Nursing Diagnosis Process PDF

1-Assessment:- Definitions: \> Is collecting, organizing, validating and recording data about patient\'s health status. 2-Definition ofN.D. NANDA (1990) North American Nursing Diagnosis Association: Nursing diagnosis is a clinical judgment about individual, family, or community response to actu...

1-Assessment:- Definitions: \> Is collecting, organizing, validating and recording data about patient\'s health status. 2-Definition ofN.D. NANDA (1990) North American Nursing Diagnosis Association: Nursing diagnosis is a clinical judgment about individual, family, or community response to actual and potential health problems\\ life processes. 3-3rd Step Planning Planning is based on patient\'s health care needs, Uselected goals, and Ustrategies achievement. directed toward goal alt is a plan of care where the appropriate nursing actions, and patient\'s desires are considered and choose to achieve goal. 4-4Th Step Implementation Is the phase in which the nurse puts nursing care plan into action. Implementation refers to carrying out the proposed plan of care. 5-Evaluating is a planned, ongoing purposeful activity, in which patients and health care professionals determine: The patient\'s progress toward goal achievement. V The effectiveness of the nursing care plan. Objective 2....... Systematic The nursing process has an ordered sequence of activities and each activity depends on the accuracy of the activity that precedes it and influences the activity following it. B.Dynamic \" The nursing process has great interaction and overlapping among the activities and each activity is fluid and flows into the next activity C.Interpersonal The nursing process ensures that nurses are client-centered rather than task- centered and encourages them to work to enhance client\'s strengths and meet human needs D.Goal-directed Thenursingprocess is ameans for nurses and clients to work together to identify specific goals (wellness promotion, disease and illness prevention, health restoration, coping and altered functioning) that are most important to the client, and to match them with the appropriate nursing actions E. Universally applicable The nursing process allows nurses to practice nursing with well or ill people,youngo rold,i nanytypeo fpracticesetting Objective 3 The Two-Part Statement The components of a nursing diagnosis typically consist of two parts. diagnostic label; The first component is aproblem statement. The diagnostic label is the name of the nursing diagnosis as listed in the NANDA The etiology; The second component of a two-part nursing diagnosis is related cause or contributorto the problem. The diagnostic label and etiology are linked by the term relatedto(RT). Examples of nursing diagnoses are Disturbed Body Image RT loss of left lower extremity Activity Intolerance RT decreased oxygen-carrying capacity of cells. 0-(4) Types of data: Objective data: observed Signs (over weight, hypertension, irregular pulse, pressure ulcer,\...), measured, and verified. The measurement is based on accepted standard (e.g. thermometer, Ht &Wt &BP., V/S). \"Subjective data: Symptoms that the patient describes; feelings of anxiety, patient physical discomfort, (e.g. frequency, complain f r o m pain, duration, location.). It is difficult to measure. O-(5) Sources ofData -1 Primary source: The patient is the primary source of data. -2 Secondary source: Family members or other other health support persons, professionals, records and reports, and laboratory and diagnostic analyses, relevant literatures are secondary sources. O-(6) Inspection: Is the visual examination the inspection begins with the nurse\'s first contact with the patient and continues through the nursing history. 2\. Palpation: Palpation is the examination of the body using the sense of touch. Percussion: Is the tapping of the body\'s surface to produce sounds can be heard or vibrations can be felt. 4\. Auscultation: Auscultation is the process of listening to sound produced within the body. O-(7)