Nursing process - University of Babylon



Nursing process

Nursing process is to provide a systematic method for nurses to plan and implement client care to achieve desired outcomes.

Important of nursing process

Systematically collect patient data

Clearly identify patient strengths and actual and potential problems (diagnosing)

Develop a holistic plan of individualized care that specifies the desired patient goals and related outcomes and the nursing interventions most likely to assist the patient to meet those expected outcomes (planning)

Execute the plan of care (implementing)

Evaluate the effectiveness of plan of care in terms of patient goal achievement (evaluating)

Steps of the Nursing Process

Assessment

Diagnosis (nursing) or analysis

Planning

Implementation

Evaluation

Characteristics of the nursing process

Systematic

Dynamic

Interpersonal

Outcome oriented

Assessment

Assessment is the first step of the nursing process when client information is gathered and examined in preparation for the second step diagnosis.

Assessment phase include the following activities:

1. Collecting data: Gathering information about the patient or client

The following summarizes the resources for gathering data

Patient/ client (primary source)

Family/ significant others

Nursing records

Medical records

Record of diagnostic studies.

Patient interview.

Physical examination By

Inspection: Examination by careful and critical observation.

Auscultation: Examination by listening with stethoscope.

Palpation: Examination by touching and felling.

Percussion: Examination by touching, tapping, and listening.

Validating data: Making sure that you know which data is actually fact and which data are questionable.

Organizing Data; clustering the data into groups of information that will help you to identify patterns of health or disease.

Identifying Patterns: making an initial impression about patterns of information, and gathering additional data impression about patterns of information, and gathering additional data to fill in the gaps to describe more clearly what the data mean.

Communicating /Recording data: reporting significant data to expedite treatment, and completing the data base

Preparing for data collection

Establishing Assessment Priorities

Before beginning to collect data on any patient, the nurse should have a good sense of the type of data needed to develop a satisfactory plan of care. For example, pediatric nurses are careful to establish the developmental age and milestones obtained by children admitted to a pediatric unit.

Another example, A school nurse who suspects child abuse pays careful attention to the child's statement about living conditions at home and relationships with family members and caregivers.

Health Orientation

Assess patient knowledge and believe about illness and wellness

Developmental stage

Nursing assessments are modified according to the developmental needs of patients. For example, when assessing an infant, special attention is given to weight gain and physical growth, feeding and elimination problems, sleep-activity cycles, and the parenting skills of caregivers.

Need for nursing

When assessing patients is to gather only data that are helpful when planning and delivering care. It would be inappropriate, for example, to collect a detailed sexual history on a patient admitted to the hospital overnight after a slight concussion.

Practical considerations

Data already collected from the patient and in the patient record should not be repeatedly sought from the patient unless there is a need to validate them.

Data Collection

Types of data

Subjective and objective

Subjective

Subjective data are information perceived only by the affected person; these data cannot be perceived or verified by another person. Examples of subjective data are feeling nervous, nauseated, or chilly and experiencing pain.

Objective

Objective data are observable and measurable data that can be seen, heard, or felt by someone other than the person experiencing them. Example, elevated body temperature

Characteristics of data

Complete

As much as possible, all the patient data needed to understand a patient health problem and develop a plan of care to maximize health and well-being should be identified. For example, knowing that a patient has lost weight is not fully meaningful until the nurse discovers (1) if the weight loss was intentional or unintentional, (2) If it was related to a change in eating or exercise patterns. (3) how the patient views and is responding to the weight loss.

Accurate

Both the patient and the nurse may intentionally or unintentionally misrepresent patient information. For example, a patient who values being thin may describe a weight gain of several pounds as the onset of obesity.

Relevant

Nursing Diagnosis

Nursing Diagnosis: An actual or potential health problem that is focuses upon the human response of an individual or group, and that nurses are responsible and accountable for identifying and treating independently.

Writing Diagnostic Statements for Actual Nursing Diagnoses

When you write a diagnostic statement for actual nursing diagnoses, you should use the PES (problem, etiology, signs and symptoms) system to describe the diagnosis. That is, you write a three-part statement, which includes the following:

1. The problem(P)

2. Its cause or etiology(E)

3. The signs and symptoms(defining characteristics) that are evident in the patient(S)

Rule: to write a diagnostic statement for an actual nursing diagnoses, link the problem and its etiology by using‘’’related to’’. Add ‘’ as manifested by’’ or ‘’as evidenced by

Diagnostic statement: Ineffective Airway Clearance related to weak cough and incisional pain, as manifested by poor or no cough effort and statements that incision hurts too much when he coughs.

Writing Diagnostic Statements for Potential Problem

Potential and Possible Nursing Diagnosis (two-part statement):

Problem +Etiology

Potential Ineffective Airway Clearance Related to Smoking

Planning

Establish the goals, interventions and outcomes

General Guidelines for Setting Priorities

Take care of immediate life-threatening issues.

Safety issues.

Patient-identified issues.

Nurse-identified priorities based on the overall picture, the patient as a whole person, and availability of time and resources.

Nurse Identified Priorities

Composite of all patient’s strengths and health concerns.

Moral and ethical issues.

Time, resources, and setting.

Hierarchy of needs.

Interdisciplinary planning.

Implementation

Implementation refers to the action phase of the nursing process in which nursing care is provided. It is the actual initiation of the plan and recording of nursing actions. Its purpose is to provide technical and therapeutic nursing care required to help the client achieve an optimal level of health.

Evaluation

Evaluation, the sixth phase of the nursing process, follows implementation of the plan of care. Evaluation is defined as the judgment of the effectiveness of nursing care to meet client goals based on the client's behavioral responses. This phase involves a thorough, systematic review of the effectiveness of nursing interventions and a determination of client goal achievement.

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