Unit 1 The Nursing Process. presentation

nutsing process

1. Nursing Process
1nursing process

2. Definition of nursing process
An organized sequence of problem-solving steps
used to identify and to manage the health
problems of clients
2nursing process

3. PURPOSE
The purpose of the nursing process is to
diagnose and treat human responses to actual or
potential health problems” (ANA)
3nursing process

4. 5 components of the Nursing
Process:
1.Assessment
2.Diagnosis
3.Planning
4.Implementing
5.Evaluating
4nursing process

5. Copyright 2008 by Pearson Education, Inc.
The Nursing Process
5nursing process

6. Copyright 2008 by Pearson Education, Inc.
Characteristics of the
Nursing Process
Cyclic and dynamic nature
Client centeredness
Focus on problem-solving and decision-making
Interpersonal and collaborative style
Universal applicability
Use of critical thinking
6nursing process

7. Copyright 2008 by Pearson Education, Inc.
Characteristics of the
Nursing Process
7nursing process

8. ASSESSMENT
8nursing process

9. Types of Assessments
Initial
Performed within a specified time period
Establishes complete database
Problem-Focused
Ongoing process integrated with care
Determines status of a specific problem
Emergency
Performed during physiologic or psychologiccrises
Identifies life-threatening problems
Identifies new or overlooked problems
Time-lapsed
Occurs several months after initial
Compares current status to baseline
9nursing process

10. Assessment Activities
Collecting data
Organizing data
Validating data
Documenting data
10nursing process

11. Assessment
Collecting data is the process of gathering
information about a client’s health status.
Organizing data is categorizing data
systematically using a specified format.
Validating data is the act of “double-checking”
or verifying data to confirm that it is accurate
and factual.
Documentingis accurately and factually
recording data.
11nursing process

12. Copyright 2008 by Pearson Education, Inc.
TYPES OF DATA
Subjective Data
Symptoms or covert data
Apparent only to the person affected
Can be described only by person affected
Includes sensations, feelings, values,
beliefs, attitudes, and perception of
personal health status and life situations
12nursing process

13. Copyright 2008 by Pearson Education, Inc.
Objective Data
Signs or overt data
Detectable by an observer
Can be measured or tested against an
accepted standard
Can be seen, heard, felt, or smelled
Obtained through observation or physical
examination
13nursing process

14. Copyright 2008 by Pearson Education, Inc.
Sources of Data
Primary Source
The client
Secondary Sources
All other sources of data
Should be validated, if possible
14nursing process

15. Copyright 2008 by Pearson Education, Inc.
Methods of Data Collection
Observing
Gathering data using the senses
Used to obtain following types of data:
Skin color (vision)
Body or breath odors (smell)
Lung or heart sounds (hearing)
Skin temperature (touch)
15nursing process

16. Copyright 2008 by Pearson Education, Inc.
Methods of Data Collection
Interviewing
Planned communication or a conversation with a
purpose
Used to:
Identify problems of mutual concern
Evaluate change
Teach
Provide support
Provide counseling or therapy
16nursing process

17. Copyright 2008 by Pearson Education, Inc.
Methods of Data Collection
Examining(physical examination)
Systematic data-collection method
Uses observation and inspection, auscultation,
palpation, and percussion
Blood pressure
Pulses
Heart and lungs sounds
Skin temperature and moisture
Muscle strength
17nursing process

18. NURSING DIAGNOSIS
18nursing process

19. Types of Nursing Diagnosis
Actual Diagnosis
RiskDiagnosis
Wellness Diagnosis
PossibleDiagnosis
Syndrome Diagnosis
19nursing process

20. 20nursing process

21. Actual Diagnosis
Problem present at the time of the assessment
Presence of associated signs and symptoms
(ineffective breathing pattern)
21nursing process

22. Components of a Nursing
Diagnosis
Problem
Etiology
Defining characteristics
22nursing process

23. Problem Statement (Diagnostic Label)
Describes the client’s health problem or response
Defining Characteristics
Cluster of signs and symptoms indicating the
presence of a particular diagnostic label (actual
diagnoses)
Factors that cause the client to be more
vulnerable to the problem (risk diagnoses)
23nursing process

24. Formats for Writing Nursing
Diagnoses
Basic two-part statement
Problem (P)
Etiology (E)
24nursing process

25. 25nursing process

26. Three part statement
Basic three-part statement
Problem (P)
Etiology (E)
Signs and symptoms (S)
26nursing process

27. Advantages of a Taxonomy of
Nursing Diagnoses
Development of a standardized nursing language
Nursing minimum data set
27nursing process

28. PLANNING PHASE
28nursing process

29. Activities that occur in the planning
process.
Prioritizing problems/diagnoses
Formulating client goals/desired outcomes
Selecting nursing interventions
Writing individualized nursing interventions
29nursing process

30. Identify essential guidelines for
writing nursing care plans.
Date and sign the plan
Use category headings
Use standardized/approved terminology and symbols
Be specific
Refer to other sources
Individualize the plan to the client
Incorporate prevention and health maintenance
Include discharge and home care plans
30nursing process

