Nursing Process

SERIES OF PLANNED ACTIONS OR OPERATIONS DIRECTED TOWARD A PARTICULAR RESULT OR GOAL.

A SYSTEMATIC, RATIONAL METHOD OF PLANNING AND PROVIDING INDIVIDUALIZED NURSING CARE. ITS PURPOSE IS TO IDENTIFY A CLIENT·S HEALTH STATUS, ACTUAL OR POTENTIAL HEALTH CARE PROBLEMS OR NEEDS, AND TO DELIVER SPECIFIC NURSING INTERVENTIONS TO MEET THOSE NEEDS. IT IS ALSO CYCLICAL. THAT IS, THE COMPONENTS OF THE NURSING PROCESS FOLLOW A LOGICAL SEQUENCE, BUT MORE THAN ONE COMPONENT MAYBE INVOLVED AT ANY ONE TIME.

ASSESSMENT
COLLECTING, ORGANIZING, VALIDATING AND RECORDING DATA ABOUT A CLIENT·S HEALTH STATUS. DATA ARE OBTAINED FROM A VARIETY OF SOURCES AND ARE THE BASIS FOR ACTIONS AND DECISIONS TAKEN IN SUBSEQUENT PHASES. NO CONCLUSIONS ABOUT THE DATA ARE DRAWN IN THIS PHASE.

DIAGNOSING
A PROCESS WHICH RESULTS IN A DIAGNOSTIC STATEMENT OR NURSING DIAGNOSIS. IN THIS PHASE, THE NURSE SORTS, CLUSTERS, AND ANALYZES THE DATA AND ASKS, ´WHAT ARE THE ACTUAL AND POTENTIAL HEALTH PROBLEMS FOR WHICH THE CLIENT NEEDS NURSING ASSISTANCE?µ AND ´WHAT FACTORS CONTRIBUTED TO THIS PROBLEM?µ RESPONSES TO THOSE QUESTIONS ESTABLISH THE NURSING DIAGNOSES.

PLANNING
A I LI N L IN I N AN P I I I AN G AL XP L INI I I N I I LI N . IN LLA A I N I LI N , N L P P I I N I N A N ING IAGN I . PLANNING P A I A I N A PLAN INA A P I ALL AL A . P

P IN P

I PL
ING ING A I L GA ALI A N N LI N · P P

N ING
I N. N I N, AN A N AN .

N ING A PLAN IN A I PL N A I N P A , P I N ING A I I A AN APP P IA P N ING A PLAN. I P A GI N N A IN LI N

. THE NURSE DETERMINES THE E TENT TO WHICH THE OUTCOMES/ GOALS OF CARE HAVE BEEN ACHIEVED.EVALUATING ASSESSING THE CLIENT·S RESPONSE TO NURSING INTERVENTIONS AND THEN COMPARING THE RESPONSE TO THE GOALS OR OUTCOME CRITERIA WRITTEN IN THE PLANNING PHASE. WHICH MAY INVOLVE CHANGES IN ANY OR ALL OF THE PREVIOUS PHASES OF THE NURSING PROCESS. THE CARE PLAN IS REASSESSED IN THIS PHASE.

EACH PHASE DEPENDS ON THE ACCURACY OF THE PRECEDING PHASE. EVALUATING INVOLVES EXAMINATION OF ALL PREVIOUS PHASES. ASSESSING DIAGNOSING PLANNING IMPLEMENTING EVALUATION .

It requires the nurse to communicate directly and consistently with clients to meet their needs. family. It is cyclic and dynamic. group or community. there is no absolute beginning or end. It is client centered. Because all steps are interrelated. .The system is open and flexible to meet the unique needs of the client. It is interpersonal and collaborative. it individualizes the approach to each client·s particular needs.

. It is universally applicable. The nursing process is used as a framework for nursing care in all types of health care settings. It emphasizes feedback. which leads either to reassessment of the problem or to revision of the care plan. It permits creativity for the nurse and client in devising ways to solve the stated health problem. with clients of all age groups.It is planned. It is goal directed.

