Nursing Process

• A systematic, rational, dynamic and cyclic process for planning and providing care for the client

  nursing process
• Is a systematic, chronological, step by step procedure of ADPIE

  o Assessment

  o Diagnosis

  o Planning

  o Implementation

  o Evaluation
• PROCESSES INVOLVED in Nursing Process

  1. Critical-thinking
  2. 2. Problem Solving
  3. 3. Decision Making
• To establish data base

  First step of the Nursing process

  It is the collection, organization, validation and documentation of data

  It begins during the first meeting of the nurse and the client

  Assessment
• 4 types of assessments

  A)

  B)

  C)

  
• 4 types of assessments

  A)

  B)

  C)

  D)

  E)

  F)

  G)

  H)

  I)

  
• SOURCES OF DATA

  PRIMARY SOURCE- Client or Family

  SECONDARY SOURCE - Physical exam, nursing history, team members, lab reports, diagnostic tests
• Second step of the nursing process

  Interpret and analyze clustered data

  • Identify client’s problems and strengths
  • Formulate Nursing Diagnosis (NANDA: North American Nursing Diagnosis Association)

  diagnosis
• TYPES OF NURSING DIAGNOSIS

  • ACTUAL - One of the commonly used type of diagnosis. Based on the actual problem of the patient. The problem is already existing
  • RISK - Also one of the commonly used type of diagnosis. Similar to POSSIBLE. The causes that can make the problem become present are already there. Can be based on the actual problem
  • WELLNESS - The patient is not ill, the patient is well
  • POSSIBLE - Similar to RISK. The patient has the tendency to develop the problem
  • SYNDROME - This is composed of two or more problem
• FORMULATING A NURSING DIAGNOSIS

  • Composed of three parts: PED/PES FORMAT
  • Problem Statement
  • Etiology
  • Defining Characteristics or S/S
• COMPONENT OF NURSING DIAGNOSIS

  1. ONE-PART STATEMENT - Consist of NANDA label only
  2. TWO-PART STATEMENT - Problem + Etiology
  3. THREE-PART STATEMENT - Problem + Etiology + Signs and Symptoms
• This is when the nurse organizes a nursing care plan based on the nursing diagnosis

  planning
• TYPES OF PLANNING

  1. INITIAL PLANNING
  2. ONGOING PLANNING
  3. DISCHARGE PLANNING
• TYPES OF GOALS

  • SHORT-TERM GOALS - We can use this if the patients problem will last no longer than 6 months
  • LONG-TERM GOALS - We can use this if the patient’s problem will last for more than 6 months
• The nurse uses clinical judgement and professional knowledge to select appropriate interventions that will aid the client in reaching their goal

  intervention
• TYPES OF INTERVENTIONS

  1. INDEPENDENT (NURSE INITIATED) - Any action the nurse can initiate without direct supervision
  2. DEPENDENT (PHYSICIAN INITIATED) - Nursing actions requiring MD orders
  3. COLLABORATIVE - Nursing actions performed jointly with other health care team members