NURSING PROCESS.pptx

NILOFAR LOLADIYA
MSN: OBGY

The common thread uniting different types of nurses who work in varied areas is the nursing process—the essential core of practice for the registered nurse to deliver holistic, patient-focused care

One of the most important tools a nurse can use in practice is the nursing process. Although nursing schools teach first-year students about the nursing process, some nurses fail to grasp the impact its proper use can have on patient care. In this article, I will share information about the nursing process, its history, its purpose, its main characteristics, and the 5 steps involved in carrying out the nursing process.

• Establishes plans to meet patient needs
• Guides nurses in the delivery of high-quality evidence-based care
• Protects nurses against potential legal problems
• Promotes a systematic approach to patient care that all members of the nursing team can follow

The nursing process consists of five steps which encompass the care provided. The five nursing process steps are:

1. Assessment
2. Diagnosis
3. Planning
4. Implementation
5. Evaluation

1. NURSING PROCESS -Mrs Nilofar Loladiya

2. WHAT is Nursing?

3. North American Nursing Diagnosis Association International (NANDA-I) WHAT is Nursing Process?

4. WHAT is Nursing Process? Systematic, rational method of planning and providing individualized nursing care It is Systematic method that directs the nurse and the patient to accomplish the desired goal established after assessing and diagnosing.

5. WHY Nursing Process? Identify nursing priorities Helps direct nursing interventions Expected outcomes for quality assurance Identify responses to actual or potential health and life processes  Identify available resources   Common basis for communication Evaluation to determine if nursing care was beneficial Sharpens problem-solving and critical thinking skills

6. Cyclic and dynamic rather than static Client centered Problem-solving Decision making Interpersonal and collaborative Universal applicability Critical thinking and Clinical reasoning skills Characteristics of Nursing Process

7. Mrs. Nilofar: CNE on nursing process

8. ASSESSMENT COLLECT DATA INITIAL COMPREHENSIVE ASSESSMENT (Database) ONGOING ASSESSMENT (patient Progress) HISTORY (subjective Data) PHYSICAL EXAMINATION (Objective Data) Patient History Biographic data History of illness Present Function Expectation Stress/Coping V/S Measurements Interview Examination observation VALIDATE ORGANIZE RECORD

9. ASSESSMENT DATA TYPES SUBJECTIVE DATA OBJECTIVE DATA “ My throat hurts to swallow “ White patches noted at back of throat Tonsillar area reddened and swollen SUBJECTIVE DATA OBJECTIVE DATA Mrs. Nilofar: CNE on nursing process

10. ASSESSMENT DATA SOURCES PRIMARY SOURCE (client) SECONDARY SOURCES (everything else) Pulse rate: 100 b/m Shortness of breath WBC count from client record Surgical dressing dry- transfer report Mrs. Nilofar: CNE on nursing process

11. CRITICAL THINKING NANDA Definition A  Nursing diagnosis  is a clinical judgment concerning a human response to health conditions/life processes, or a vulnerability to that response, by an individual, family, group, or community.  Nursing diagnoses  are developed based on data obtained during the nursing assessment and enable the nurse to develop the care plan.

12. Nursing diagnosis V/S Medical diagnosis Second step in the nursing process,  diagnosis . Nursing diagnosis is focused on care. Classification system established and approved by NANDA A nursing diagnosis is based upon the patient’s response to the medical condition. Associated with what nurses have the autonomy to take action about  Anything that is a physical, mental, and spiritual type of response

13. Nursing diagnosis V/S Medical diagnosis

14. Diagnosing: Refers to the reasoning process Diagnosis: A statement or conclusion regarding the nature of phenomenon Diagnostic labels: Standardized NANDA names for diagnoses Etiology: Causal relationship between ad problem and its related factors Nursing diagnosis: Problem statement consisting of diagnostic label plus etiology C ommon Terminologies

15. Problem (diagnostic label) and definition Describes the client's health problem or response May require specification Qualifiers added to give additional meaning Deficient , (Inadequate in amount, quality; insufficient) Impaired , (Made worse, weakened, damaged, deteriorated) Decreased , (less in size, amount) Ineffective , (Not producing desired effect) Compromised (vulnerable, threat)

16. Qualifier Focus of the Diagnosis Deficient Fluid volume Imbalanced Nutrition: Less Than Body Requirements Impaired Gas Exchange Ineffective Tissue Perfusion Risk for Injury

17. Etiology (related factors and risk factors) Identifies one or more probable causes of the health problem Gives direction to the required nursing therapy Enables the nurse to individualize the client's care

18. Defining characteristics Cluster of existing signs and symptoms indicates actual diagnosis Clients have signs and symptoms.

19. Problem-focused diagnosis Also known as  actual diagnosis It is a client problem present at the time of the nursing assessment. These diagnoses are based on the presence of associated signs and symptoms.