31. Identify factors that the nurse must
consider when setting priorities.
Setting Priorities
Establishing a preferential sequence for
addressing nursing diagnoses and interventions
High priority (life-threatening)
Medium priority (health-threatening)
Low priority (developmental needs)
31nursing process

32. Factors to Consider When Setting
Priorities
Client’s health values and beliefs
Client’s priorities
Resources available to the nurse and client
Urgency of the health problem
Medical treatment plan
32nursing process

33. Describe the relationship of
goals/desired outcomes to the
nursing diagnoses.
Goals derived from diagnostic label
Diagnostic label contains the unhealthy response
(problem)
Goal/desired outcome demonstrates resolution
of the unhealthy response (problem)
33nursing process

34. Identify guidelines for writing goals/desired
outcomes.
Components of Goal/Desired Outcome
Statements
Subject
Verb
Condition or modifier
Criterion of desired performance
34nursing process

35. 35nursing process

36. Guidelines for Writing
Goal/Outcome Statements
Write in terms of the client responses
Must be realistic
Ensure compatibility with the therapies of
other professionals
Derive from only one nursing diagnosis
Use observable, measurable terms
36nursing process

37. Describe the process of selecting
and choosing nursing interventions.
Nursing Interventions and Activities
Actions nurse performs to achieve goals/desired
outcomes
Focus on eliminating or reducing etiology of
nursing diagnosis
Treat signs/symptoms and defining
characteristics
37nursing process

38. Types of Nursing Interventions
Direct
Indirect
Independent interventions
Dependent interventions
Collaborative interventions
38nursing process

39. Direct care is an intervention performed
through interaction with the client.
Indirect care is an intervention performed
away from but on behalf of the client such as
interdisciplinary collaboration or management of
the care environment. ( prevention to infection)
39nursing process

40. independent interventions, those activities
that nurses are licensed to initiate on the basis of
their knowledge and skills;
dependent interventions, activities carried out
under the primary care provider’s orders or
supervision, or according to specified routines;
collaborative interventions, actions the nurse
carries out in collaboration with other health
team members. The nurse must choose
interventions that are most likely to achieve the
goal/desired outcome.
40nursing process

41. Direct such as medication administration, health
education, emotional support
Independent interventions such as routine
nursing tasks such as checking vital signs
dependent interventions such as prescribing new
medication, insertion of a urinary catheter
41nursing process

42. example of a collaborative nursing intervention
isconsulting with a respiratory therapist when
the patient has deteriorating oxygen saturation
levels. post-surgery
42nursing process

43. Criteria for Choosing Appropriate
Intervention
Safe and appropriate for the client’s age, health, and
condition
Achievable with the resources available
Congruent with the client’s values, beliefs, and culture
Congruent with other therapies
Based on nursing knowledge and experience or
knowledge from relevant sciences
Within established standards of care
43nursing process

44. Implementation phase
Discuss the five activities of the
implementing phase.
Five Activities of the Implementing Phase
Reassessing the client
Determining the nurse’s need for assistance
Implementing nursing interventions
Supervising delegated care
44nursing process

45. Explain how evaluating relates to other
phases of the nursing process.
Depends on the effectiveness of phases that
precede
Assessing and nursing diagnosis must be
accurate
Goals/desired outcomes must be stated
behaviorally to be useful for evaluating
Without implementing phase, there would be
nothing to evaluate
45nursing process

46. Evaluation
Evaluating and assessing phases overlap
1.Evaluating is a planned, ongoing, purposeful
activity in which clients and health care
professionals determine the client’s progress
toward achievement of goals/ outcomes and the
effectiveness of the nursing care plan. Successful
evaluation depends on the effectiveness of the
steps that precede it.
46nursing process

47. Assessment data must be accurate and complete
so the nurse can formulate appropriate nursing
diagnoses and goals/desired outcomes. The
goals/desired outcomes must be stated
concretely in behavioral terms to be useful for
evaluating client responses. Without the
implementing phase in which the plan is put into
action, there would be nothing to evaluate. The
evaluating and assessing phases overlap.
47nursing process

48. During the assessment phase the nurse collects
data for the purpose of making diagnoses.
During the evaluation step the nurse collects
data for the purpose of comparing the data to
preselected goals and judging the effectiveness
of the nursing care. The act of assessing (data
collection) is the same. The differences lie in
when the data are collected and how the data are
used.
48nursing process

49. Components of the Evaluation
Process
Collecting data related to the desired outcomes
( nursing outcomes classifications NOC indicators)
Comparing the data with outcomes
Relating nursing activities to outcomes
Drawing conclusions about problem status
Continuing, modifying, or terminating the
nursing care plan
49nursing process

50. Example:
The nurse obtains a patient's blood pressure
after administering an anti-hypertensive
medication.The nurse evaluates the
effectiveness of the medication
50nursing process

51. 51nursing process

52. Reference
http://www.registerednursern.com/nursing/fre
e-care-plans/
52nursing process

53. Any Questions?
53nursing process