Nursing Process - nur.uobasrah.edu.iqnur.uobasrah.edu.iq/images/pdffolder/Nursing Process.pdf ·...
Transcript of Nursing Process - nur.uobasrah.edu.iqnur.uobasrah.edu.iq/images/pdffolder/Nursing Process.pdf ·...
![Page 1: Nursing Process - nur.uobasrah.edu.iqnur.uobasrah.edu.iq/images/pdffolder/Nursing Process.pdf · •Nursing process –is a systematic method of providing care to clients –Allows](https://reader034.fdocuments.net/reader034/viewer/2022052612/5f0a5a117e708231d42b3892/html5/thumbnails/1.jpg)
Nursing Process
Nursing Fundamentals
![Page 2: Nursing Process - nur.uobasrah.edu.iqnur.uobasrah.edu.iq/images/pdffolder/Nursing Process.pdf · •Nursing process –is a systematic method of providing care to clients –Allows](https://reader034.fdocuments.net/reader034/viewer/2022052612/5f0a5a117e708231d42b3892/html5/thumbnails/2.jpg)
Introduction
• Nursing process – is a systematic method of providing care to clients
– Allows nurses to communicate plans and activities to • Clients
• Other health care professionals
• Families
– Encourages orderly thought, analysis, planning
![Page 3: Nursing Process - nur.uobasrah.edu.iqnur.uobasrah.edu.iq/images/pdffolder/Nursing Process.pdf · •Nursing process –is a systematic method of providing care to clients –Allows](https://reader034.fdocuments.net/reader034/viewer/2022052612/5f0a5a117e708231d42b3892/html5/thumbnails/3.jpg)
Overview of the Nursing Process
• Process:
– “A series of steps or acts that lead to accomplishment of some goal or purpose”
• Purpose is to provide client care that is:
– Individualized
– Holistic
– Effective
– Efficient
![Page 4: Nursing Process - nur.uobasrah.edu.iqnur.uobasrah.edu.iq/images/pdffolder/Nursing Process.pdf · •Nursing process –is a systematic method of providing care to clients –Allows](https://reader034.fdocuments.net/reader034/viewer/2022052612/5f0a5a117e708231d42b3892/html5/thumbnails/4.jpg)
Overview of the Nursing Process
• Consists of 5 steps
– Assessment
– Diagnosis
– Planning
– Implementation
– Evaluation
• Build on each other
• Not linear
![Page 5: Nursing Process - nur.uobasrah.edu.iqnur.uobasrah.edu.iq/images/pdffolder/Nursing Process.pdf · •Nursing process –is a systematic method of providing care to clients –Allows](https://reader034.fdocuments.net/reader034/viewer/2022052612/5f0a5a117e708231d42b3892/html5/thumbnails/5.jpg)
• Nursing process is dynamic and requires creativity in its application
– Steps remain the same
– Application and results different
• Used throughout the life span in any care setting
![Page 6: Nursing Process - nur.uobasrah.edu.iqnur.uobasrah.edu.iq/images/pdffolder/Nursing Process.pdf · •Nursing process –is a systematic method of providing care to clients –Allows](https://reader034.fdocuments.net/reader034/viewer/2022052612/5f0a5a117e708231d42b3892/html5/thumbnails/6.jpg)
Assessment
• Step #1
• Involves
– Collecting data (from variety of sources)
– Validating the data
– Organizing the data
– Interpreting the data
– Documenting the data
![Page 7: Nursing Process - nur.uobasrah.edu.iqnur.uobasrah.edu.iq/images/pdffolder/Nursing Process.pdf · •Nursing process –is a systematic method of providing care to clients –Allows](https://reader034.fdocuments.net/reader034/viewer/2022052612/5f0a5a117e708231d42b3892/html5/thumbnails/7.jpg)
Assessment
• Purpose of assessment:
– Data collection
• Types of assessment:
– Comprehensive assessment
