Unit 1 (c) Nursing Process.ppt..........

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1. ADVANCE CONCEPTS IN
NURSING

2. INTRODUCTION TO
NURSING PROCESS

3. LEARNING OUTCOMES
Discuss the concepts and theories that underpin the
process of nursing.
Formulate nursing diagnosis on actual and potential
patient’s problems.
Plan and document appropriate patient’s goals and
interventions with the collaboration of patient, family
and the multidisciplinary team.
Implement the Nursing Care Plan.
Evaluate and reassess each component of the Nursing
Care Plan appropriately.
Educate patients and their families during their stay at
hospital and at the time of discharge.
Demonstrate appropriate communication skills and
interaction skills with patients, families and colleagues.

4. THE NURSING PROCESS IS:
A systematic, rational method of planning and providing
individualized nursing care.
An organized, systematic method of giving individualized
nursing care that focuses on identifying and treating unique
responses of individuals or groups to actual-(Alfaro)
Nursing is the protection, promotion, and
optimization of health and abilities, prevention of
illness and injury, alleviation of suffering through
the diagnosis and treatment of human responses,
and advocacy in the care of individuals, families,
communities, and populations. (ANA)

5. CHARACTERISTICS OF NP
• A problem-solving method
•Systematic, goal-directed, flexible, rational approach
•Ensures consistent, continuous, quality nursing care
•Provides a basis for professional accountability
•Utilizes critical thinking processes

6. CHARACTERISTICS:
a) Systematic
The nursing process has an ordered sequence of activities and each
activity depends on the accuracy of the activity that precedes it and
influences the activity following it.
b)Dynamic
The nursing process has great interaction and overlapping among the
activities and each activity is fluid and flows into the next activity
c) Interpersonal
The nursing process ensures that nurses are client-centered rather than
task-centered and encourages them to work to enhance client’s
strengths and meet human needs
d)Goal-directed
The nursing process is a means for nurses and clients to work together
to identify specific goals (wellness promotion, disease and illness
prevention, health restoration, coping and altered functioning) that are
most important to the client, and to match them with the appropriate
nursing actions
e)Universally applicable
The nursing process allows nurses to practice nursing with well or ill
people, young or old, in any type of practice setting

7. BACK
GROUND
The nursing process is based on a nursing theory
developed by Ida Jean Orlando.
She developed this theory in the late 1950's as she
observed nurses in action.
She saw "good" nursing and "bad" nursing.
From her observations she learned that the patient
must be the central character.
Nursing care needs to be directed at improving outcomes for
the patient, and not about nursing goals.
The nursing process is an essential part of the nursing care
plan.

8. BACK GROUND OF NURSING
PROCESS
The original concept of the nursing process was introduced in
the 1950s as a three-step process of
Assessment, Planning, and Evaluation
Based on the scientific method of
Observing, Measuring, Gathering data, and Analyzing the
findings.
Over time, became part of the;
Conceptual framework of all nursing curricula and
Included in the legal definition of nursing in the nurse
practice acts of most states.
After years of study, use, and refinement, the three step
process was expanded into five steps.

9. ADVANTAGES OF NURSING
PROCESS
Provides individualized
care
Client is an active
participant
Promotes continuity of
care
Provides more effective
communication among
nurses and healthcare
professionals
Develops a clear and
efficient plan of care
Provides personal
satisfaction as you see
client achieve goals
Professional growth as
you evaluate
effectiveness of your
interventions

10. 5 STEPS IN THE NURSING
PROCESS
Assessment
Nursing
Diagnosis
Planning
Implementing
Evaluating

11. 1
ST
COMPONENT OF THE NURSING
PROCESS- ASSESSMENT:
The first step, or phase, of the nursing process is
assessment.
During this phase, you are collecting data (factual
information) from several sources.
The collection and organization of these data allow to:
Determine the patient’s current health status.
Determine the patient’s strengths and problem areas
(both actual and potential).
Prepare for the second step of the process—diagnosis.

