THE NURSING PROCESS FUNDAMENTAL II..pptx

It will help nurses to understand the concept

1. THE NURSING PROCESS UNIT 1 FUNDAMENTALS OF NURSING II MS. CHIMBWALI

2. The Nursing Process The nursing process is a problem solving approach to nursing that involves interaction with the client, making decisions and carrying out nursing actions based on an assessment of individual patient situation . The use of the nursing process allows the nurse to integrate elements of critical thinking to make judgments and take actions based on reason. The nursing process is used to identify, diagnose and treat human responses to health and illness

3. Components of the Nursing Process The nursing process has 5 components. These are: Assessment Nursing diagnosis Planning Implementation Evaluation

4. ASSESSMENT This refers to the systematic collection of subjective (what the patients feels and says) and objective (what you observe) data with the goal of making clinical nursing judgment about the patient or family. During assessment you have to consider the physical, psychological, emotional, socio-cultural and spiritual factors that may affect the health status of your client . This stage is characterized by data collection, grouping of data into meaningful categories, physical examinations, laboratory tests and observation skills .

5. Types of data Subjective data: this is the information that is only obvious to the patient. It is also known as covert data or symptoms, for example, pain. Objective data : this is information that is detected by the observer, for example, pallor. It is also known as overt data or signs.  

6. Sources of data The following are the sources of assessment data: Primary data : this information is obtained from the patient. It is gathered through informal and formal interviews, and physical examinations. Secondary data: this information is obtained from the patient, patient’s family, patient records, diagnostic tests, and reports.

7. Nursing Diagnosis This is a combination of signs and symptoms that indicate an actual or potential health problem that nurses are licensed to treat and are capable of treating .   Nursing diagnosis can be formulated in 2 ways, that is, for an actual problem or for a potential problem.

8. Actual problem: this is a problem that already exists. When the nurse interacts with the patient it can be elicited because the patient is experiencing it. The nursing diagnosis for an actual problem should have a problem , cause and manifestation . For example, if you identify dyspnoea as a problem in a patient with Pulmonary Tuberculosis, the nursing diagnosis could be ‘Dyspnoea related to reduced lung capacity evidenced by laboured breathing’.

9. Potential or risk problem: this is a problem that is likely to occur due to the condition of the patient if certain nursing measures are not observed. The problem is not actually there, for example, the risk of developing pressure sores is a potential problem for a patient who is unconscious. The nursing diagnosis for a patient with a potential problem should have a problem and a cause . For example, ‘susceptibility to develop pressure sores related to immobility.’

10. Selected Approved International Nursing Diagnoses   Knowledge deficit related to …. Impaired mobility related to … Self-care deficit related to bathing/dressing/grooming/feeding/toileting Ineffective airway clearance Anxiety Risk for aspiration Bowel incontinence Ineffective breastfeeding Ineffective breathing patterns Decreased cardiac output

11. CONT’ Impaired verbal communication Constipation Delayed development Ineffective feeding patterns Fluid volume deficit Fluid volume excess Impaired gas exchanged Unstable glucose levels

12. CONT’ Risk for impaired skin integrity Hyperthermia Hypothermia Urinary incontinence Risk for infection Risk for injury Nutritional deficit less than body requirement Acute pain related to Chronic pain related to Impaired skin integrity

13. Planning Planning is creating an organized course of action, that is designed to change negative health response to a more positive one. The nurse, patient and family must participate actively in this stage to set goals .

14. The stage involves four (4) main activities: Setting priorities from among identified potential and actual problems. Setting objectives that must be Specific, Measurable, Achievable, and Realistic and Time bound (SMART). Select appropriate nursing interventions that should be done with scientific reasoning. Writing of the care plan.  

15. Implementation This is the step that involves action or doing, and the actual carrying out of nursing interventions outlined in the nursing care plan. This phase requires nursing interventions such as applying a cardiac monitor or oxygen, direct or indirect care, administration of medication, etc.

16. CONT’ It involves therapeutic interaction between the nurse and the client. This requires technical competence and proper manual dexterity. The nursing actions focus on resolving, dissolving or diminishing the patient’s functional health status problem.

17. Evaluation This is the process of determining to what extent the established goals have been achieved. Evaluation involves analysing the outcome of the nursing action to see if the care given is effective. Observations are important in this stage and are widely used. The outcome should be compared with the objective. Evaluation is an on-going and continuous process performed throughout the nursing process.

18. Advantages of the nursing process to the client It is adaptable to every patient It contributes to individualized care. It contributes to high quality care. Client feels part of the care team. It helps the client to co-operate and become involved in his/her care. It responds to the continually changing needs of a client.  

19. Disadvantages of the nursing process to the client It may lead to frustration especially when the patient’s need is not given the first priority It subjects the patient to a lot of talking and thinking thereby disturbing rest and sleep.

20. Advantages of the nursing process to the Nurse   It can be used in any situation in which a nurse gives care. It provides for constant evaluation It is a basis for improving care It is a logical, organized way of approaching a nursing care problem It allows for great creativity or innovation

21. CONT ’ It is oriented to obtaining objectives. It helps to make wise decisions It prevents duplication of work It helps the nurse to diagnose and treat human response to actual or potential health Problems. It helps the nurse to help clients meet agreed upon outcomes. It provides a common language and process for nurses to think through client’s clinical problems.

22. Disadvantages of the nursing process to the Nurse It requires a lot of stationary It is time consuming It is difficult to implement due to shortage of manpower It requires use of observation skills such as cues on non-verbal communication

23. Advantages of the nursing process to the Community   Participation of the relatives in the care of the patient helps the patient feel loved and supported. It helps the community participate in the care of the patient or the health care system. The community is able to evaluate care provided to the client and try to improve on it. The community is able to participate in identifying the problem in their community .  

24. Disadvantages of the nursing process to the Community As the community is involved, the nursing process is no longer client centred, because family members may put their own needs, fears in the nursing process, thus dictating the plan of care. The family members participating in the care of patient may lack the required skill, knowledge and resources needed to offer comprehensive care to the client.

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