TO ESTABLISH A DATABASE ABOUT THE CLIENT·S RESPONSE TO HEALTH CONCERNS OR ILLNESS AND THE ABILTY TO MANAGE HEALTH CARE NEEDS ESTABLISH A DATABASE * OBTAIN HEALTH HISTORY * CONDUCT PHYSICAL ASSESSMENT * REVIEW CLIENT RECORDS * REVIEW LITERATUIRE * CONSULT SUPPORT PERSONS * CONSULT HEALTH PROFESSIONALS UPDATE DATA AS NEEDED ORGANIZE DATA VALIDATE DATA COMMUNICATE/DOCUMENT DATA .

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OBSERVATION EXAMINING INTERVIEWING .

Gathering data using the five senses« OBSERVATION INTERVIEWING Planned communication or conversation with a purpose to identify problems of mutual concern« Physical examination is a systematic data-collection method that uses observational skills to detect the health problems« EXAMINING .

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. It must be both systematic and continuous to prevent the omission of significant data and reflect a client·s changing health status.Gathering information about a client·s health status.

The patient voices a complaint.SUBJECTIVE DATA Data belong under subjective if« The patient or family member tells the history. . The patient or family member tells about lifestyle or home situation. The patient reports a response to treatment. The patient or family member tells emotions or attitudes. The patient states his or her goals. It is anything that the patient tells which is relevant to his case or present condition.

OBJECTIVE DATA Data belong under objective if« It is part of the patient·s history taken from medical record and relevant to the current problem. S/P fx L Hip prosthesis insertion It is a result of the therapist·s objective measurements or observations. Hx: ASHD. AROM: WNL throughout UEs & LEs except 120° L shoulder flexion noted It is part of the treatment given to a patient. CHF. Tolerated 3 repetitions of ROM exercises of UEs & LEs . COPD.

µ Lung sounds are diminished in the left lower lobe of the lung RR ² 25/min Leans forward .µ ´ I have difficulty breathing.Types of data: SUBJECTIVE DATA OBJECTIVE DATA OBJECTIVE BP ² 90/50 Apical Pulse ² 104 Skin pale and diaphoretic SUBJECTIVE ´ I feel pain at my right knee.

Sources of data: Primary data: patient Secondary data: support people. records and reports. literature . other health professionals.

Using an organized assessment framework. FRAMEWORKS NURSING CONCEPTUAL MODELS WELLNESS MODELS NONNURSING MODELS . often referred to as a nursing history or nursing assessment.

NUTRITIONAL-METABOLIC PATTERN. Describes PATTERN OF FOOD AND FLUID CONSUMPTION RELATIVE TO METABOLIC NEED AND PATTERN INDICATORS OF LOCAL NUTRIENT SUPPLY.NURSING CONCEPTUAL MODELS HEALTH PERCEPTION-HEALTH MANAGEMENT PATTERN. Describes client·s perceived pattern of health and well-being and how health is managed. .

Describes pattern of exercise. Describes patterns of excretory function (bowel. and recreation COGNITIVE-PERCEPTUAL PATTERN. Describes patterns of sleep. SLEEP-REST PATTERN. SELF-PERCEPTION-SELF-CONCEPT PATTERN. Body image. ROLE RELATIONSHIP PATTERN.perceptual and cognitive pattern. body comfort.ELIMINATION PATTERN. Describes the pattern of role-engagements and relationships. feeling state). . Describes sensory. bladder. Describes self-concept pattern and perceptions of self (eg. activity leisure. rest and relaxation. skin) ACTIVITY-EXERCISE PATTERN.

Describes client·s patterns of satisfaction and dissatisfaction with sexuality.SEXUALITY-REPRODUCTIVE PATTERN. Describes patterns of values. COPING-STRESS-TOLERANCE PATTERN. beliefs (including spiritual). or goals that guide choices or decisions. . describes reproductive patterns. VALUE-BELIEF PATTERN. Describes general coping pattern and effectiveness of the pattern in terms of stress tolerance.

The Maintenance of a sufficient intake of food. The Maintenance of a sufficient intake of water. The Maintenance of a balance between activity and rest. The Provision of care associated with elimination processes and increments. 5. 6. 2. 3. The Maintenance of a sufficient intake of air.Universal Self-Care Deficits 1. The Maintenance of a balance between solitude and social interaction . 4.

