Nsg Process

8/8/2019 Nsg Process

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Nursing

Process


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SERIES OF PLANNED ACTIONS OR OPERATIONS DIRECTEDTOWARD A PARTICULAR RESULT OR GOAL.

A SYSTEMATIC, RATIONAL METHOD OF PLANNING ANDPROVIDING INDIVIDUALIZED NURSING CARE.

ITS PURPOSE IS TO IDENTIFY A CLIENTS HEALTH STATUS,ACTUAL OR POTENTIAL HEALTH CARE PROBLEMS OR NEEDS,AND TO DELIVER SPECIFIC NURSING INTERVENTIONS TO

MEET THOSE NEEDS.

IT IS ALSO CYCLICAL. THAT IS, THE COMPONENTS OF THENURSING PROCESS FOLLOW A LOGICAL SEQUENCE, BUT MORETHAN ONE COMPONENT MAYBE INVOLVED AT ANY ONE TIME.


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ASSESSMENT

COLLECTING, ORGANIZING, VALIDATING AND RECORDINGDATA ABOUT A CLIENTS HEALTH STATUS. DATA ARE

OBTAINED FROM A VARIETY OF SOURCES AND ARE THEBASIS FOR ACTIONS AND DECISIONS TAKEN IN

SUBSEQUENT PHASES. NO CONCLUSIONS ABOUT THEDATA ARE DRAWN IN THIS PHASE.

DIAGNOSING

A PROCESS WHICH RESULTS IN A DIAGNOSTICSTATEMENT OR NURSING DIAGNOSIS. IN THIS PHASE,

THE NURSE SORTS, CLUSTERS, AND ANALYZES THE DATAAND ASKS, WHAT ARE THE ACTUAL AND POTENTIALHEALTH PROBLEMS FOR WHICH THE CLIENT NEEDS

NURSING ASSISTANCE? AND WHAT FACTORSCONTRIBUTED TO THIS PROBLEM? RESPONSES TO THOSE

QUESTIONS ESTABLISH THE NURSING DIAGNOSES.


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EVALUATING

ASSESSING THE CLIENTS RESPONSE TO NURSINGINTERVENTIONS AND THEN COMPARING THE RESPONSETO THE GOALS OR OUTCOME CRITERIA WRITTEN IN THEPLANNING PHASE. THE NURSE DETERMINES THE E TENTTO WHICH THE OUTCOMES/ GOALS OF CARE HAVE BEEN

ACHIEVED. THE CARE PLAN IS REASSESSED IN THISPHASE, WHICH MAY INVOLVE CHANGES IN ANY OR ALLOF THE PREVIOUS PHASES OF THE NURSING PROCESS.


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EVALUATION

IMPLEMENTING

PLANNING

DIAGNOSING

ASSESSINGEACH PHASEDEPENDS ON THE

ACCURACY OF

THE PRECEDING

PHASE.

EVALUATING

INVOLVES

EXAMINATION OF

ALL PREVIOUS

PHASES.


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The system is open and flexible to meet the unique

needs of the client, family, group or community.

It is cyclic and dynamic. Because all steps areinterrelated, there is no absolute beginning or end.

It is client centered; it individualizes the approach to

each clients particular needs.

It is interpersonal and collaborative. It requires the

nurse to communicate directly and consistently with

clients to meet their needs.


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It is planned.

It is goal directed.

It permits creativity for the nurse and client in

devising ways to solve the stated health problem.

It emphasizes feedback, which leads either to

reassessment of the problem or to revision of the

care plan.

It is universally applicable. The nursing process isused as a framework for nursing care in all types of

health care settings, with clients of all age groups.


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TO ESTABLISH A DATABASE ABOUT

THE CLIENTS RESPONSE TO HEALTH

CONCERNS OR ILLNESS AND THE

ABILTY TO MANAGE HEALTH CARE

NEEDS

ESTABLISH A DATABASE

* OBTAIN HEALTH HISTORY

* CONDUCT PHYSICAL ASSESSMENT

* REVIEW CLIENT RECORDS

* REVIEW LITERATUIRE

* CONSULT SUPPORT PERSONS

* CONSULT HEALTH PROFESSIONALS

UPDATE DATA AS NEEDED

ORGANIZE DATA

VALIDATE DATA

COMMUNICATE/DOCUMENT DATA


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OBSERVATION

INTERVIEWING

EXAMINING


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OBSERVATION

Gathering data using

the five senses

INTERVIEWING Planned communication orconversation with a purpose to

identify problems of mutual concern

EXAMINING

Physical examination is asystematic data-collection

method that uses

observational skills to

detect the health

problems


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Gathering information about a clientshealth status. It must be both

systematic and continuous to preventthe omission of significant data and

reflect a clients changing healthstatus.


