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2. Chapter 1. Nursing Process. 3. Nursing Process. An organized sequence of problem-solving steps used to identify and to manage the health problems of clients.Steps of the Nursing ProcessAssessing.Diagnosing.Planning.Implementing.Evaluating.. 4. Assessment. Assessment: Collecting data to determine the needs and health problems of patient. .
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1. 1 Fundamentals of Nursing (NUR 101) Prepared by Nabeel Al-Mawajdeh RN.Mcs. King Saud University- Aflaj College
2. 2 Chapter 1 Nursing Process
3. 3 Nursing Process An organized sequence of problem-solving steps used to identify and to manage the health problems of clients.
Steps of the Nursing Process
Assessing.
Diagnosing.
Planning.
Implementing.
Evaluating.
4. 4 Assessment Assessment: Collecting data to determine the needs and health problems of patient.
5. 5 Data Collection Types of Data:
Subjective data (symptoms)
Are information perceived such as (feeling nervous, nauseated, chilly or experiencing pain)
6. 6 Data Collection (Contd) Objective data (signs)
Are observable and measurable data that can be seen, heard and felt, and its observed by one person can be verified by another person observing the same patients. Such as (increase temperature, lab. results, moist skin, refusal to look at or eat food)
7. 7 Sources of Data Primary source: Client.
Secondary source: Clients family, reports, test results, information in current and past medical records, and discussions with other health care workers ( physicians , social workers , dietitians , physiotherapists and laboratory technicians )
8. 8 Data Collection Methods Observation.
Is the conscious and deliberate use of the five
senses to gather data (sighting, smelling and hearing)
Interview.
Is the planned communication, during the assessment step of the nursing process to obtain and establish a successful working partnership with the patient , then to obtain the necessary patient data .
9. 9 Data Collection Methods (contd) Techniques of Physical Assessment.
Is the examination of the patient for objective data that may better define the patients condition and help the nurse in planning care, include:
inspection , palpation , percussion , and auscultation .
10. 10 Problems Related to Data Collection Inappropriate organization of the database.
Omission of pertinent data.
Inclusion of irrelevant or duplicate data.
Misinterpreted data.
Failure to establish rapport and partnership.
11. 11 Diagnosis Health issue that can be prevented, reduced, resolved, or enhanced through independent nursing measures.
12. 12 Nursing Diagnosis Categories Actual.
Risk.
Possible.
Syndrome.
Wellness.
13. 13 Diagnostic Statements Name of the health-related issue or problem as identified in the NANDA (North American Nursing Diagnosis Association) list.
Etiology (its cause)
Signs and Symptoms.
The name of the nursing diagnosis is linked to the etiology with the phrase related to, and the signs and symptoms are identified with the phrase as manifested (or evidenced) by.
14. 14 Purpose of Diagnosis To identify:
Actual and potential problems.
Factor that contribute the problems (etiologies)
Strengths the patients can drawn to prevent or resolve the problems.
15. 15 Formulating and Validating Nursing Diagnosis Parts of Nursing Dxs.
Problem.
The purpose of the problem statement is to describe the health state or health problem of the patient as possible.
Identifies what is unhealthy about the patient, indicating the need for change
Etiology.
Identifies the factors that are maintaining the unhealthy state or response (causative factor )
Defining characteristics.
The subjective and objective data that signal the existence of the problem identify.
16. 16 Diagnosis Examples Example 1 :
Hygiene self-care deficit ( problem )
related to
fear of falling in the obesity (etiology )
as manifested by
strong body and urine odder (characteristics )
17. 17 Diagnosis Examples (Contd) Example 2 :
Chest pain ( problem )
related to
decrease coronary blood flow (etiology) as manifested by
facial expression (characteristics )
18. 18 Diagnosis Examples (Contd) Example 3 :
Ineffective individual coping (problem)
related to
loss of job ( etiology )
as manifested by
increase daily use of alcohol (characteristics )
19. 19 Planning The process of prioritizing nursing diagnoses and collaborative problems, identifying measurable goals or outcomes, selecting appropriate interventions, and documenting the plan of care.
