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Handout Nursing Process

Handout Nursing Process

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Published by Mark Llego
To download this document visit http://nursingstudentreviewers.blogspot.com/.
To download this document visit http://nursingstudentreviewers.blogspot.com/.

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Published by: Mark Llego on Nov 12, 2009
Copyright:Attribution Non-commercial


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Joannes Paulus T. Hernandez, B.S.H.B.,B.S.N., R.N.1
JoannesPaulusT. Hernandez, BS (Human) Biology, BS Nursing, R.N.
Nursing Process, Nursing Skills,and Clinical Reasoning
The Nursing Process
One of the major guidelines for nursing practiceHelps nurses implement their rolesIntegrates art and science of nursingAllows nurses to use critical thinkingDefines the areas of care that are within the domain of nursingIt is a systematic method that directs the nurse andclient as they together determine the need for nursingcare, plan and implement the care, and evaluate theresult.
Historical Development of the NursingProcess
1955 —nursing process term was first used by
1960’s —specific steps delineated1967 —Yuraand Walsh published first comprehensivebook on nursing process1973 —ANA Congress for Nursing Practice developedStandard of Practice1982 —state board examinations for professionalnursing uses nursing process as organizingconcept
Characteristics of the Nursing Process
Systematic —part of an ordered sequence of activitiesDynamic —great interaction and overlapping among thefive stepsInterpersonal —human being is always at the heart of nursingOutcome oriented —nurses and patients work togetherto identify outcomesUniversally applicable —a framework for all nursingactivities
Characteristics of the Nursing Process(Continued)
It is a GOSH approach for efficient and effective provisionof nursing care.
G oal-orientedO –rganizedS –ystematicH –umanisticcare
Problem solving and the Nursing Process
Trial-and-error problem solvingScientific problem solvingIntuitive thinkingCritical thinking
Joannes Paulus T. Hernandez, B.S.H.B.,B.S.N., R.N.2
Benefits of the Nursing Process
Scientifically based, holistic individualized patientcareContinuity of careClear, efficient, cost-effective plan of action
Opportunity to work collaboratively with otherhealthcare workersSatisfaction of making a difference in lives of patientsOpportunity to grow professionally
Five Steps of the Nursing ProcessFive Steps of the Nursing Process
Assessing —collecting, validating and communicating of patient dataDiagnosing —analyzing patient data to identify patientstrengths and problemsPlanning —specifying patient outcomes and relatednursing interventionsImplementing —carrying out the plan of careEvaluating —measuring extent to which patient achievedoutcomes
Overview of the Five Steps of the Nursing Process:ASSESSINGOverview of the Five Steps of the Nursing Process:ASSESSING
It is the systematic and continuous collection, validation, and communication of client data ascompared to standard.
1. Collection of data2. Validation of data data confirmation/comparing to standards3. Organizing data4. Analyzing data5. Recording/documentation of data
Types of data:
1.Subjective data (symptoms) –described by person experiencing it2. Objective data (signs) –can be observed and measured
Sources of data:
1. Primary Data data directly gathered from the client2. Secondary data –data gathered from client’s significant others, client’smedical records, patient’s chart, other members of the health team, andrelated health care literature
Methods of collecting data:
1.Interview –a planned communication with the client2. Observation –the use of five senses and instruments3. Physical Assessment –assessment for objective data and is focused primarilyon the client’s functional abilities
Assessing is primarily focused on the client’s response to health problem.
Four Types of Nursing Assessments
Comprehensive initialFocusedEmergencyTime-lapsed
Joannes Paulus T. Hernandez, B.S.H.B.,B.S.N., R.N.3
Comprehensive Initial Assessment
Performed shortly after admittance to hospitalPerformed to establish a complete database for problemidentification and care planningPerformed by the nurse to collect data on all aspects of patient’s health
Focused Assessment
May be performed during initial assessment or as routineongoing data collectionPerformed to gather data about a specific problemalready identified, or to identify new or overlookedproblemsPerformed by the nurse to collect data about the specificproblem
Emergency Assessment
Performed when a physiologic or psychological crisispresentsPerformed to identify life-threatening problemsPerformed by the nurse to gather data about the life-threatening problem
Time-Lapsed Assessment
Performed to compare a patient’s current status tobaseline data obtained earlierPerformed to reassess health status and make necessaryrevisions in plan of care.Performed by the nurse to collect data about currenthealth status of patient
Establishing Assessment Priorities
Health orientationDevelopmental stageNeed for nursing
Medical vs. Nursing Assessments
Medical assessmentsTarget data pointing to pathologic conditionsNursing assessmentsFocus on the patient’s response to health problems

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