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SUBJECTIVE DATA

Data belong under subjective if

The patient or family member tells the history.

The patient or family member tells about lifestyle or home

situation.

The patient or family member tells emotions or attitudes.

The patient states his or hergoals.

The patient voices a complaint.

The patient reports a response to treatment.

It is anything that the patient tells which is relevant to his

case or present condition.


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OBJECTIVE DATA

Data belong under objective if

It is part of the patients history taken from medical recordand relevant to the current problem.

It is a result of the therapists objective measurements or

observations.

It is part of the treatment given to a patient.

Hx: ASHD, CHF, COPD, S/P fx L Hip prosthesis insertion

AROM: WNL throughout UEs & LEs except 120

shoulder flexion noted

L

Tolerated 3 repetitions of ROM exercises of UEs & LEs


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Types of data: SUBJECTIVE DATA OBJECTIVE DATA

SUBJECTIVE OBJECTIVE

I feel pain at my right

knee.

BP 90/50

Apical Pulse 104

Skin pale and

diaphoretic

I have difficulty

breathing.

Lung sounds are diminished in

the left lower lobe of the lung

RR 25/min

Leans forward


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Sources of data:

Primary data: patient

Secondary data: support people, other health

professionals, records and reports,literature


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Using an organized assessmentframework, often referred to as a

nursing history or nursing assessment.

FRAMEWORKS

NURSING CONCEPTUAL MODELSWELLNESS MODELS

NONNURSING MODELS


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HEALTH PERCEPTION-HEALTH MANAGEMENTPATTERN. Describes clients perceived pattern ofhealth and well-being and how health ismanaged.

NUTRITIONAL-METABOLIC PATTERN. DescribesPATTERN OF FOOD AND FLUID CONSUMPTIONRELATIVE TO METABOLIC NEED AND PATTERNINDICATORS OF LOCAL NUTRIENT SUPPLY.

NURSING CONCEPTUAL MODELS


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ELIMINATION PATTERN. Describes patterns ofexcretory function (bowel, bladder, skin)

ACTIVITY-EXERCISE PATTERN. Describes patternof exercise, activity leisure, and recreation

COGNITIVE-PERCEPTUAL PATTERN. Describessensory- perceptual and cognitive pattern.

SLEEP-REST PATTERN. Describes patterns of sleep,rest and relaxation.

SELF-PERCEPTION-SELF-CONCEPT PATTERN.Describes self-concept pattern and perceptions

of self (eg, body comfort. Body image, feelingstate).

ROLE RELATIONSHIP PATTERN. Describes thepattern of role-engagements and relationships.


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SEXUALITY-REPRODUCTIVE PATTERN. Describesclients patterns of satisfaction anddissatisfaction with sexuality; describes

reproductive patterns.

COPING-STRESS-TOLERANCE PATTERN. Describesgeneral coping pattern and effectiveness of thepattern in terms of stress tolerance.

VALUE-BELIEF PATTERN. Describes patterns ofvalues, beliefs (including spiritual), or goals thatguide choices or decisions.


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Universal Self-Care Deficits

1. The Maintenance of a sufficient intake of air.

2. The Maintenance of a sufficient intake of water.

3. The Maintenance of a sufficient intake of food.

4. The Provision of care associated with elimination

processes and increments.

5. The Maintenance of a balance between activity and rest.

6. The Maintenance of a balance between solitude and social

interaction


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7. The prevention of hazards to human life, human

functioning, and human well-being.

8. The promotion of human functioning and development within

social groups in accord with human potential, known human

limitations, and human desire to be normal.