20. Ineffective Breathing Pattern   related to pain as evidenced by pursed-lip breathing, reports of pain during inhalation, use of accessory muscles to breathe Anxiety  related to Pre-operative status as evidenced by body language, apprehension, and expression of concern regarding upcoming Surgery Acute Pain  related to decreased myocardial flow as evidenced by grimacing, expression of pain, guarding behavior . Impaired Skin Integrity  related to pressure over bony prominence as evidenced by pain,  bleeding , redness, wound drainage. Problem-focused diagnosis

21. Risk nursing diagnosis Clinical problem does not exist, Presence of risk factors indicates that a problem is likely to develop unless nurses intervene. The individual (or group) is more susceptible to developing the problem than others in the same or a similar situation because of risk factors.

22. For example, an  elderly  client with  diabetes  and vertigo who has difficulty walking refuses to ask for assistance during ambulation Risk for Injury . Risk for fall Risk nursing diagnosis

23. Health promotion diagnosis Also known as  wellness diagnosis It is a clinical judgment about motivation and desire to increase well-being. Concerned with the individual, family, or community transition from a specific level of wellness to a higher level of wellness. Components of a health promotion diagnosis generally include only the diagnostic label or a one-part statement.

24. Health promotion diagnosis Examples of health promotion diagnosis: Readiness for Enhanced Spiritual Well Being Readiness for Enhanced Family Coping Readiness for Enhanced Parenting

25. Syndrome diagnosis  A clinical judgment concerning a cluster of problem or risk nursing diagnoses that are predicted to present because of a certain situation or event. written as a one-part statement requiring only the diagnostic label.

26. Syndrome diagnosis  Chronic Pain  Syndrome Post-trauma Syndrome Frail Elderly Syndrome

27. Using “secondary to” to make the diagnostic statement more descriptive and useful. Following the “secondary to” is often a pathophysiologic or disease process or a medical diagnosis. For example,  Risk for  Decreased Cardiac Output  related to reduced preload secondary to  myocardial infarction . Specifying a second part of the general response or NANDA label to make it more precise. e.g.  Impaired Skin Integrity (Right Anterior Chest) related to disruption of skin surface secondary to  burn injury .

28. Mrs. Nilofar: CNE on nursing process

29. GOAL SETTING WHAT YOU WANT TO ACHIEVE THROUGH YOUR NURSING ACTIVITIES. Clients need to be able participate in setting goals; unless goals are set mutually and there is a clear plan for action, clients may not follow the plan of care. SHORT TERM Are those you expect the patient to achieve within few hours or days LONG TERM Changes in health status to be achieved over a longer period, a week, a month or more They describe the optimum level of functioning you expect the patient to achieve, given health status and available resources. Mrs. Nilofar: CNE on nursing process

30. Previously Goals and expected outcomes are same but now they have been defined separately. GOAL EXPECTED OUTCOMES Decision Making Patient participates in discussion about own care Chooses between two or more alternatives Relief Constipation Bowel will be soft and having bowel movement within 24 hours Mrs. Nilofar: CNE on nursing process

31. EXPECTED OUTCOMES: They are specific client behaviours or physiological responses that the registered nurse and the client set to achieve. (Potter & Perry, 2010). Client admitted for a total joint replacement could be; • Client’s self report of pain will be 3 or less on a scale of 0 to 10. • Client will be able to mobilize with minimal discomfort within 2 days of care. Mrs. Nilofar: CNE on nursing process

32. INTERVENTIONS Action based on clinical judgement and nursing knowledge that nurses perform to achieve client outcomes. DIRECT CARE: INDIRECT CARE: INDEPENDENT/AUTONOMOUS DEPENDENT COLLABORATIVE Mrs. Nilofar: CNE on nursing process

33. Interventions flow from Nursing Diagnosis PROBLEM CONSTIPATION STANDARDISED CARE INTERVENTION: Administer prescribed stool softner and laxatives -HS Encourage fluid intake ETIOLOGY r/t immobility and decreased GI Mobility Secondary to narcotic analgesics INDIVIDUALIZED CARE INTERVENTION: Encourage high fibre diet Use Non- Pharamacological measures Mrs. Nilofar: CNE on nursing process

34. EVALUATION COMPLETE PARTIAL INCOMPLETE Needs assessment Outcome evaluation Mrs. Nilofar: CNE on nursing process

35. CASE STUDY A 46 YEAR OLD FEMALE NEWLY DIAGNOSED WITH ASTHMA HAS COME TO YOUR CLINIC FOR THE FIRST TIME. SHE IS A SMOKER AND HAS HAD ASTMATIC SYMPTOMS FOR THE LAST 36 HOURS .SHE HAS BEEN PRESCRIBED A SHORT ACTING BRONCHODIATOR VIA INLAHER AND LONG ACTING MEDICATION . Mrs. Nilofar: CNE on nursing process

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61. DOUBTS??

62. THANK YOU