Nursing Process Lecture Notes PDF

Lecture #1 First semester Nursing Process :by lecturer Ameer Mahmood Abdulabbas M.S.N The nursing process...

Lecture #1 First semester Nursing Process :by lecturer Ameer Mahmood Abdulabbas M.S.N The nursing process ⚫ Is a deliberate problem-solving approach for meeting people’s health care and nursing needs. ⚫ Although the steps of the nursing process have been stated in various ways by different writers, the common components cited are assessment, diagnosis, planning, implementation, and evaluation (2017). 1  1- Assessment The first step in the nursing process that include systematic collection of data through interview, observation, and examination to determine the patient’s health status as well as any actual or potential health problems Types of assessment  Data base assessment – ⚫ comprehensive information you gather on initial contact with the person to assess all aspects of health status.  Focus assessment – ⚫ the data you gather to determine the status of a specific condition. Emergency assessment: the data you gather to determine the threatening status of a specific condition related to C AB system. Ongoing assessment or (follow-up ) Data gathering extended to the client discharge to maintain his health condition 2  Data collection ⚫ Data collection Is the process of gathering information about client health status. ⚫ The collection of patient data is vital steps in nursing process because the remaining steps depend on these steps. Characteristic of data: ⚫ Complete. ⚫ Accurate ⚫ Relevant. Data collection ⚫Sources of Data  Primary source: Client  Secondary source: Client’s family, reports, test results, information in current and past medical records. ⚫ Types of data  Subjective data: (symptoms, covert data), the client only client can be described. Such as itching,pain,feeling, I feel weak all over.  Objective data:referred to as (signs or overt data) are detectable by observe or can be measured,it can be seen, heard. ⚫ Example Blood pressure reading, pulse, redness, cyanosis. ⚫ Blood pressure:90/50 mmHg. 3  Methods of Data Collection 1. Observation 2. Interview – Notes the general appearance – Preparation and behavior of the client – Stages – Helps to determine the client’s Introduction status, both physical and Working Closure mental Methods of Data Collection 4. Physical examination Assessment techniques – Inspection – Palpation – Percussion – Auscultation 5. Laboratory and diagnostic data 4  Subjective Data A. Biographical data 6. Occupation (worker, officer, (demographical data) gainer( 7. Religion (Muslimism, Jewish, (ID) Christian 1. Name 8. Birth date 2. Age 9. Birth place 3. Gender (male-or-female) 10. Phone number 4. Marital status (married, 11. Phone number of significant single, divorce) person 5. Educational level ( primary, 12. Address secondary, diploma,….) Subjective Data B. Past history C. Present history (pain 1. Previous Illness or Diseases assessment) 2. Previous Surgery 1. C: Characteristics 3. Allergies —> (from food, 2. O: Onset drug) 3. L: Location + Radiation 4. Accident and injury 4. D: Duration 5. Immunization 6. Medication 1. S: Severity (0-10 scale) 7. Previous hospitalization 0-4 mild\ 5-6 moderate\ 7-10 sever 5. P: Pattern 6. A: Association sign and symptom 5  Subjective Data D. Family History (genogram) Diseased Diseased (continued) Subjective Data E. Social History 1. Alcohol Use 10. Hobbies and Leisure 2. Tobacco Use Activities 3. Drug Use 11. Roles and Relationships 4. Sleep 5. Diet 6. Exercise 7. Stress 8. Stress Management 9. Economic Status 6  Subjective Data E. Social History 12. Characteristic Patterns of Daily Living Daly activities (dependent, independent, need assistant) – Bathing – Dressing – Eating – Toileting – Grooming – Drinking – Ambulating 2- Nursing Diagnosis: ⚫ Second step of the Nursing Process that describes clinical judgments about individual, family,or community responses to actual or potential health problems/life processes” that can be managed by independent nursing interventions N A N D A Definition: (North America Nursing DiagnosisAssociate) ⚫ Nursing diagnosis is a clinical judgment about individual, family, or community responses to actual and potential health problems/life processes. 10/8/2022 7 A nursing diagnosis (Nsg Dx) vs A medical diagnosis(MD Dx) ⚫ Within the scope of nursing practice ⚫ Within the scope of medical practice ⚫ Identify responses to actual or ⚫ determines a specific disease, potential health problems/life condition or pathological state. processes. ⚫ Stays the same as long as the ⚫ Can change from day to day disease is present Types of Nursing D iagnoses ⚫ Actual: A problem exists Imbalanced nutrition; less than body requirements RT chronic diarrhea, nausea, and pain AEB height 5’5” weight 105 lbs. ⚫ Risk: A problem does not yet exist Risk for falls RT altered gait and generalized weakness. 8  Components of Nursing Diagnosis It contains three parts: Example: Problem: ⚫ problem ⚫ 1) Identifies unhealthy response ⚫ Etiology ⚫ 2) Indicates what should change ⚫ Sign Ex: Anxiety related to Fear of death Etiology: manifested by patient verbalization. 1) Identifies causative or contributing Ex: Activity intolerance related to obesity factors manifested by body weight 140 KG. ◦ suggests nursing interventions Sign and symptom: redness, cyanosis, loss of appetite. It called PES system. 10/8/2022 1 3 Writing Diagnostic Statements 2 Writing Diagnostic Statements 9  3- Planning Third step of the Nursing Process; That is development of goals and outcomes as well as a plan of care designed to assist the patient in resolving the diagnosed problems and achieving the identified goals and desired outcomes. Planning process: ⚫ Select problem. ⚫ Formulate goal. ⚫ Select nursing intervention. ⚫ Write nursing order. ⚫ Record and modify. 10  Interventions – 3 types ⚫ Independent ( Nurse initiated )- any action the nurse can initiate without direct supervision ⚫ Dependent ( Physician initiated )-nursing actions requiring M D orders ⚫ Collaborative- nursing actions performed jointly with other health care team members 4- Implementation forth step of nursing process, The implementation phase of the nursing process involves carrying out the proposed plan of nursing care.. Process of implementation: ◦ Re-assessing the client. ◦ Determine the nurse need for assistance. ◦ Supervising. ◦ Document the action. 10/8/2022 11  5- Evaluation Final step of the Nursing Process that determine the client progress toward goals achievement and effectiveness of the nursing care plan.  A comparison of client behavior and/or response to the established outcome criteria  Continuous review of the nursing care plan  Examines if nursing interventions are working  Determines changes needed to help client reach stated goals 10/8/2022 12 Case study: ⚫ Mrs.A 23 years old admitted to the hospital,married,the temperature is elevated, productive cough,rapid respiration with difficulty. ⚫ 1) Assessment: V/S are temperature 39.1C, pulse 92 b/m,respiration rate 28 b/m and blood pressure 122/80 mm/hg. nurse observe that Mrs. A is dry skin, her cheeks are flushed, she is experience of chill. ⚫ On chest, auscultation reveals respiratory crackles. 10/8/2022 2) Diagnosis: Ineffective breathing pattern related to accumulation of secretion as manifested by productive cough,rapid respiration with difficulty. 3) Planning: Goal: The patient (S) will able to breath (V) normally (c) within 8 hours (T). Restore effective breathing pattern. Interventions: Deep breathing exercise. Increase fluid intake, Bronchodilator medications. 10/8/2022 13 4) Implementation: Mrs.A agree to practice: Deep breathing exercise q4hrs. Increase the fluid intake. Take bronchodilator medications. 5) Evaluation: (The goal not met) the nurse detects failure of the client to breath normally, the plan modify to reach normal breathing and then reevaluation. 10/8/2022 Thanks For Listening 14