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WELLNESS MODELS

GENERALLYINCLUDES:

^^^ HEALTH HISTORY^^^

^^^ PHYSICAL FITNESS EVALUATION^^^

^^^ NUTRITIONAL ASSESSMENT^^^

^^^ LIFE-STRESS ANALYSIS^^^^^^ LIFE-STYLE AND HEALTH HABITS^^^^^^ HEALTH BELIEFS^^^^^^ SE UAL HEALTH^^^

^^^ SPIRITUAL HEALTH^^^^^^ RELATIONSHIPS^^^

^^^ HEALTH RISKS APPRAISALS^^^


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NONNURSING MODELS

BODY SYSTEMS MODEL

MASLOWS HIERARCHY OFNEEDS

DEVELOPMENTAL THEORIES


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1. Physiologic Needs

* Activity and rest

* Nutrition

* Elimination* Fluid and Electrolytes

* Oxygenation

* Protection

* Regulation:temperature* Regulation:the senses

* Regulation:endocrine system


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2. Self-concept

* Physical Self

* Personal Self

3. Role Function

4. Interdependence


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Act of double-checking or verifyingdata (cues) to confirm that they are

accurate and factual.


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Data are documented in factualmanner and are not interpreted by the

nurse.


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TO IDENTIFY CLIENT STRENGTHS AND

HEALTH PROBLEMS THAT CAN BE

PREVENTED OR RESOLVED BY

COLLABORATIVE AND INDEPENDENT

NURSING INTERVENTIONS

TO DEVELOP A LISTING OF NURSING

DIAGNOSES AND COLLABORATIVE

PROBLEMS

INTERPRET & ANALYZE DATA

* COMPARE DATA AGAINST STANDARDS

* CLUSTER OR GROUP DATA

* IDENTIFY GAPS AND INCONSISTENCIES

DETERMINE CLIENTS STRENGTHS, RISKS

AND PROBLEMS

FORMULATE NURSING DIAGNOSIS AND

COLLABORATIVE PROBLEM STATEMENTS


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A CLINICAL JUDGEMENTABOUTINDIVIDUAL, FAMILY OR COMMUNITY

RESPONSES TOACTUAL ANDPOTENTIAL HEALTH PROBLEMS/LIFE

PROCESSES.

IT PROVIDES THE BASIS FOR

SELECTIO

NO

F NUR

SINGINTERVENTIONS TOACHIEVEOUTCOMES FOR WHICH THE NURSE IS

ACCOUNTABLE.


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STATEMENT OF NURSING JUDGMENT AND REFERS TOA CONDITION THAT NURSES ARE LICENSED TO

TREAT; DECRIBES A CLIENTS PHYSICAL,SOCIOCULTURAL, PSYCHOLOGIC AND SPIRITUAL

RESPONSES TO AN ILLNESS OR POTENTIAL HEALTH

PROBLEM.

MADE BY THE PHYSICIAN AND REFERS TO A CONDITION

ONLY A PHYSICIAN CAN TREAT; REFERS TO DISEASE

PROCESSES THAT ARE FAIRLY UNIFORM FROM ONE

CLIENT TO ANOTHER.


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PROBLEM STATEMENT (DIAGNOSTIC LABEL)

ETIOLOGY (RELATED FACTORS & RISK FACTORS)

DEFINING CHARACTERISTICS


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ActivityIntolerance/ relatedto/prolonged

bedrest/ asmanifestedby/ body

weaknessandfatigue

P E

S

1. PROBLEM (P) --- STATEMENT OF THE CLIENTS

RESPONSES

2. ETIOLOGY (E) --- FACTORS CONTRIBUTING TO OR

PROBABLE CAUSES OF THE RESPONSE

3. SIGNS & SYMPTOMS (S) --- DEFININGCHARACTERISTICS MANIFESTED BY THE CLIENT


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Alterationincomfort, pain/

associatedwith/ abdominalincision/ asmanifestedby/ muscle

guardingandgrimace

Alteredthermoregulation, / related

toinfection/ asmanifestedby/ high

gradefeverandexcessiveperspiration


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TO DEVELOP AN INDIVIDUALIZED CARE

