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Basic Nursing: Foundations of Skills & Concepts Chapter 9. NURSING PROCESS. The Nursing Process. A systematic method of providing care to clients. The 5-Step Nursing Process. Assessment. Diagnosis. Planning and outcome identification. Implementation.
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Basic Nursing: Foundations of Skills & Concepts Chapter 9 NURSING PROCESS
The Nursing Process • A systematic method of providing care to clients.
The 5-Step Nursing Process • Assessment. • Diagnosis. • Planning and outcome identification. • Implementation. • Evaluation.
Assessment or Data Collection • The first step in the nursing process involves the following: • Collecting data. • Validating data. • Organizing data. • Interpreting data. • Documenting data
Purpose of Assessment • To establish a database concerning a client’s physical, psychosocial, and emotional health. • To identify health-promoting behaviors as well as actual and/or potential health problems.
Types of Assessment • Comprehensive - Provides baseline data including complete health history and current needs assessment. • Focused - Limited in scope in order to focus on a particular need or concern or potential risk. • Ongoing - Includes systematic monitoring and observation related to specific problems.
Sources of Data • Primary Source: The client. • Secondary Source: The client’s family members, other health care providers, and medical records.
Types of Data • Subjective: Data from client’s (and sometimes family’s) point of view. Includes feelings, perceptions, and concerns. Collected by the interview. • Objective: Also called signs. Observable and measurable data obtained through physical examination and laboratory and diagnostic testing.
Validating Data • Validation prevents omissions, misunderstandings, and incorrect inferences and conclusions.
Organizing Data • Collected information must be organized to be useful. • Data Clustering is a useful tool to identify issues.
Interpreting Data Three critical components: • Distinguishing between relevant and irrelevant data • Determining whether and where there are gaps in the data • Identifying patterns of cause and effect
Documenting Data • Assessment data must be recorded and reported. • Accurate and complete recording of assessment data is essential for communicating information to health care team.
Diagnosis • A medical diagnosis is a clinical judgment by the physician that determines a specific disease, condition or pathological state. • A nursing diagnosis is a clinical judgment about individual, family, or community responses to actual or potential health problems/life processes.
Nursing Diagnosis Questions • Are there problems here? • If so, what are the specific problems? • What are some possible causes? • Is there a situation involving risk factors? • What are the risk factors? • What are the client’s strengths? • What data are available to answer these questions? • Is more data needed? • If so, what are the possible sources of further data?
Nursing Diagnosis is a Two-Part Statement • A problem statement or diagnostic label that describes the client’s response to an actual or potential health problem or wellness condition. • And the etiology - the related cause or contributor to the problem.
Nursing Diagnosis is a Three-Part Statement • Includes first two parts of Two-Part Statement: the diagnostic label and the etiology. • Also includes defining characteristics, the collected data, also known as signs and symptoms, subjective and objective data, and clinical manifestations.
Types of Nursing Diagnosis • Actual nursing diagnosis: A problem exists; it is composed of the diagnostic label, related factors, and signs and symptoms. • Risk nursing diagnosis: A problem does not yet exist, but special risk factors are present. • Wellness nursing diagnosis: Indicates client’s desire to attain higher level of wellness in some area of function.
Planning and Outcome Identification • Planning combines with outcome identification to comprise the third step of the nursing process.
Three Phases of Planning • Initial Planning: developing a preliminary plan of care by the nurse who performs the admission assessment. • Ongoing Planning: continuous updating of client’s plan of care. • Discharge Planning: Involves critical anticipation and planning for client’s needs after discharge.
Tasks Involved with Planning • Prioritizing list of nursing diagnoses. • Identifying and writing client-centered long- and short-term goals and outcomes. • Developing specific nursing interventions. • Recording entire nursing plan in client’s record.
Intervention • A nursing intervention is an action performed by the nurse that helps the client achieve the results specified by the goals and expected outcomes.
Categories of Nursing Interventions • Independent: Actions initiated by nurse that do not require direction or an order from another health care professional • Interdependent: Actions implemented in collaborative manner by nurse in conjunction with other health care professionals • Dependent: Actions that require an order from a physician or other health care professional.
Types of Nursing Interventions • Specific order - written by physician or nurse especially for an individual client. • Standing order - A standardized intervention written, approved and signed by a physician that is kept on file to be used in predictable situations or in circumstances requiring immediate attention. • Protocol - A series of standing orders or procedures.
Types of Nursing Interventions • Specific order: written by physician or nurse especially for an individual client • Standing order: A standardized intervention written, approved and signed by a physician that is kept on file to be used in predictable situations or in circumstances requiring immediate attention. • Protocol: A series of standing orders or procedures
The Nursing Care Plan • A written guide that organizes data about a client’s care into a formal statement of the strategies that will be implemented to help the client achieve optimal health.
Implementation • This fourth step of the nursing process involves the execution of the nursing care plan derived during the Planning phase.
Evaluation • This fifth step of the nursing process, determining whether client goals have been met, partially met, or not met.
Nursing Audit • The process of collecting and analyzing data to evaluate the effectiveness of nursing interventions.
The Nursing Process is Critical Thinking • Critical thinking, problem-solving, and decision-making are important in the use of the nursing process. • These skills can be learned!