The nurse works in partnership with the patient and family.
20. 20 Elements of Planning Establishing priorities.
Writing goals / outcomes that determine the evaluative strategy .
Selecting appropriate nursing interventions.
Communicating the plan of nursing care.
21. 21 Priorities of Planning Determine problems that require immediate action.
Maslows Hierarchy of Human Needs
Physiologic needs.
Safety.
Love and belonging needs.
Self-esteem needs.
Self- actualization needs.
22. 22 Writing Goals / Outcomes Short-Term Goals
Outcomes achievable in a few days or 1 week.
Long-Term Goals
Desirable outcomes that take weeks or months to accomplish for clients with chronic health problems.
23. 23 Guidelines For Goal/Outcome Writing One of the most important consideration in goal/outcome writing is to encourage the patient and family to be as involved in goal development as their abilities and interest permit .
Each patient goal/outcome must have
1- a subject : which is the patient.
2- a verb : which indicates the action.
The patient will perform , and criteria which describe in observable such as ( define , identify , list , select , apply , explain , prepare
etc
24. 24 Problems Related to Planning Insufficient data collection.
Nursing Dxs developed from inaccurate data.
Goals /outcomes that are stated too broadly .
Goals/outcomes that are derived from poorly developed nursing Dxs.
25. 25 Implementation (Intervention) Execute the plan of care (action phase)
The nurse implements medical orders and nursing orders.
Implementation involves the client and one or more health care team.
The information in the chart shows a correlation between the plan and the care that has been provided.
Nurses are accountable for carrying out nursing orders and physician orders.
26. 26 Types of Nursing Intervention Dependent nursing action.
Which involve carrying physician prescribed orders.
Independent nursing action.
Carrying out nurse- prescribed interventions written on the nursing plan of care as well as any other actions that nurses initiate without the direction of anther health care professional and that result from their assessment of patient needs .
Interdependent nursing action.
Which performed jointly by nurses and other members of the health care team .
27. 27 Carrying Out The Plan of Care When carrying out the plan of care , nurses use specialized abilities to
Determine the patients continuing need for nursing assistance.
Promote self-care .
Assist the patient to achieve health goals.
28. 28 Evaluation Evaluate the effectiveness of the plan of care in terms of patient goal achievements.
The nurse and patient together measure how well the patient has achieved the goals/outcomes specified in the plan of care , and the purpose of evaluation is to allow the patients achievement of expected outcomes to direct future nurse patient interactions , based on the patients responses to the plan of care .
29. 29 Measuring Patient Goal/Outcomes Achievement Collecting evaluative data.
The data collected to determine whither the identified health problems have been resolved through goal achievement.
Documenting evaluation.
After the data have been collected the nurse writes an evaluative statement to summarize the findings. And the nurse has three decision options for how goals have been (met
.. Partially met
.. not met...)
30. 30 Factors That Influence Goal/Outcome Achievement Numerous patient:( cognitive , cooperate .etc )
Nurse: excellent , frustrate , bored.
Health care system : inadequate staffing . relationships
. etc
31. 31 Documenting , Reporting and Conferring Documenting care.
Is the written , legal record of all pertinent interaction with the patient assessing , diagnosing , planning , implementing and evaluation to facilitate patient care .
Patient record.
Is a compilation of patients health information
32. 32 Purposes of Patient Records Communication : between health care professionals
Care planning : patient responding to treatment from day to day .
Education : for the manifestations and treatment
Decision analysis.
Research .
Legal documentation.
33. 33 Methods of Documentation Source oriented records : one in which each health care group keeps data on its own separate form .
Problem- oriented medical records:
POMR is organized around a patients problems rather than a round sources of information .
Charting by exception:
Is a shorthand documentation method that makes use of well-defined standards of practice
Computerized records.
34. 34 Common Methods of Communication Among Health Care Professionals Face to face meeting.
Telephone conversation.
Written message.
Computer message .
35. 35 Nursing Care Rounds Its procedures in which a group of nurses visit selected patients individually at each patients bed side to:
Evaluate the nursing care for the patient has received.
Gather information to help plan nursing care.
36. 36 THE END