The promotion of human functioning and development within social groups in accord with human potential. 8.7. . human functioning. and human desire to be normal. and human well-being. The prevention of hazards to human life. known human limitations.

WELLNESS MODELS GENERALLY INCLUDES: ^^^ HEALTH HISTORY^^^ ^^^ PHYSICAL FITNESS EVALUATION^^^ ^^^ NUTRITIONAL ASSESSMENT^^^ ^^^ LIFE-STRESS ANALYSIS^^^ ^^^ LIFE-STYLE AND HEALTH HABITS^^^ ^^^ HEALTH BELIEFS^^^ ^^^ SE UAL HEALTH^^^ ^^^ SPIRITUAL HEALTH^^^ ^^^ RELATIONSHIPS^^^ ^^^ HEALTH RISKS APPRAISALS^^^ .

NONNURSING MODELS BODY SYSTEMS MODEL MASLOW·S HIERARCHY OF NEEDS DEVELOPMENTAL THEORIES .

Physiologic Needs * Activity and rest * Nutrition * Elimination * Fluid and Electrolytes * Oxygenation * Protection * Regulation: temperature * Regulation: the senses * Regulation: endocrine system .1.

2. Role Function 4. Interdependence . Self-concept * Physical Self * Personal Self 3.

.Act of ´double-checkingµ or verifying data (cues) to confirm that they are accurate and factual.

Data are documented in factual manner and are not interpreted by the nurse. .

RISKS AND PROBLEMS FORMULATE NURSING DIAGNOSIS AND COLLABORATIVE PROBLEM STATEMENTS .TO IDENTIFY CLIENT STRENGTHS AND HEALTH PROBLEMS THAT CAN BE PREVENTED OR RESOLVED BY COLLABORATIVE AND INDEPENDENT NURSING INTERVENTIONS INTERPRET & ANALYZE DATA * COMPARE DATA AGAINST STANDARDS * CLUSTER OR GROUP DATA * IDENTIFY GAPS AND INCONSISTENCIES TO DEVELOP A LISTING OF NURSING DIAGNOSES AND COLLABORATIVE PROBLEMS DETERMINE CLIENT·S STRENGTHS.

. FAMILY OR COMMUNITY RESPONSES TO ACTUAL AND POTENTIAL HEALTH PROBLEMS/LIFE PROCESSES.A CLINICAL JUDGEMENT ABOUT INDIVIDUAL. IT PROVIDES THE BASIS FOR SELECTION OF NURSING INTERVENTIONS TO ACHIEVE OUTCOMES FOR WHICH THE NURSE IS ACCOUNTABLE.

REFERS TO DISEASE PROCESSES THAT ARE FAIRLY UNIFORM FROM ONE CLIENT TO ANOTHER. SOCIOCULTURAL.STATEMENT OF NURSING JUDGMENT AND REFERS TO A CONDITION THAT NURSES ARE LICENSED TO TREAT. MADE BY THE PHYSICIAN AND REFERS TO A CONDITION ONLY A PHYSICIAN CAN TREAT. . PSYCHOLOGIC AND SPIRITUAL RESPONSES TO AN ILLNESS OR POTENTIAL HEALTH PROBLEM. DECRIBES A CLIENT·S PHYSICAL.

PROBLEM STATEMENT (DIAGNOSTIC LABEL) ETIOLOGY (RELATED FACTORS & RISK FACTORS) DEFINING CHARACTERISTICS .

1. PROBLEM (P) --. SIGNS & SYMPTOMS (S) --.FACTORS CONTRIBUTING TO OR PROBABLE CAUSES OF THE RESPONSE 3.DEFINING CHARACTERISTICS MANIFESTED BY THE CLIENT ´Activity Intolerance / related to / S prolonged P E bed rest / as manifested by / body weakness and fatigueµ .STATEMENT OF THE CLIENT¶S RESPONSES 2. ETIOLOGY (E) --.

pain / associated with / abdominal incision / as manifested by / muscle guarding and grimaceµ ´Altered thermoregulation.´Alteration in comfort. / related to infection / as manifested by / high grade fever and excessive perspirationµ .