– Focused
– Ongoing
![Page 8: Nursing Process - nur.uobasrah.edu.iqnur.uobasrah.edu.iq/images/pdffolder/Nursing Process.pdf · •Nursing process –is a systematic method of providing care to clients –Allows](https://reader034.fdocuments.net/reader034/viewer/2022052612/5f0a5a117e708231d42b3892/html5/thumbnails/8.jpg)
Assessment
• Comprehensive assessment
– Baseline
– Physical & psychosocial
![Page 9: Nursing Process - nur.uobasrah.edu.iqnur.uobasrah.edu.iq/images/pdffolder/Nursing Process.pdf · •Nursing process –is a systematic method of providing care to clients –Allows](https://reader034.fdocuments.net/reader034/viewer/2022052612/5f0a5a117e708231d42b3892/html5/thumbnails/9.jpg)
Assessment
• Focused Assessment
– Limited in scope
– Screening for a specific problem
– Short stay
• Ongoing assessment
– Follow-up
– Monitoring and observation related to specific problems
![Page 10: Nursing Process - nur.uobasrah.edu.iqnur.uobasrah.edu.iq/images/pdffolder/Nursing Process.pdf · •Nursing process –is a systematic method of providing care to clients –Allows](https://reader034.fdocuments.net/reader034/viewer/2022052612/5f0a5a117e708231d42b3892/html5/thumbnails/10.jpg)
Assessment
• Sources of Data
– Primary sources
• Client
• Interview
• Physical examination
– Secondary sources
• Family members
• Other health care providers
• Medical records
![Page 11: Nursing Process - nur.uobasrah.edu.iqnur.uobasrah.edu.iq/images/pdffolder/Nursing Process.pdf · •Nursing process –is a systematic method of providing care to clients –Allows](https://reader034.fdocuments.net/reader034/viewer/2022052612/5f0a5a117e708231d42b3892/html5/thumbnails/11.jpg)
Assessment
• Types of data – Subjective
• Data from the client’s point of view – Feelingsمشاعر, Perceptionsتصورات, Concernsمخاوف
• Main way to collect subjective data: – Interview
– Objective • Observable & measurable data
• Main way to collect objective data: – Physical assessment
– Lab and diagnostic testing
![Page 12: Nursing Process - nur.uobasrah.edu.iqnur.uobasrah.edu.iq/images/pdffolder/Nursing Process.pdf · •Nursing process –is a systematic method of providing care to clients –Allows](https://reader034.fdocuments.net/reader034/viewer/2022052612/5f0a5a117e708231d42b3892/html5/thumbnails/12.jpg)
Assessment
• Validating the Data
• Organizing the Data
• Interpreting the Data
– Relevant vs. irrelevant
– Gaps?
– Identify patterns
• Document the Data
![Page 13: Nursing Process - nur.uobasrah.edu.iqnur.uobasrah.edu.iq/images/pdffolder/Nursing Process.pdf · •Nursing process –is a systematic method of providing care to clients –Allows](https://reader034.fdocuments.net/reader034/viewer/2022052612/5f0a5a117e708231d42b3892/html5/thumbnails/13.jpg)
Diagnosis
• Step 2 in the nursing process
– Formulating a nursing diagnosis
– Analysis and synthesis of data
![Page 14: Nursing Process - nur.uobasrah.edu.iqnur.uobasrah.edu.iq/images/pdffolder/Nursing Process.pdf · •Nursing process –is a systematic method of providing care to clients –Allows](https://reader034.fdocuments.net/reader034/viewer/2022052612/5f0a5a117e708231d42b3892/html5/thumbnails/14.jpg)
• Nursing diagnosis:
– “A clinical judgment about individual, family or community responses to actual or potential heal problems / life processes.
– A nursing diagnosis provides the basis for selection of nursing interventions to achieve outcomes for which the nurse is accountable.”
