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Nursing Process

Nursing Process. Critical Thinking Problem Solving. 5 steps to Nursing Process. Assessing Diagnosing Planning Implementation Evaluation. Characteristics of Nursing Process. Systematic Dynamic Interpersonal Goal-oriented Universally applicable. Data Base Sources of data

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Nursing Process

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  1. Nursing Process Critical Thinking Problem Solving

  2. 5 steps to Nursing Process • Assessing • Diagnosing • Planning • Implementation • Evaluation

  3. Characteristics of Nursing Process • Systematic • Dynamic • Interpersonal • Goal-oriented • Universally applicable

  4. Data Base Sources of data Primary Sources Secondary sources Types of data Objective Subjective Data collection Observation Interview Examination Assessing

  5. Diagnosing • Analyze and interpret • Compare to standards • Recognize patterns • Identify gaps • No problem • Possible problem • Clinical problem

  6. Writing Nursing Diagnoses • NANDA • The client’s problem • Etiology (r/t) • Defining characteristics (a.m.b.) • Risk nursing diagnoses • Actual diagnosis • Syndrome diagnosis • Wellness diagnosis

  7. Prioritizing • Threat to well-being or life • Non-life threatening • Not related to current illness • Maslow

  8. Planning • Writes goals • Develops evaluative strategy • Selects nursing measures • Writes the nursing care plan

  9. Writing goals • Subject … the patient or client • Verb… indicated action that is directly observable… administer, demonstrate, etc. • Criteria • Observable • Timed • realistic

  10. Selection nursing measures • Problem statement suggests the goals • Etiology suggests the nursing measures • Nursing measures must be • Tailored to the client • Consistent with agency’s policies • Realistic • Compatible with client values

  11. Writing nursing orders • Describe the action • Answer • Who • What • Where • When • How • Independent • Dependent (we include collaborative here)

  12. Implementing • Reassessment • Obtaining help • Implementing the orders • Delegating and supervising • Documenting

  13. Evaluating • Based on the client’s response • Terminate the plan • Modify or revise the plan • Continue the plan

  14. Care Plan forms and examples • Care Plan Guidelines • Care Plan Form • Patient Profile

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