TO DEVELOP AN INDIVIDUALIZED CARE SET PRIORITIES AND GOALS/OUTCOMES IN PLAN THAT SPECIFIES CLIENT COLLABORATION WITH THE CLIENT GOALS/EXPECTED OUTCOMES AND WRITE GOALS/OUTCOME CRITERIA RELATED NURSING INTERVENTIONS SELECT NURSING STRATEGIES/INTERVENTIONS CONSULT OTHER HEALTH PROFESSIONALS WRITE NURSING ORDERS AND NURSING CARE PLAN COMMUNICATE CARE PLAN TO RELEVANT HEALTH CARE PROVIDERS .

TO ASSIST THE CLIENT TO MEET DESIRED GOALS/OUTCOMES. PREVENT ILLNESS AND DISEASE. AND FACILITATE COPING WITH HEALTH PROBLEMS. PROMOTE HEALTH AND WELLNESS. REASSESS THE CLIENT TO UPDATE THE DATABASE DETERMINE THE NEED FOR NURSING ASSISTANCE PERFORM OR DELEGATE PLANNED NURSING INTERVENTIONS COMMUNICATE NURSING ACTIONS IMPLEMENTED * DOCUMENT CARE AND CLIENT RESPONSES TO CARE * GIVE VERBAL REPORTS AS NECESSARY .

TO DETERMINE THE EXTENT TO WHICH CLIENT GOALS/OUTCOMES HAVE BEEN ACHIEVED AND TO DETERMINE WHETHER TO CONTINUE. MODIFY OR TERMINATE THE PLAN OF CARE COLLABORATE WITH THE CLIENT AND COLLECT DATA RELATED TO EXPECTED OUTCOMES JUDGE WHETHER GOALS/OUTCOMES HAVE BEEN ACHIEVED RELATE NURSING ACTIONS TO CLIENT OUTCOMES MAKE DECISIONS ABOUT PROBLEM STATUS REVIEW AND MODIFY THE CARE PLAN AS INDICATED OR TERMINATE NURSING CARE .

R. GOALS (JUSTIFIES THE USE OF OF CARE) THE NURSING DIAGNOSIS) INTERVENTION/ IMPLEMENTATION (PRIORITIZED) RATIONALE (JUSTIFIES THE USE OF THE NURSING DIAGNOSIS) EVALUATION (EXAMINES THE PREVIOUS PHASES) .A.M.CUES (Subjective and objective cues) NURSING DIAGNOSIS (Using NANDA list) RATIONALE E PECTED OUTCOME (S.T.

6°C Ate two full meals. no leftovers Was able to take a bath. move around Appeared cheerful and conversant Subjective: ³I have been feeling so weak and exhausted for the last four days´ ‡ Decreased appetite. have eaten only small amounts during meal time Objective: Temp = 38 °C ‡Pulse = 85/min Invasion of the body by the Corona virus compromised the body¶s immune system as it attacks the respiratory system. The body attempts to get rid of these microorganisms by releasing pyrogens causing the elevation of body temperature TSB small frequent feedings.CUES NURSING DIAGNOS IS Altered thermoreg ulation related to infection RATIONALE EXPECTED OUTCOMES At the end of 8 hours nursing intervention.5°C ‡Eat at least 3 times during the day in satisfactory amounts ‡Resume ADL¶s ‡Have INTERVE NTIONS ‡Perform RATIONA LE TSB lowers down body temperatur e ‡Gradually EVALUATI ON Afebrile ± 37. then gradually increase ‡Give increasing the intake will promote tolerance of foods help lower down body temperatur e ‡Promoting ‡Fluids ‡Encourage increased fluid intake ‡Loosen clothings airflow assist in lowering body temperatur e . the patient will be able to: lowered temp to 37 37.

CUES NURSING DIAGNOSIS RATIONALE EXPECTED OUTCOMES INTERVE NTIONS RATIONA LE EVALUATI ON flushed face ‡ diaphoretic ‡ teary-eyed ‡ ‡Provide ventilation but kept on isolation * Isolation prevents spread of the virus thereby minimizing contaminati on .

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