actions. 5. Evaluation – Assessing the outcome of interventions.

6. Assessment: Definition & Purpose • First step of the nursing process. • Purpose: Establish a baseline for care planning. • Collects data through observation, interview, and examination. • Ensures data is accurate, complete, and relevant.

7. Types of Assessment • Initial Assessment – On admission; establishes baseline. • Problem-focused – Ongoing; focused on identified issues. • Emergency – Rapid assessment in life-threatening situations. • Time-lapsed – After time interval to compare progress.

8. Types and Sources of Data • Subjective Data – Client-reported symptoms (e.g., pain, nausea). • Objective Data – Observable signs (e.g., fever, BP). • Primary Source – Direct from client. • Secondary Source – Family, medical records, lab results.

9. Methods of Data Collection • Interview: Directive and Non-directive approaches. • Physical Examination: Inspection, palpation, percussion, auscultation. • Observation: Physical, psychological, and environmental cues. • Diagnostic Tests: Lab reports, imaging studies.

10. Nursing Diagnosis: Definition & Importance • Second step in the process. • Clinical judgment about human responses to health conditions. • Uses NANDA-approved terminology. • Directs planning and intervention.

11. Types and Format of Nursing Diagnosis • Actual – Problem currently exists. • Risk – High possibility of developing issue. • Health Promotion – Readiness to improve health. • Format: PES (Problem, Etiology, Symptoms).

12. Formulating Nursing Diagnosis Example 1: Fever related to infection as evidenced by elevated temperature. Example 2: Risk for falls related to impaired mobility. • Always verify diagnosis with client. • Document and update as needed.

13. Planning Phase Overview • Third step in the process. • Sets client-specific goals and interventions. • Promotes structured, measurable care outcomes. • Types: Initial, Ongoing, Discharge planning.

14. Goal Setting and Prioritization • Goals must be SMART (Specific, Measurable, Achievable, Relevant, Time-bound). • Prioritize based on: - Maslow's Hierarchy of Needs - Urgency and client preference - Safety and resources

15. Types of Interventions • Independent – Initiated by nurse (e.g., teaching). • Dependent – Require physician’s order (e.g., medication). • Collaborative – Involve interdisciplinary teams. • Must be documented and evaluated for effectiveness.

16. Implementation: Definition & Process • Fourth step in the process. • Executing planned nursing actions. • Requires skill integration: - Cognitive (knowledge) - Interpersonal (communication) - Technical (procedures) • Process: 1. Reassess 2. Prioritize 3. Perform 4. Delegate 5. Record

17. Evaluation Phase • Final step in the nursing process. • Measures effectiveness of interventions. • Involves comparing outcomes with goals. • Determines whether to continue, modify, or terminate the care plan.

18. Types and Components of Evaluation • Structure – Environment and resources. • Process – Nurse’s performance and adherence. • Outcome – Client’s health status changes. • Components: - Data collection - Outcome comparison - Response analysis - Identify barriers - Revise plan