12. 1
ST
COMPONENT OF THE NURSING
PROCESS- ASSESSMENT:
Data Collection
Assessment involves taking vital signs (TPR
BP & Pain assessment).
Performing a head to toe assessment
Listening to the patient's comments and
questions about his health status
Observing his reactions and interactions with
others. It involves asking pertinent questions
about his signs (observable) and symptoms
(Non-observable), and listening carefully to
the answers.

13. DURING ASSESSMENT, THE CARE
PROVIDER
A.Establishes A Data Base
B.Continuously Updates
The Data Base
C.Validates Data
D.Communicates Data

14. ASSESSMENT
First step of the Nursing Process
Gather Information/Collect Data
Primary Source - Client / Family
Secondary Source - physical exam,
nursing history, team members, lab reports,
diagnostic tests…..
 Subjective -from the client (symptom)

“I have a headache”
Objective - observable data (sign)

Blood Pressure 130/80

15. ASSESSMENT-
COLLECTING DATA
Nursing Interview (history)
Health Assessment -Review of
Systems
Physical Exam
Inspection
Palpation
Percussion
Auscultation

17. EXAMPLE OF
ASSESSMENT
Obtain info from nursing assessment, history and
physical (H&P) etc…...
Client diagnosed with hypertension
B/P 160/90
2 Gm Na diet and antihypertensive medications
were prescribed
Client statement “ I really don’t watch my salt” “
It’s hard to do and I just don’t get it”

18. 2
ND
COMPONENT OF THE NURSING
PROCESS- DIAGNOSIS:
Diagnosis means reaching a definite
conclusion regarding the patient’s strengths
and human responses.
This diagnostic process is complex and
utilizes aspects of intelligence, thinking, and
critical thinking.
The diagnosis of human responses is a
complex process involving the interpretation
of human behavior related to health.

19. NURSING DIAGNOSIS
Second step of the Nursing Process
Interpret & analyze clustered data
Identify client’s problems and strengths
Formulate Nursing Diagnosis (NANDA : North
American Nursing Diagnosis Association)-Statement
of how the client is RESPONDING to an actual or
potential problem that requires nursing intervention

20. NSG DX VS MD
DX
Within the scope
of nursing
practice
Identify
responses to
health and
illness
Can change
from day to day
Within the scope
of medical
practice
Focuses on
curing pathology
Stays the same
as long as the
disease is present

21. FORMULATING A NURSING DIAGNOSIS
Composed of 3 parts:
Problem statement- the client’s response to a
problem
Etiology- what’s causing/contributing to the
client’s problem
Defining Characteristics- what’s the evidence of
the problem

22. NURSING DIAGNOSIS
Problem( Diagnostic Label)-based on your
assessment of client…(gathered information), pick
a problem from the NANDA list...
Etiology- determine what the problem is caused by
or related to (R/T)...
Defining characteristics- then state as
evidenced by (AEB) the specific facts the problem is
based on...

23. EXAMPLE OF NURSING DX
Ineffective therapeutic regimen
management
R/T difficulty maintaining lifestyle changes and
lack of knowledge
AEB B/P= 160/90, dietary sodium restrictions
not being observed, and client statements of “ I
don’t watch my salt” “It’s hard to do and I just
don’t get it”.

24. TYPES OF NURSING DIAGNOSES
Actual
Imbalanced nutrition; less than body
requirements RT chronic diarrhea, nausea,
and pain AEB height 5’5” weight 105 lbs.
Risk/Potential
Risk for falls RT altered gait and
generalized weakness
Wellness
Family coping: potential for growth RT
unexpected birth of twins.

25. COLLABORATIVE PROBLEMS
Require both nursing interventions and medical
interventions
EXAMPLE: Client admitted with medical dx of
pneumonia
Collaborative problem = respiratory insufficiency
Nsg interventions: Raise HOB, Encourage C&DB
MD interventions: Antibiotics IV, O2 therapy

26. 3
RD
COMPONENT OF THE NURSING
PROCESS- PLANNING:
The establishment of client goals/outcomes
Working with the client, to prevent, reduce, or
resolve problems
 To determine related nursing interventions (actions)
that are most likely to assist client in achieving goals
This is about improving the quality of life for your
patient.
This is about what your patient needs to do to
improve his health status or better cope with his
illness.

