SEMINAR ON NURSING PROCESS msc nursing PPT.pptx

Advanced nursing

1. PRESENTED BY BHANUMATI SOLANKI PREETI ISKAPE M.SC.NURSING PREVIOUS YEAR GOVERNMENT COLLEGE OF NURSING UJJAIN SEMINAR ON NURSING PROCESS

2. Definition Nursing process is a critical thinking process that professional nurses use to apply the best available evidence to caregiving and promoting human functions and responses to health and illness (American Nurses Association, 2010).

3. Purposes of nursing process • To identify a client's health status and actual or potential health care problems or needs. • To establish plans to meet the identified needs. • To deliver specific nursing interventions to meet those needs.

4. Components of nursing process • It involves assessment (data collection), nursing diagnosis, planning, implementation, and evaluation .

5. Characteristics of Nursing Process • Cyclic Dynamic nature, • Client centeredness • Focus on problem solving and decision making • Interpersonal and collaborative style • Universal applicability • Use of critical thinking and clinical reasoning

6. Definition Assessment is the systematic and continuous collection, organization, validation, and documentation of data (information

7. Types of assessment The four different types of assessments are; 1. Initial nursing assessment 2. Problem-focused assessment 3. Emergency assessment 4. Time-lapsed reassessment

8. 1.Initial nursing assessment: Performed within specified time after admission. To establish a complete database for problem identification. Eg : Nursing admission assessment 2. Problem-focused assessment: To determine the status of a specific problem identified in an earlier assessment. Eg : hourly checking of vital signs of fever patient

9. 3. Emergency assessment: During emergency situation to identify any life threatening situation. Eg : Rapid assessment of an individual's airway, breathing status, and circulation during a cardiac arrest. 4. Time-lapsed reassessment: Several months after initial assessment. To compare the client's current health status with the data previously obtained

10. Collection of data Data collection is the process of gathering information about a client's health status. It includes the health history, physical examination, results of laboratory and diagnostic tests, and material contributed by other health personnel.

11. Types of Data Two types: subjective data and objective data. Subjective data , also referred to as symptoms or covert data, are clear only to the person affected and can be described only by that person. Itching, pain, and feelings of worry are examples of subjective data .

12. Objective data , also referred to as signs or overt data, are detectable by an observer or can be measured or tested against an accepted standard. They can be seen, heard, felt, or smelled, and they are obtained by observation or physical examination. For example, a discoloration of the skin or a blood pressure reading is objective data.

13. Sources of Data Sources of data are primary or secondary. Primary: It is the direct source of information. The client is the primary source of data. 2. Secondary: It is the indirect source of information. All sources other than the client are considered secondary sources. Family members, health professionals, records and reports, laboratory and diagnostic results are secondary sources .

14. Methods of data collection • The methods used to collect data are observation, interview and examination. Observation: It is gathering data by using the senses. Vision, Smell and Hearing are used. Interview: An interview is a planned communication or a conversation with a purpose.

15. • There are two approaches to interviewing: directive and nondirective. • The directive interview is highly structured and directly ask the questions. And the nurse controls the interview. • A nondirective interview, or rapport building interview and the nurse allows the client to control the interview

16. STAGES OF AN INTERVIEW An interview has three major stages: 1. The opening or introduction 2. The body or development 3. The closing

17. Examination: The physical examination is a systematic data collection method to detect health problems. To conduct the examination, the nurse uses techniques of inspection, palpation, percussion and auscultation .

18. Organization of data The nurse uses a format that organizes the assessment data systematically. This is often referred to as nursing health history or nursing assessment form

19. Validation of data The information gathered during the assessment is "double-checked" or verified to confirm that it is accurate and complete

20. Documentation of data To complete the assessment phase, the nurse records client data. Accurate documentation is essential and should include all data collected about the client's health status.

21. DIAGNOSIS

22. Diagnosis is the second phase of the nursing process. In this phase, nurses use critical thinking skills to interpret assessment data to identify client problems. • North American Nursing Diagnosis Association (NANDA) define or refine nursing diagnosis.

