NCM 103

• Nursing Process


  1. A systematic rational method of planning and providing nursing care

  2. A cyclical process; its components follow a logical sequence, but maybe one component maybe involved at one time

  
• Goals of the Nursing Process

  • To identify client's actual or potential health care needs/problems
  • To establish plans to meet the identified needs
  • To deliver & evaluate specific nursing intervention to meet those needs

  
• Sources of Data


  • Primary (patient/client)
  • Secondary (Family members, significant others, Patient's record/chart, Health Care Professionals, Literature, etc.)
• Gordon's Typology of 11 functional health patterns


  • Health Perception/Health management
  • Nutritional/Metabolic Pattern
  • Elimination pattern
  • Activity-exercise pattern
  • Sleep-rest pattern
  • Cognitive-perceptual pattern
  • Self-perception/self-concept pattern
  • Role-relationship patterns
  • Sexuality-reproductive pattern
  • Coping/Stress-tolerance pattern
  • Value-belief pattern
• Diagnosing


  Formulate diagnostic statement/interpreting data and identify client strengths and problems
• Nursing Diagnoses


  • A statement of nursing judgement and refers to a condition that nurses, by virtue of their education, experience and expertise are licensed to treat
  • Describe the human response, a client's physical, sociocultural, psychologic, and spiritual response to illnessor health problem
  • Change as the client response change

  
• Types of Nursing Diagnoses


  • Actual Diagnosis
  • Risk Nursing Diagnosis
  • Wellness Diagnosis
  • A Possible Nursing Diagnosis
  • Syndrome diagnosis

  
• Formulating Diagnostic Statements

  • Basic Two-Part Statements (Problem, Etiology)
  • Basic Three-Part Statements (Problem, Etiology, Signs and Symptoms)
  • Basic One-Part Statements
• NANDA (North American Nursing Diagnosis Association) was organized and published a book in 1990 that serves as guide in formulating nursing diagnosis
• Activities During Diagnosing

  • Organize or cluster data
  • Compare data against standards
  • Analyze Data
  • Identify gaps and inconsistencies in data
  • Determine the client's health problems
  • Formulate nursing diagnosis statements
  • Validate the diagnosis
• Process


  Planned actions or operations directed toward a particular result
• Nursing Process


  Systematic rational method of planning and providing nursing care
• Lydia Hall (1955)


  • Originated 3 steps of Nursing Process:
  • note observation
  • ministration of care
  • validation
• Kreuter (1957)


  • Precede - proceed model
• Dorothy Johnson (1959)

  • Behavioral system model
• Ida Jean Orlando (1961) -

  3 interactive elements of NP

  • client's behavior
  • nurse's reaction
  • nursing actions
• V. Henderson (1965)


  • Nursing Process is the same with scientific method
• L. Heidgerken (1965)


  • 6 Steps of professional Nursing Care:
  • evaluating behavior & situations
  • recognizing physical symptoms
  • diagnosing
  • planning
  • meeting nursing needs
  • coordinating
• Yura & Walsh (1967)


  • 4 components of Nursing Process:
  • Assessing
  • Planning
  • Implementing
  • Evaluating
• Knowles (1967)


  • 4Ds of Nursing Process:
  • Discover
  • Delve
  • Decide
  • Do
  • Discriminate
• Orientation


  First stage of Peplau's interpersonal relationship model
• Identification


  Second stage of Peplau's interpersonal relationship model
• Exploitation


  Third stage of Peplau's interpersonal relationship model
• Resolution


  Fourth stage of Peplau's interpersonal relationship model
• WICHE

  Western Interstate Commission on Higher Education (1967)
• WICHE: '"NP is the interrelationship bet. a pt. & a nurse it incorporates the behaviors of both & the result of the interaction"'
• Diagnosis as a separate step of Nursing Process

  1973
• Diagnosis is the actual & potential health problems delineated as integral part of Nursing Process

  1980
• Outcome identification as a distinct step in the Nursing Process

  1991
• NANDA


  North American Nursing Diagnosis Association, organized in 1982 and published a book in 1990 that serves as guide in formulating nursing diagnosis
• Nursing Process


  • A systematic rational method of planning and providing nursing care
  • A cyclical process; its components follow a logical sequence, but maybe one component maybe involved at one time
• Gordon's Typology of 11 functional health patterns


  Gordon uses the word pattern to signify sequence of recurring behavior
• Diagnosing


  Formulate diagnostic statement/interpreting data and identify client strengths and problems- a pivotal step in the nursing process
• Actual Diagnosis


  Problem that is present at the time of the nursing assessment and based on the presence of the associated signs and symptoms
• Risk Nursing Diagnosis


  A clinical judgment that a problem does not exist, but the presence of risk factors indicates that a problem is likely to develop unless intervened
• Wellness Diagnosis


  Describes human responses to levels of wellness in an individual, family or community that have a readiness for enhancement
• Syndrome diagnosis


  Diagnosis associated with cluster of other diagnoses
• Purpose of NANDA


  To define, refine, and promote a taxonomy of nursing diagnostic terminology of general use to professional nurses
• Taxonomy


  A classification system or set of categories arranged based on a single principles
• Diagnosing


  Refers to reasoning process