27. DURING PLANNING, THE PROVIDER:
A.Establishes Priorities
B.Writes Client Goals/Outcomes And
Develops An Evaluative Strategy
C.Selects Nursing Interventions
D.Communicates The Plan

28. PLANNING
Third step of the Nursing Process
This is when the nurse organizes a nursing care plan
based on the nursing diagnoses.
Nurse and client formulate goals to help the client with
their problems
Expected outcomes are identified
Interventions (nursing orders) are selected to aid the
client reach these goals.

29. PLANNING – BEGIN BY
PRIORITIZING CLIENT
PROBLEMS
Prioritize list of
client’s nursing
diagnoses using
Maslow
Rank as high,
intermediate or low
Client specific
Priorities can change

30. PLANNING- TYPES OF
GOALS
Short term goals
Long term goals
Cognitive goals
Psychomotor goals
Affective goals

31. GOALS ARE PATIENT-
CENTERED AND
SMART
Specific
Measurable
Attainable
Relevant
Time Bound
Pt)

32. 3RD COMPONENT OF THE NURSING
PROCESS- IMPLEMENTING :
The provider carries out the plan of care

33. DURING IMPLEMENTING , THE CARE
PROVIDER:
Carries Out The Plan Of Nursing Care or Setting your
plans in motion and delegating responsibilities for
each step.
Continues Data Collection And Modifies The Plan Of
Care As Needed
Documents Care

34. IMPLEMENTION
“Doing” step
Carrying out nursing intervention
 s
This includes monitoring, teaching, further
assessing, reviewing NCP, incorporating physicians
orders and monitoring cost effectiveness of
interventions

35. PLANNING-SELECT
INTERVENTIONS
Interventions are selected and written.
The nurse uses clinical judgment and professional
knowledge to select appropriate interventions that
will aid the client in reaching their goal.
Interventions should be examined for feasibility
and acceptability to the client
Interventions should be written clearly and
specifically.

36. INTERVENTIONS –
Independent ( Nurse initiated )- any action the
nurse can initiate without direct supervision
Dependent ( Physician initiated )-nursing
actions requiring MD orders
Collaborative- nursing actions performed jointly
with other health care team members

37. 4TH COMPONENT OF THE NURSING
PROCESS- EVALUATING:
The measuring of the extent to which
client goals have been met
Evaluation involves not only analyzing
the success of the goals and
interventions, but examining the need
for adjustments and changes as well.
 The evaluation incorporates all input
from the entire health care team,
including the patient.

38. DURING EVALUATING, THE CARE
PROVIDER:
Measures The Clients Achievement
Of Desired Goals/Outcomes
Identifies Factors That Contribute To
The Client’s Success Or Failure
Modifies The Plan Of Care, If
Indicated

39. EVALUATION-
A comparison of client behavior and/or
response to the established outcome criteria
Continuous review of the nursing care plan
Examines if nursing interventions are
working

40. EVALUATION ERRORS
Factors that impede goal attainment:
Incomplete database
Unrealistic client outcomes
Nonspecific nsg interventions
Inadequate time for clients to achieve outcomes.

41. PURPOSE OF THE NURSING PROCESS:
To Achieve Scientifically-
Based, Holistic, Individualized
Care For The Client
To Achieve The Opportunity To
Work Collaboratively With
Clients, Others
To Achieve Continuity Of Care

42. THE WHOLE PATIENT
The nursing process involves looking at the whole
patient at all times. It personalizes the patient. He is
not "the CVA in 214B."
It also forces the health care team to observe and
interact with the patient, and not just the task they are
performing such as a dressing change, or a bed bath.
The process provides a roadmap that ensures good
nursing care and improves patient outcomes.

43. HOLISTIC
Physical-
Emotional-
Psychosocial-
Developmental-
Spiritual Being
Medical
Diagnosis
Nursing
Diagnosis
Rheumatoid ArthritisSelf-care deficit:
bathing, related to
joint stiffness