NURSING PROCESS

PREPARED BY: WISAM SALIM

Nursing Process
Definition:
Is a systematic, rational method of planning and providing individualized nursing care.

Purpose of Nursing Process:
1-Identify a client health status and actual or potential health care problems and needs. 2-Establish plans to meet the identifying needs. 3-Deliver specific nursing intervention to meet needs.

NURSING PROCESS:  An organizational framework for the practice of nursing  Orderly. systematic  Central to all nursing care  Encompasses all steps taken by the nurse in caring for a patient .

Benefits of Nursing Process  Provides an orderly & systematic method for planning & providing care  Enhances nursing efficiency by standardizing nursing practice  Facilitates documentation of care  Provides a unity of language for the nursing profession  Is economical  Stresses the independent function of nurses  Increases care quality through the use of deliberate actions .

4.Planning. .The five phases of the nursing process are not discrete entities but overlapping. 2.Implementing.Evaluating. continuing sub process.Assessing. 5.Diagnosis. .The Nursing Process consist of a series of five component or phases: 1. 3.

universally applicable. client centered.Nursing Process:  characteristic of nursing process:      It It It It It is is is is is cyclic and dynamic. . planned. goal directed.

II. organization. validation and documentation of data.Assessment: 1-Assessing: Is a systematic and continuous collection. III.Collecting data. .Validating data.Organizing data. The assessment process involve four closely activities: I.Nursing assessment focus upon client's responses to a health problem.Documenting data. IV. .

e.g itching. vital organ. lungs sounds.felt.Objective data( signs): that can be seen heard.lecture. vomited 100ml. feelings.g discoloration.or smelled. * Source of data: a. e. II.Assessment: Collecting Data: Is the process of gathering information about clients. . b. c. pain.client. and health status.Health care d.Support people f.subjective data (symptoms): these data that can be described or verified only by that person.by observation and physical examination. * Types of data: I.Client records. stress. professionals.

Observing: it is gather data by using the five senses.Assessment: Data collection methods: I. II.Interviewing. .

.g.Nursing Diagnosis: Nursing Diagnosis: is a clinical judgment about individual. and is based on the presence of associated signs and symptoms. 2.An actual diagnosis: is a client problem that is present at the time of nursing assessment. but the presence of risk factors indicate that a problem is likely to develop unless nurses intervention. family or community responses to actual and potential health problems/life processes. e. Types of nursing diagnosis: 1. risk for infection.A risk nursing diagnosis: is a clinical judgment that a problem does not exit.

altered . e. Knowledge deficit. chronic. decrease. 3.g. Ineffective breathing pattern 2-Etiology :( related factor and risk factor): identifies one or more probable causes of the health problem.Problem: ( diagnostic lable ) There are words that have been added to some NANDA label to give additional meaning. impaired .Nursing Diagnosis: Component of NANDA nursing diagnosis: I.Basic tow or three-part statement: 1. ineffective.Defining characteristics: .Are cluster of sign and symptoms that indicate the presence of a particular diagnostic label. . acute .

risks and strengths.Analyzing data. 2.Identifying health problem.Nursing Diagnosis: Nursing Diagnosis process: 1. 3.Formulating diagnostic statement. .

Effective Breastfeeding. Death Aspiration. Risk for Blood Glucose. Chronic Constipation Constipation. Risk for Coping: Community. Parent/Infant/Child. Decreased Caregiver Role Strain Caregiver Role Strain. Interrupted Breathing Pattern. Risk for Bowel Incontinence Breastfeeding. Acute Confusion. Ineffective Coping: Community. Disturbed Body Temperature: Imbalanced. Ineffective Anxiety Anxiety. Verbal Communication. Readiness for Enhanced Coping. Risk for Impaired Autonomic Dysreflexia Autonomic Dysreflexia. Ineffective Breastfeeding. Perceived Constipation. Defensive . Risk for Comfort. Readiness for Enhanced Communication: Impaired. Risk for Confusion. Risk for Unstable Body Image. Acute. Risk for Contamination Contamination. Readiness for Enhanced Confusion. Risk for Airway Clearance. Risk for Attachment. Ineffective Cardiac Output.APPENDIX C 2007–2008 NANDA-Approved Nursing Diagnoses                                    Activity Intolerance Activity Intolerance.

