Reviewer

• Nursing Process


  Deliberate problem-solving approach for meeting people's health care and nursing needs

  
• Common components of the Nursing Process

  • Assessment
  • Diagnosis
  • Planning
  • Implementation
  • Evaluation

  
• Characteristics of the Nursing Process

  • Provides the framework for care
  • It is client centered
  • Adapted of problem solving technique
  • It is planned
  • It is cyclic and dynamic

  
• Assessment


  First step in nursing process, includes systematic collection of data through interview, observation and examination
• Purpose of Assessment


  Determine the patient's health status as well as any actual or potential health problems
• Types of Assessment


  • Data base assessment
  • Focus assessment
  • Emergency assessment
  • Ongoing assessment (follow-up)
• Data Collection


  The process of gathering information about client health status, vital for the remaining steps of the nursing process
• Characteristics of Data


  • Complete
  • Accurate
  • Relevant
• Sources of Data


  • Primary source - client
  • Secondary source - client's family, test results, information in current and past medical records
• Types of Data


  • Subjective data
  • Objective data
• Methods of Data Collection

  • Observation
  • Interview
  • Physical examination
  • Laboratory and diagnostic data
• Subjective Data


  • Biographical data
  • Past History
  • Present history (pain assessment)
  • Family History (Genogram)
  • Social History
• Nursing Diagnosis


  Second step of nursing process, describes clinical judgments about individual, family, or community responses to actual or potential health problems/life processes, managed by independent nursing interventions

  
• NANDA


  North America Nursing Diagnosis Associate
• Nursing diagnosis (Nsg Dx) vs Medical diagnosis (MD Dx)

  Nsg Dx: Within the scope of nursing practice, identify responses to actual or potential health problems, can change from day to day

  MD Dx: Within the scope of medical practice, determines a specific disease, condition or pathological state, stays the same as long as the disease is present
• Types of Nursing Diagnoses

  • Actual
  • Risk
• PES System


  1. Problem - Identifies unhealthy response, indicated what should change, manifested by patient verbalization

  2. Etiology - Identifies causative or contributing factors, suggests nursing interventions

  3. Sign and Symptom - Redness, cyanosis, loss of appetite
• Planning


  Third step of the nursing process, development of measurable goals and outcomes as well as a plan of care designed to assist the patient in resolving the diagnosed problems and achieving the identified goals and desired outcomes
• Planning Process


  • Prioritize problem
  • Formulate goal
  • Select nursing intervention
  • Write nursing order
  • Record and modify

  
• Setting Priorities


  Determine problems that require immediate action, based on Maslow's Hierarchy of Human Needs
• Types of Goals


  • Short-term Goals
  • Long-term Goals
• Components of Outcomes


  Subject - who is the person expected to achieve the outcome

  Verb - what actions must the person take the achieve the outcome

  Condition - under what circumstances is the person to perform the actions

  Performance criteria - how well is the person to perform the actions

  Target time - by when is the person expected to be able to perform the actions
• Types of Interventions


  • Independent (Nurse Initiated)
  • Dependent (Physician initiated)
  • Collaborative
• Implementation


  Fourth step of the nursing process, involves carrying out the proposed plan of nursing care

  
• Evaluation


  Final step of the nursing process, determine the client progress toward goals achievement and effectiveness of the nursing care plan

  
• Nursing Care Plan (NCP)


  Formal process that correctly identifies existing needs and recognizes a client's potential needs or risks, provides a way of communication among nurses, patients and other healthcare providers to achieve healthcare outcomes

  
• Types of NCP


  • Informal NCP
  • Formal NCP
• Purposes of NCP


  • Defines nurse's role
  • Provides direction for individualized care of the client
  • Continuity of care
  • Coordinate care
  • Documentation
  • Serves as a guide for assigning a specific staff to a specific client
  • Monitor progress
  • Serves as a guide for reimbursement
  • Defines client's goals

  
• Components of NCP


  • Assessment
  • Nursing Diagnosis
  • Expected Client Outcomes
  • Nursing Interventions
  • Rationales
  • Evaluation

  
• Writing a NCP


  1. Data Collection or Assessment

  2. Data Analysis and Organization

  3. Formulating your Nursing Diagnoses

  4. Setting Priorities

  5. Establishing Client Goals and Desired Outcomes

  6. Selecting Nursing Interventions

  7. Providing Rationale

  8. Evaluation

  9. Putting it on Paper