23. Definition • The official NANDA definition of a nursing diagnosis is: "a clinical judgment concerning a human response to health conditions/life processes, or a vulnerability for that response, by an individual, family, group, or community

24. Status of the Nursing Diagnosis The status of nursing diagnosis are actual, health promotion and risk. 1. An actual diagnosis is a client problem that is present at the time of the nursing assessment. 2. A health promotion diagnosis relates to clients' preparedness to improve their health condition.

25. A risk nursing diagnosis is a clinical judgement that a problem does not exist, but the presence of risk factors indicates that a problem may develop if adequate care is not given .

26. Components of a NANDA Nursing Diagnosis A nursing diagnosis has three components: (1) The problem and its definition (2) The etiology (3) The defining characteristics.

27. 1.The problem statement describes the client's health problem. 2. The etiology component of a nursing diagnosis identifies causes of the health problem. 3. Defining characteristics are the cluster of signs and symptoms that indicate the presence of health problem.

28. Formulating Diagnostic Statements The basic three-part nursing diagnosis statement is called the PES format and includes the following: 1. Problem (P): statement of the client's health problem (NANDA label) 2. Etiology (E): causes of the health problem 3. Signs and symptoms (S): defining characteristics manifested by the client.

29. Acute pain related to abdominal surgery as evidenced by patient discomfort and pain scale. Problem Pain Etiology Surgery of abdomen Signs and symptoms Pain and discomfort of patient

30. NANDA nursing diagnosis Class: Circulation Anatomical structures and physiological processes involved in vital and peripheral circulation Decreased cardiac output Risk for decreased cardiac output Risk for decreased cardiac tissue perfusion Risk for impaired cardiovascular function Risk for ineffective cerebral tissue perfusion Risk for ineffective gastrointestinal perfusion Risk for ineffective renal perfusion Ineffective peripheral tissue perfusion Risk for ineffective peripheral tissue perfusion

31. Class: Respiration Anatomical structures and physiological processes involved in ventilation and gas exchange Ineffective airway clearance Ineffective breathing pattern Impaired gas exchange Impaired spontaneous ventilation Dysfunctional ventilatory weaning response

32. Class: Physical Regulation Anatomical structures and physiological processes involved in hematological , immunological, and metabolic regulatory mechanisms Risk for adverse reaction to iodinated contrast media Risk for allergy response Risk for unstable blood glucose level Risk for imbalanced body temperature Risk for electrolyte imbalance Readiness for enhanced fluid balance Deficient fluid volume Risk for deficient fluid volume Excess fluid volume Risk for imbalanced fluid volume

33. Hyperthermia Risk for hyperthermia Hypothermia Risk for hypothermia Risk for perioperative hypothermia Neonatal jaundice Risk for neonatal jaundice Latex allergy response Risk for latex allergy response Risk for impaired liver function Ineffective thermoregulation

34. Class: Nutrition Anatomical structures and physiological processes involved in the ingestion, digestion, and absorption of nutrients Insufficient breast milk Ineffective breastfeeding Interrupted breastfeeding Readiness for enhanced breastfeeding Ineffective infant feeding pattern Imbalanced nutrition: less than body requirements Readiness for enhanced nutrition Obesity Overweight Risk for overweight

35. Class: Elimination Anatomical structures and physiological processes involved in discharge of body waste Bowel incontinence Constipation Risk for constipation Perceived constipation Chronic functional constipation Diarrhea Dysfunctional gastrointestinal motility Risk for dysfunctional gastrointestinal motility Impaired urinary elimination Readiness for enhanced urinary elimination Functional urinary incontinence Overflow urinary incontinence Reflex urinary incontinence

36. Class: Elimination Anatomical structures and physiological processes involved in discharge of body waste Bowel incontinence Constipation Risk for constipation Perceived constipation Chronic functional constipation Diarrhea Dysfunctional gastrointestinal motility Risk for dysfunctional gastrointestinal motility Impaired urinary elimination Functional urinary incontinence Overflow urinary incontinence Reflex urinary incontinence

37. Stress urinary incontinence Urge urinary incontinence Risk for urge urinary incontinence Urinary retention Risk for urinary tract injury Class: Skin/Tissue Anatomical structures and physiological processes of skin and body tissues involved in structural integrity Risk for corneal injury Impaired dentition Risk for dry eye Impaired oral mucous membrane