Disabled Coping: Family.APPENDIX C 2007–2008 NANDA-Approved Nursing Diagnoses                             Coping: Family. Ineffective Decisional Conflict Decision Making. Adult Falls. Impaired . Impaired Development: Delayed. Dysfunctional: Alcoholism Family Processes. Readiness for Enhanced Fatigue Fear Fluid Balance. Ineffective Dentition. Interrupted Family Processes. Compromised Coping: Family. Deficient. Readiness for Enhanced Coping. Risk for Diversional Activity. Deficient Energy Field. Readiness for Enhanced Denial. Deficient Fluid Volume. Risk for Diarrhea Disuse Syndrome. Disturbed Environmental Interpretation Syndrome. Risk for Fluid Volume. Readiness for Enhanced Fluid Volume. Risk for Gas Exchange. Impaired Failure to Thrive. Excess Fluid Volume. Risk for Family Processes. Readiness for Enhanced Coping (Individual). Imbalanced.

Disorganized Infant Behavior: Disorganized. Readiness for Enhanced Hopelessness Human Dignity. Deficient (Specify) Knowledge (Specify). Readiness for Enhanced Latex Allergy Response Latex Allergy Response. Risk for Growth and Development. Risk for Insomnia Intracranial Adaptive Capacity. Delayed Health Behavior. Risk for Compromised Hyperthermia Hypothermia Immunization Status. Risk for Injury. Risk for . Readiness for Enhanced Infant Feeding Pattern. Readiness for Enhanced Infant Behavior. Ineffective Infection. Impaired Hope. Risk for Infant Behavior: Organized. Decreased Knowledge.APPENDIX C 2007–2008 NANDA-Approved Nursing Diagnoses                               Grieving Grieving. Ineffective Health-Seeking Behaviors (Specify) Home Maintenance. Complicated Grieving. Risk for Complicated Growth. Disproportionate. Risk for Liver Function. Risk for Loneliness. Impaired. Risk-Prone Health Maintenance.

Risk for Power. Imbalanced: More than Body Requirements. Impaired Mobility: Physical. Chronic Parenting. Readiness for Enhanced Oral Mucous Membrane. Disturbed Poisoning. Risk for Impaired Perioperative Positioning Injury. Risk for Noncompliance (Specify) Nutrition. Impaired Mobility: Bed. Risk for Nutrition. Readiness for Enhanced Parenting.APPENDIX C 2007–2008 NANDA-Approved Nursing Diagnoses                             Memory. Impaired Mobility: Wheelchair. Impaired Moral Distress Nausea Neurovascular Dysfunction: Peripheral. Imbalanced: More than Body Requirements Nutrition. Impaired Parenting. Readiness for Enhanced Powerlessness . Impaired Pain. Imbalanced: Less than Body Requirements Nutrition. Risk for Post-Trauma Syndrome Post-Trauma Syndrome. Risk for Personal Identity. Acute Pain.

Readiness for Enhanced Self-Esteem. Chronic Low Self-Esteem. Readiness for Enhanced Social Interaction. Ineffective Sedentary Lifestyle Self-Care. Parental Role Performance. Impaired Skin Integrity. Risk for Role Conflict. Ineffective Skin Integrity. Risk for Situational Low Sexual Dysfunction Sexuality Pattern. Situational Low Self-Esteem. Risk for Impaired Sleep Deprivation Sleep. Readiness for Enhanced Self-Care Deficit: Bathing/Hygiene Self-Care Deficit: Dressing/Grooming Self-Care Deficit: Feeding Self-Care Deficit: Toileting Self-Concept.APPENDIX C 2007–2008 NANDA-Approved Nursing Diagnoses                      Powerlessness. Impaired Social Isolation .

Readiness for Enhanced Spontaneous Ventilation. Risk for Suffocation. Ineffective Therapeutic Regimen Management. Overload Sudden Infant Death Syndrome. Risk for Spiritual Well-Being. Renal) . Gastrointestinal. Impaired Therapeutic Regimen Management: Community. Risk for Suicide. Disturbed Tissue Integrity. Ineffective Therapeutic Regimen Management. Ineffective Therapeutic Regimen Management. Readiness for Enhanced Thermoregulation. Risk for Surgical Recovery. Cardiopulmonary.APPENDIX C 2007–2008 NANDA-Approved Nursing Diagnoses                        Spiritual Distress Spiritual Distress. Impaired Tissue Perfusion. Effective Therapeutic Regimen Management: Family. Ineffective (Specify: Cerebral. Impaired Stress. Ineffective Thought Processes. Delayed Swallowing.

