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Chapter 09 (5)

Chapter 09 (5)

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Published by Sujith Kuttan

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Published by: Sujith Kuttan on Jul 30, 2011
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Basic Nursing: Foundations of Skills & Concepts Chapter 9 NURSING PROCESS

The Nursing Process 

A systematic method of providing care to clients.

 Implementation.  .  Evaluation.  Planning and outcome identification.  Diagnosis.The 5-Step Nursing Process Assessment.

Assessment or Data Collection       The first step in the nursing process involves the following: Collecting data. Validating data. Documenting data . Organizing data. Interpreting data.

and emotional health.Purpose of Assessment  To establish a database concerning a client¶s physical. psychosocial.  To identify health-promoting behaviors as well as actual and/or potential health problems. .

Focused .Includes systematic monitoring and observation related to specific problems.   .Provides baseline data including complete health history and current needs assessment. Ongoing .Limited in scope in order to focus on a particular need or concern or potential risk.Types of Assessment  Comprehensive .

Sources of Data  Primary Source: The client.  . Secondary Source: The client¶s family members. and medical records. other health care providers.

Collected by the interview. Includes feelings. Objective: Also called signs. perceptions.Types of Data  Subjective: Data from client¶s (and sometimes family¶s) point of view. and concerns.  . Observable and measurable data obtained through physical examination and laboratory and diagnostic testing.

.Validating Data  Validation prevents omissions. and incorrect inferences and conclusions. misunderstandings.

Organizing Data  Collected information must be organized to be useful.  Data Clustering is a useful tool to identify issues. .

Interpreting Data Three critical components:  Distinguishing between relevant and irrelevant data  Determining whether and where there are gaps in the data  Identifying patterns of cause and effect .

.  Accurate and complete recording of assessment data is essential for communicating information to health care team.Documenting Data  Assessment data must be recorded and reported.

or community responses to actual or potential health problems/life processes. A nursing diagnosis is a clinical judgment about individual.Diagnosis  A medical diagnosis is a clinical judgment by the physician that determines a specific disease. condition or pathological state.  . family.

what are the possible sources of further data? . what are the specific problems? What are some possible causes? Is there a situation involving risk factors? What are the risk factors? What are the client¶s strengths? What data are available to answer these questions? Is more data needed? If so.Nursing Diagnosis Questions          Are there problems here? If so.

And the etiology .Nursing Diagnosis is a Two-Part Statement  A problem statement or diagnostic label that describes the client¶s response to an actual or potential health problem or wellness condition.  .the related cause or contributor to the problem.

Also includes defining characteristics.  . also known as signs and symptoms. the collected data.Nursing Diagnosis is a Three-Part Statement  Includes first two parts of Two-Part Statement: the diagnostic label and the etiology. subjective and objective data. and clinical manifestations.

Types of Nursing Diagnosis  Actual nursing diagnosis: A problem exists. Risk nursing diagnosis: A problem does not yet exist. but special risk factors are present. and signs and symptoms. it is composed of the diagnostic label. Wellness nursing diagnosis: Indicates client¶s desire to attain higher level of wellness in some area of function. related factors.   .

.Planning and Outcome Identification  Planning combines with outcome identification to comprise the third step of the nursing process.

Three Phases of Planning  Initial Planning: developing a preliminary plan of care by the nurse who performs the admission assessment.   . Ongoing Planning: continuous updating of client¶s plan of care. Discharge Planning: Involves critical anticipation and planning for client¶s needs after discharge.

   . Developing specific nursing interventions. Identifying and writing client-centered long.Tasks Involved with Planning  Prioritizing list of nursing diagnoses.and short-term goals and outcomes. Recording entire nursing plan in client¶s record.

.Intervention  A nursing intervention is an action performed by the nurse that helps the client achieve the results specified by the goals and expected outcomes.

Categories of Nursing Interventions  Independent: Actions initiated by nurse that do not require direction or an order from another health care professional Interdependent: Actions implemented in collaborative manner by nurse in conjunction with other health care professionals Dependent: Actions that require an order from a physician or other health care professional.   .

A standardized intervention written. Protocol . Standing order .written by physician or nurse especially for an individual client.   .A series of standing orders or procedures.Types of Nursing Interventions  Specific order . approved and signed by a physician that is kept on file to be used in predictable situations or in circumstances requiring immediate attention.

Protocol: A series of standing orders or procedures . approved and signed by a physician that is kept on file to be used in predictable situations or in circumstances requiring immediate attention.Types of Nursing Interventions    Specific order: written by physician or nurse especially for an individual client Standing order: A standardized intervention written.

.The Nursing Care Plan  A written guide that organizes data about a client¶s care into a formal statement of the strategies that will be implemented to help the client achieve optimal health.

Implementation  This fourth step of the nursing process involves the execution of the nursing care plan derived during the Planning phase. .

partially met. .Evaluation  This fifth step of the nursing process. or not met. determining whether client goals have been met.

.Nursing Audit  The process of collecting and analyzing data to evaluate the effectiveness of nursing interventions.

problem-solving.  These skills can be learned! . and decisionmaking are important in the use of the nursing process.The Nursing Process is Critical Thinking  Critical thinking.

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