38. Risk for impaired oral mucous membrane Risk for pressure ulcer Impaired skin integrity Risk for impaired skin integrity Risk for thermal injury Impaired tissue integrity Risk for impaired tissue integrity Risk for vascular trauma

39. Class: Neurological Response Anatomical structures and physiological processes involved in the transmission of nerve impulses Decreased intracranial adaptive capacity Autonomic dysreflexia Risk for autonomic dysreflexia Disorganized infant behavior Readiness for enhanced organized infant behavior Risk for disorganized infant behavior Risk for peripheral neurovascular dysfunction Unilateral neglect

40. Class: Cognition Neuropsychological processes involved in orientation, information processing, and memory Acute confusion Risk for acute confusion Chronic confusion Impaired memory Class: Self-Concept Psychological patterns involved in self-perception, identity, and self-regulation Disturbed body image Ineffective denial Labile emotional control Ineffective impulse control Chronic low self-esteem

41. Risk for chronic low self-esteem Situational low self-esteem Risk for situational low self-esteem Disturbed personal identity Risk for disturbed personal identity Readiness for enhanced self-concept Sexual dysfunction Ineffective sexuality pattern Class: Mood Regulation Biophysical and emotional interaction processes involved in mood regulation Impaired mood regulation

42. Perceptions of symptoms and experience of suffering Anxiety Impaired comfort Readiness for enhanced comfort Death anxiety Fear Acute pain Chronic pain Labor pain Chronic pain syndrome

43. Nausea Chronic sorrow Class: Well-Being Perceptions of life qualities and experience of existential needs satisfaction Grieving Complicated grieving Risk for complicated grieving Readiness for enhanced hope Hopelessness Risk for compromised human dignity Readiness for enhanced power

44. Powerlessness Risk for powerlessness Spiritual distress Risk for spiritual distress Readiness for enhanced spiritual well-being Class: Life Principles Personal values, beliefs, and religiosity Decisional conflict Moral distress Noncompliance Impaired religiosity

45. Readiness for enhanced religiosity Risk for impaired religiosity Class: Coping Perceptions of coping, coping experiences, and coping strategies Ineffective activity planning Risk for ineffective activity planning Defensive coping Ineffective coping Readiness for enhanced coping Readiness for enhanced decision-making Impaired emancipated decision-making Readiness for enhanced emancipated decision-making Risk for impaired emancipated decision-making Post-trauma syndrome

46. Risk for post-trauma syndrome Rape-trauma syndrome Relocation stress syndrome Risk for relocation stress syndrome Impaired resilience Readiness for enhanced resilience Risk for impaired resilience Stress overload

47. Class: Lifespan Processes The processes of growth, mental development, physical maturation, and aging Risk for delayed development Risk for disproportionate growth Class: Physical Ability Audiovisual abilities, sexual function, and mobility Impaired bed mobility Impaired physical mobility Impaired wheelchair mobility Impaired sitting Impaired standing Impaired transfer ability Impaired walking

48. Class: Energy Balance Energy usage and energy regulation pattern Activity intolerance Risk for activity intolerance Deficient diversional activity Fatigue Insomnia Sedentary lifestyle Readiness for enhanced sleep Sleep deprivation Disturbed sleep pattern Wandering

49. Class: Communication Communication abilities and communication skills Readiness for enhanced communication Impaired verbal communication Class: Social Function Social network, social roles, social skills, and social interaction Risk for loneliness Readiness for enhanced relationship Ineffective relationship Risk for ineffective relationship Ineffective role performance Impaired social interaction Social isolation

50. Class: Self Care Self-care abilities and home maintenance skills Impaired home maintenance Bathing self-care deficit Dressing self-care deficit Feeding self-care deficit Toileting self-care deficit Readiness for enhanced self-care Self-neglect

51. Class: Self Care Self-care abilities and home maintenance skills Impaired home maintenance Bathing self-care deficit Dressing self-care deficit Feeding self-care deficit Toileting self-care deficit Readiness for enhanced self-care Self-neglect