Functional Urinary Retention Ventilatory Weaning Response. Total Urinary Incontinence.APPENDIX C 2007–2008 NANDA-Approved Nursing Diagnoses                      APPENDIX C 1531 Tissue Perfusion. Risk for Violence: Self-Directed. Used with permission . Overflow Urinary Incontinence. Philadelphia: North American Nursing Diagnosis Association. Impaired Trauma. Readiness for Enhanced Urinary Incontinence. Stress Urinary Incontinence. Risk for Urge Source: NANDA Nursing Diagnoses: Definitions and Classification. Peripheral Transfer Ability. Reflex Urinary Incontinence. Dysfunctional Violence: Other-Directed. Impaired Wandering Urinary Incontinence. Urge Urinary Incontinence. 2007–2008. Risk for Unilateral Neglect Urinary Elimination. Impaired Urinary Elimination. Risk for Walking. Ineffective.

III.PLANNING Planning: : is a deliberative. . systematic phase of nursing process that involve decision making and problem solving .Ongoing planning: . 2.Initial planning: the nurse who performs the admission assessment usually develops the initial comprehensive plan of care.It is the beginning of shift as the nurse plans the care to be given that day.Discharge planning: The process of anticipating and planning for needs after discharge.Is done by all nurses who work with the client. Types of planning: 1. . 3.

3. . 4.Selecting nursing strategies.Setting priorities. 2.Establishing client goals/desired out comes.Writing nursing orders.Planning: Planning Process: 1.

. e.g.loss of respiratory and cardiac function. low priority.Instead of rank-ordering diagnosis. medium.normal development need or requires minimal nursing support. which second. and so on. . .Low priority------.high priority-----.Planning Process: 1-Setting priorities: Is the process of establishing a preferential order for nursing diagnosis and interventions. nurses can group them as having high.The nurse and client begin planning by deciding which nursing diagnosis requires attention first. coping ability. .Medium priority----.acute illness. . .

c.Enable the client and the nurse to determine when the problem has been resolved.Planning Process: 2.Serve as criteria for evaluating client progress. For those who are frustrated by long-term goals that seem difficult to attain and who need satisfaction of achieving ashortterm goal.Long Term Goals: Are often used for clients who live at home and have a chronic health problem.provide direction for planning nursing interventions b.Establishing client goal/desired out comes: The nurse client set goals for each nursing diagnosis. * Purpose of Goals: a. .Short Term Goals: For a client who require health care for a short time. Types of Goals: a. b.

3.Selecting nursing intervention and activities are actions that nurse performs to a achieve client goals. .The specific strategies chosen should focus on eliminating or reducing the etiology.Independent intervention: are those activities that nurses are licensed to initiate on the basis of their knowledge and skills.Dependent intervention: are activities carried out under the physician orders. Types of Nursing Intervention: 1. 2.Planning Process: .Collaborative intervention: are actions the nurse carries out in collaboration with other health team member. .

Time element. 2.Planning Process: 3. 4. 3.Safe and appropriate for patient.Content area.Action verb. 3.Writing Nursing Orders: * The component of nursing order: 1.Determined by state law. 4.Congruent with other strategies. 5. 4.Choosing nursing strategies: *criteria for choosing nursing strategies: 1.An achievable with the resources available. 2.Signature.Date. .

3.Delegating and Supervising. .Communicating the nursing actions.Determining the nurse need for assistance. * Process of implementing: 1. 4.Implementing the nursing orders( strategies).Reassessing the client. 2. 5.IV-Implementing: Is the phase in which the nurse puts the nursing care plan into action.

The clients progress toward goals an achievement. . .Evaluating: Evaluating: Is to judge or to appraise. 5. ongoing.Draw conclusions about problem status.The effectiveness of the nursing care plan.Relate nursing actions to client goals/desired outcomes.Continue to modify or terminate the clients care plan.Compare the data with desired out comes 4. .evaluating is a planned.Collecting data related to desired out comes. 2. 3. .Identify the desired out comes.V. purposeful activity in which clients and health care professionals determine: * Process of evaluating client responses: 1. 6.

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