Nursing process

1. Nursing process

2. Nursing process (N.P) is a systematic ,organized way of providing nursing care (N.C) for any patient in any situation

3. Characteristics of nursing process • Its framework for providing N.C to individual, family and community. • it's orderly and systematic. • It does interdependent. • Its, appropriate for we through out the lifespan.

4. phasesof nursing process • Assessment. • Diagnosis. • Outcome identification. • Planning. • Implementation. • Evaluation.

5. Skills requirement for nursing process • Sound of knowledge base. • Ability to communicate in writing • Ability to listen.

6. Assessment • is the collection of subjective and objective data from the client and other sources for the purpose of describing health problems.

7. Assessment skills • Observation • Interviewing • Physical Examination

8. The responsibilities of the nurse in physical examination • Gathering the necessary equipment and supplies. Preparing the examining room or patient unit. Explanation about the examination what is to be done and why. • Helping the patient in putting on gown for exam. Ensure the patient's primary by draping and not cold. • Check vital signs and observation of general and physical and emotional status of patient. • Helping, both examiner and patient with physical examination.

9. Methods of physical assessment I- Inspection –looks at the body part to detect normal characteristics. To inspection body part accurately. • Make sure bond lighting is available. • Position and expose body part. • Inspect each area for size shape , color ,symmetry ,position and abnormalities. 2-Palpation – is made through the sense of touch..,

10. Area examined by palpation ; • Skin. • organs {e.g. liver and intestine }. • Glands thyroid and lymph. • Blood vessels {e. g. carotid. or femoral artery) 3- Percussion –eliciting, sound or vibration by tapping or striking the body to aid diagnosis. Helpful in confirming other assessment finding . 4-. Auscultation – is listen to sound created in body organs to detected variations from normal. 5- Olfaction –to detect abnormalities in nature of body odor , infection unfamiliar odor.

11. Position in physical examination • Standing position {erect position ) • Sitting position • Supine position • Sims position – • Knee– chest position -- lithotomic position

12. Diagnostic test for surgery • CBC- a complete blood count. • Serum electrolyte analysis. • Coagulation studies. • Serum, creatinine test. • Urine analysis . • Chest X ray

13. Diagnostic test • With physical examination various laboratory tests are usually or-- • Blood analysis: complete blood count or picture {C.B.C} or{c.B.P} which include hemoglobin , red blood count ,W.B.C erythrocyte sedimentation rate (E.S.R.) • Platelets count • Fasting blood sugar {F.B.S} • Glucose tolerance test{g.T.T}. • Electrolyte test .( s. Sodium, S. Potassium, S. Chloride,s. Calcium}

14. 5-Arterial blood gas's analysis {A.B.G}. •. • 6- Urine analysis(G.U.E general urine exam) , (M.S.U mid stream urine). • 7- Sputum analysis • 8- Electro diagnosis • electro cardiogram (E.C.G) ---- for heart diagnosis • encephalogram(E.E.G) ---- for brain diagnosis • electro myogram (E.M. G)------- for muscle diagnosis • 9- tissue biopsies

15. The role of nurses in collecting specimens • Explaining procedure to the patient &gaining his cooperation. • Collecting the amount of specimen . • Placing the specimen in correct container • Labeling the container accurately. • Completing the laboratory requisition. • Recording in chart of patient a bout the appearance of the specimen.

16. Formulates the nursing diagnosis statement Involves writing the label of the actual, risk, wellness or possible nursing diagnosis Actual :- Determine the main focus of the problem (the diagnostic label) and the factor that is contributing to the clients inability to resolve it( related factor)to a void the problem ex. Accurate: impaired physical mobility related pain Inaccurate: ineffective movement related to arthritis – Risk (potential):- NANDA replaced potential with term risk ex. All client admitted to hospital are at risk for infection but some people such as those with compromised immune system are at higher risk than other

17. -Risk nursing diagnosis (as defined by NANDA ) • Is a clinical judgment that person more to develop the problem than other in the same situation? • -A wellness • -Describes the human response to level of wellness • the term that can be used • Associated • With • Related • Contribution to

18. Outcome Identification Is the formulation of goals and measurable outcome that provide the goal for evaluation nursing diagnoses. • Activities performed in outcome identification • 1- Establish priorities • High priority nursing diagnosis are those that potentially life threatening –and require immediate action • ex. Difficulty breathing , hemorrhage • B. Medium priority (ex. physical or emotional impairment, fatigue, Tess.)

19. 2- Intellectual skill (include problem solving, decision making) 3-nterpersonal (ability to work with other) 4- Technical (carry out treatment and procedures)

20. Activities of implementation I- Re-assess (Because a patient condition can change quickly and dramatically) 2- Set priority ''`Rank nursing problems in order importance Set priority based on several factors • The clinical condition • New information from reassessment • Time & resources available for nursing intervention • Feed back from client, family and health care staff • The nurses experience in assessing, situations and setting priorities • Performing nursing intervention • Record action

21. Evaluation The judgment of the effectiveness of nursing care to must client go judgment based on the client behavioral responses

22. Activities during evaluation • 1- Review client goals and out come criteria • 2-Collect data • 3- Measure goals attainment • The 4 possible judgment that may made • The goal was completely met • The goal was partially met • The new problems or nursing diagnosis have develop • 4-record judgment or measurement of goal attainment • 5-Revise or modify the nursing planed care