PLAN THAT SPECIFIES CLIENT

GOALS/EXPECTED OUTCOMES ANDRELATED NURSING INTERVENTIONS

SET PRIORITIES AND GOALS/OUTCOMES IN

COLLABORATION WITH THE CLIENT

WRITE GOALS/OUTCOME CRITERIA

SELECT NURSING STRATEGIES/INTERVENTIONS

CONSULT OTHER HEALTH PROFESSIONALS

WRITE NURSING ORDERS AND NURSING CARE

PLAN

COMMUNICATE CARE PLAN TO RELEVANT

HEALTH CARE PROVIDERS


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TO ASSIST THE CLIENT TO MEET

DESIRED GOALS/OUTCOMES,

PROMOTE HEALTH AND WELLNESS;

PREVENT ILLNESS AND DISEASE; AND

FACILITATE COPING WITH HEALTH

PROBLEMS.

REASSESS THE CLIENT TO UPDATE THE

DATABASE

DETERMINE THE NEED FOR NURSINGASSISTANCE

PERFORM OR DELEGATE PLANNED NURSING

INTERVENTIONS

COMMUNICATE NURSING ACTIONS

IMPLEMENTED

* DOCUMENT CARE AND CLIENT RESPONSES

TO CARE

* GIVE VERBAL REPORTS AS NECESSARY


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TO DETERMINE THE EXTENT TO WHICH

CLIENT GOALS/OUTCOMES HAVE BEEN

ACHIEVED AND TO DETERMINEWHETHER TO CONTINUE, MODIFY OR

TERMINATE THE PLAN OF CARE

COLLABORATE WITH THE CLIENT AND COLLECT

DATA RELATED TO EXPECTED OUTCOMES

JUDGE WHETHER GOALS/OUTCOMES HAVEBEEN ACHIEVED

RELATE NURSING ACTIONS TO CLIENT

OUTCOMES

MAKE DECISIONS ABOUT PROBLEM STATUS

REVIEW AND MODIFY THE CARE PLAN ASINDICATED OR TERMINATE NURSING CARE


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(JUSTIFIES THE USE OF

THE NURSING DIAGNOSIS)

RATIONALE

(S.M.A.R.T. GOALS

OF CARE)

E PECTEDOUTCOME

(PRIORITIZED)

INTERVENTION/IMPLEMENTATION

(EXAMINES THE

PREVIOUS PHASES)

EVALUATION

(JUSTIFIES THE USE OF

THE NURSING DIAGNOSIS)

RATIONALE

CUES

(Subjective

and

objective

cues)

NURSINGDIAGNOSIS

(Using

NANDA list)


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CUES NURSING

DIAGNOS

IS

RATIONALE EXPECTED

OUTCOMES

INTERVE

NTIONS

RATIONA

LE

EVALUATI

ON

Subjective:

I have been

feeling so

weak and

exhausted

for the last

four days

Decreased

appetite;have eaten

only small

amounts

during meal

time

Objective:

Temp = 38

C

Pulse =

85/min

Altered

thermoreg

ulationrelated to

infection

Invasion of the

body by the

Corona viruscompromised the

bodys immune

system as it

attacks the

respiratory

system. The body

attempts to get rid

of thesemicroorganisms by

releasing

pyrogens causing

the elevation of

body temperature

At the end of 8

hours nursing

intervention,the patient will

be able to:

Have lowered

temp to 37 -

37.5C

Eat at least 3times during

the day in

satisfactory

amounts

Resume

ADLs

Perform

TSB

Give small

frequent

feedings,

then

gradually

increase

Encourage

increased

fluid intake

Loosen

clothings

TSB lowers

down body

temperature

Gradually

increasing

the intake

will

promote

tolerance of

foods

Fluids help

lower down

body

temperatur

e

Promoting

airflow

assist in

lowering

body

temperatur

e

Afebrile

37.6C

Ate two full

meals, no

leftovers

Was able to

take a bath,

move around

Appeared

cheerful and

conversant


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CUES NURSING

DIAGNOSIS

RATIONALE EXPECTED

OUTCOMES

INTERVE

NTIONS

RATIONA

LE

EVALUATI

ON

flushed

face

diaphoretic

teary-eyed

Provide

ventilationbut kept on

isolation

* Isolation

preventsspread of

the virus

thereby

minimizing

contaminati

on


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Thankyou!

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Nsg Process