52. Class: Health Promotion Health literacy and health maintenance skills Ineffective health maintenance Ineffective health management Readiness for enhanced health management Frail elderly syndrome Risk for frail elderly syndrome Ineffective protection Risk-prone health behavior Deficient knowledge Readiness for enhanced knowledge

53. Class: Self-Harm Self-directed risk behavior and suicidal behavior Self-mutilation Risk for self-mutilation Risk for self-directed violence Risk for suicide Class: Violence Other-directed risk behavior and violent behavior Risk for other-directed violence

54. Class: Health Hazard Health hazards associated with healthcare processes and social processes Risk for aspiration Risk for bleeding Risk for disuse syndrome Risk for falls Risk for infection Risk for injury Risk for perioperative positioning injury Risk for shock Risk for sudden infant death syndrome Risk for suffocation Delayed surgical recovery Risk for delayed surgical recovery Impaired swallowing Risk for trauma

55. Class: Milieu Hazard Health impacts of economy, housing standard, and working environment Contamination Risk for contamination Risk for poisoning

56. Class: Reproduction Biophysical and psychological processes involved in fertility and conception, and the delivery and postpartum phase of childbirth Ineffective childbearing process Readiness for enhanced childbearing process Risk for ineffective childbearing process Risk for disturbed maternal-fetal dyad

57. Class: Caregiving Roles Caregiving and caregiver functions Risk for impaired attachment Caregiver role strain Risk for caregiver role strain Parental role conflict Impaired parenting Risk for impaired parenting Readiness for enhanced parenting

58. Class: Family Unit Family coping, family functionality, and family integrity Compromised family coping Disabled family coping Readiness for enhanced family coping Ineffective family health management Dysfunctional family processes Interrupted family processes Readiness for enhanced family processes

59. Class: Family Unit Family coping, family functionality, and family integrity Compromised family coping Disabled family coping Readiness for enhanced family coping Ineffective family health management Dysfunctional family processes Interrupted family processes Readiness for enhanced family processes

60. PLANNING

61. EVALUATING ASSESSING DIAGNOSING Planning • Prioritize problems/ diagnoses • Formulate goals/desired outcomes • Select nursing interventions • Write nursing interventions IMPLIMENTING

62. • Planning involves decision making and problem solving. • It is the process of formulating client goals and designing the nursing interventions required to prevent, reduce, or eliminate the client's health problems .

63. • Planning involves decision making and problem solving. • It is the process of formulating client goals and designing the nursing interventions required to prevent, reduce, or eliminate the client's health problems .

64. Initial Planning: Planning which is done after the initial assessment. 2. Ongoing Planning: It is a continuous planning. 3. Discharge Planning: Planning for needs after discharge

65. Planning process Planning includes; • Setting priorities • Establishing client goals/desired outcomes • Selecting nursing interventions and activities • Writing individualized nursing interventions on care plans.

66. Setting priorities • The nurse begin planning by deciding which nursing diagnosis requires attention first, which second, and so on. • Nurses frequently use Maslow's hierarchy of needs when setting priorities .

67. Establishing client goals/desired outcomes • After establishing priorities, the nurse set goals for each nursing diagnosis. Goals may be short term or long term

68. Nursing interventions • A nursing intervention is any treatment, that a nurse performs to improve patient's health.

69. Nursing interventions • A nursing intervention is any treatment, that a nurse performs to improve patient's health.

70. TYPES OF NURSING INTERVENTIONS 1. Independent interventions are those activities that nurses are licensed to initiate on the basis of their knowledge and skills. 2. Dependent interventions are activities carried out under the orders or supervision of a licensed physician. 3. Collaborative interventions are actions the nurse carries out in collaboration with other health team members

71. IMPLEMENTATION

72. • Implementation consists of doing and documenting the activities. The process of implementation includes; • Implementing the nursing interventions • Documenting nursing activities

73. EVALUATION

74. • Evaluation is a planned, ongoing, purposeful activity in which the nurse determines (a)the client's progress toward achievement of goals/outcomes and (b)the effectiveness of the nursing care plan

75. The evaluation includes; • Comparing the data with desired outcomes • Continuing, modifying, or terminating the nursing care plan