![Page 15: Nursing Process - nur.uobasrah.edu.iqnur.uobasrah.edu.iq/images/pdffolder/Nursing Process.pdf · •Nursing process –is a systematic method of providing care to clients –Allows](https://reader034.fdocuments.net/reader034/viewer/2022052612/5f0a5a117e708231d42b3892/html5/thumbnails/15.jpg)
Medical vs. Nursing diagnosis
Medical diagnosis Nursing diagnosis
Identifies conditions the
MD(Doctor of Medicine)
is licensed & qualified to
treat
Identifies situations the
nurse is licensed &
qualified to treat
Focuses on illness,
injury or disease
processes
Focuses on the clients
responses to actual or
potential health / life
problems
![Page 16: Nursing Process - nur.uobasrah.edu.iqnur.uobasrah.edu.iq/images/pdffolder/Nursing Process.pdf · •Nursing process –is a systematic method of providing care to clients –Allows](https://reader034.fdocuments.net/reader034/viewer/2022052612/5f0a5a117e708231d42b3892/html5/thumbnails/16.jpg)
Medical vs. Nursing diagnosis
Medical diagnosis Nursing diagnosis
Remains constant
until a cure is
effected
Changes as the clients
response and/or the health
problem changes
![Page 17: Nursing Process - nur.uobasrah.edu.iqnur.uobasrah.edu.iq/images/pdffolder/Nursing Process.pdf · •Nursing process –is a systematic method of providing care to clients –Allows](https://reader034.fdocuments.net/reader034/viewer/2022052612/5f0a5a117e708231d42b3892/html5/thumbnails/17.jpg)
Medical vs. Nursing diagnosis
Medical diagnosis Nursing diagnosis
i.e. Breast cancer i.e. Knowledge deficit
Powerlessness
Grieving, anticipatory
Body image disturbance
Individual coping, ineffective
![Page 18: Nursing Process - nur.uobasrah.edu.iqnur.uobasrah.edu.iq/images/pdffolder/Nursing Process.pdf · •Nursing process –is a systematic method of providing care to clients –Allows](https://reader034.fdocuments.net/reader034/viewer/2022052612/5f0a5a117e708231d42b3892/html5/thumbnails/18.jpg)
Planning & Outcome identification
• Step 3
– Types of planning
• Initial planning
• Ongoing planning
• Discharge planning
![Page 19: Nursing Process - nur.uobasrah.edu.iqnur.uobasrah.edu.iq/images/pdffolder/Nursing Process.pdf · •Nursing process –is a systematic method of providing care to clients –Allows](https://reader034.fdocuments.net/reader034/viewer/2022052612/5f0a5a117e708231d42b3892/html5/thumbnails/19.jpg)
Planning & Outcome identification
• Identifying outcomes
– Goals
• An aim,
-Short term goals
• Hours to days (less than a week)
– Long term goals
• Weeks to months
![Page 20: Nursing Process - nur.uobasrah.edu.iqnur.uobasrah.edu.iq/images/pdffolder/Nursing Process.pdf · •Nursing process –is a systematic method of providing care to clients –Allows](https://reader034.fdocuments.net/reader034/viewer/2022052612/5f0a5a117e708231d42b3892/html5/thumbnails/20.jpg)
Planning & Outcome identification
• Developing specific nursing interventions
– Independent nursing interventions • No order needed
– Elevate edematous legs
– Interdependent nursing interventions • In conjunction with an interdisciplinary team member
– Assist client with physical therapy exercises
– Dependent nursing interventions • Require an order
– Administering of medications
![Page 21: Nursing Process - nur.uobasrah.edu.iqnur.uobasrah.edu.iq/images/pdffolder/Nursing Process.pdf · •Nursing process –is a systematic method of providing care to clients –Allows](https://reader034.fdocuments.net/reader034/viewer/2022052612/5f0a5a117e708231d42b3892/html5/thumbnails/21.jpg)
• Prioritizing the nursing diagnosis
– Maslow’s hierarchy of needs
![Page 22: Nursing Process - nur.uobasrah.edu.iqnur.uobasrah.edu.iq/images/pdffolder/Nursing Process.pdf · •Nursing process –is a systematic method of providing care to clients –Allows](https://reader034.fdocuments.net/reader034/viewer/2022052612/5f0a5a117e708231d42b3892/html5/thumbnails/22.jpg)
Maslow’s Hierarchy of Needs
![Page 23: Nursing Process - nur.uobasrah.edu.iqnur.uobasrah.edu.iq/images/pdffolder/Nursing Process.pdf · •Nursing process –is a systematic method of providing care to clients –Allows](https://reader034.fdocuments.net/reader034/viewer/2022052612/5f0a5a117e708231d42b3892/html5/thumbnails/23.jpg)
Implementation
• 4th step:
– Execution of the nursing care plan
– Delegation
–DO IT
–DO IT RIGHT
–DO IT RIGHT NOW!
![Page 24: Nursing Process - nur.uobasrah.edu.iqnur.uobasrah.edu.iq/images/pdffolder/Nursing Process.pdf · •Nursing process –is a systematic method of providing care to clients –Allows](https://reader034.fdocuments.net/reader034/viewer/2022052612/5f0a5a117e708231d42b3892/html5/thumbnails/24.jpg)
Evaluation
• 5th step
– Determining whether the clients goals have been met, partially met or not met.