Lecture 2 Nursing Process PDF

Lecture 2 Nursing Process Dr. Sabah Jaafar  Learning objective: At the end of lecture: Explain the purpose and significance of each step in providing patient care. Identify different types of nursing diagnoses (e.g., actual, risk, wellness). Describe the components of a we...

Lecture 2 Nursing Process Dr. Sabah Jaafar  Learning objective: At the end of lecture: Explain the purpose and significance of each step in providing patient care. Identify different types of nursing diagnoses (e.g., actual, risk, wellness). Describe the components of a well-written nursing diagnosis. List various types of nursing interventions and their purposes. Construct nursing process.  Nursing process A systematic method of providing care to clients.  ‫فوائد العملية التمريضية‬ ‫‪ -1‬هي طريقة منظمة لحل مشكالت المريض ‬ ‫‪ -2‬تسهل عملية التواصل بين مقدمي الرعاية الصحية ‬ ‫‪-3‬تقديم نوعية متميزة من الخدمة الخاصة الشاملة لكل مريض ‬ ‫‪-4‬يمكن استخدامها الغراض البحث العلمي ‬ ‫‪ -5‬توفر الوقت والجهد ‬ The 5 step nursing process A@ *Assessment B@ *Diagnosis C@ *Planning D@ *Implementation E@ *Evaluation Assessment or Data collection 1-Collecting data ‫جمع المعلومات‬ 2-Validating data ‫التحقيق من صحة المعلومات‬ 3-Organizing data ‫تصنيف المعلومات‬ 4-Interpreting data ‫تفسير وتحليل المعلومات‬ 5-Documenting data ‫توثيق وتدوين المعلومات‬  ‫نشاط‬ ‫امسح الباركود واجب عن السؤال التالي‪:‬‬  Purpose of assessment To establish a data base concerning a client’s physical, psychosocial and emotional health. To identify health promotion behaviors as well as actual and /or potential health problems  Type of assessment *Comprehensive – provides baseline data including complete health history and current needs assessment.)‫التقيم الشامل(تاريخ الصحي الكامل‬ *Focused – limited in scope in order to focus on a particular or concern or potential risk. ‫التقيم‬ )‫المركز(يكون محدد ويتركز على حاجة معينه‬ *Ongoing – includes systematic monitoring and observation related to specific problems. ‫القيم المستمر (يتضمن المراقبة المستمرةويتعلق بمشكلة معينة‬  Source of data *Primary source :the client. *Secondary source : the client’s family members, other health care providers , and medical records  Types of data *Subjective data (from client , family) point of view. Includes feelings, perceptions and concerns. collected by the interview. )‫معلومات ذاتية (تاتي من المقابلة‬ *Objective – called signs observable and measurable data obtained through physical examination and laboratory and diagnostic testing.‫معلومات المنظورة‬  2-Validating data Verifies understanding of information Comparison with another source Patient or family member Record Health team member Validation prevents omissions ,misunderstandings , incorrect inferences and conclusions  3- Organizing data *Collected information must be organized to be useful.‫المعلومات المنظمه يمكن تنظيمها بسهولة‬ *Data clustering is a useful tool to identify issues. ‫تجمع البيانات اداة مفيدة للتعريف‬  4- Interpreting data Process of inferential reasoning and judgment (critical thinking) ‫عملية تفكر وحكم استنتاجي وتحليل معلومات‬ *interpretation of what information is relevant to present status. ‫تفسير المعلومات ذات العالقة بالحالة‬ *summary of data ‫تلخيص المعلومات‬ *provides focus for nursing attention ‫تزود بالقوة‬ Three critical components ‫ثالثة مكونات حرجة‬ 1- distinguishing between relevant and irrelevant data ‫تميز المعلومات ذات العالقة وغير ذات العالقة‬ 2- determining whether and where there are gaps in the data ‫لتحديد هل هنالك فجوات في البيانات‬ 3- identifying patterns of cause and effect ‫لتعريف انماط االسباب والمؤثرات‬  5- Documenting data *Assessment data must be recorded and reported‫تقيم المعلومات يجب ان يسجل ويوثق‬ *Accurate and complete recording of assessment data is essential for communicating information to health care team  B@ *Diagnosis *A medical diagnosis is a clinical judgment by the physician that determines a specific disease, condition or pathological state. *A nursing diagnosis is a clinical judgment about individual, family , or community responses to actual or potential health problems/ life processes  Nursing diagnosis A nursing diagnosis is written in a format called “PES” developed by NANDA. “P” stands for Problem. “E” stands for Etiology or cause of problem. “S” stands Signs and Symptoms of problem. By using all of the components of the nursing diagnosis , the problem is clearly communicated to everyone in the clients care.  Types of nursing diagnosis *Actual nursing diagnosis: A problem exists; it is composed of the diagnostic label , related factors and signs and symptoms. *Risk nursing diagnosis: a problem does not yet exist , but special risk factors are present. *Wellness nursing diagnosis: indicates client’s desire to attain higher level of wellness in some area of function.  Measurement criteria of nursing diagnosis Diagnosis are derived from the assessment data. Diagnosis is validated with the client. Diagnosis is documented to aid in the expected outcomes and plan of care.  Examples: Ineffective breathing patterns related to airway obstruction as evidenced by increased respiratory rate, use of accessory muscles, and audible wheezing. In this example: Label: Ineffective breathing patterns Etiology: related to airway obstruction Defining characteristics: increased respiratory rate, use of accessory muscles, and audible wheezing  3@ * planning Planning combines with outcome identification to comprise the third step of the nursing process. There are three phases of planning 1- initial planning developing a preliminary plan of care by the nurse who performs the admission assessment. 2-Ongoing planning: continuous updating of client’s plan of care 3-Discharge planning: involves critical anticipation and planning for client’s needs after discharge.  Measurement criteria of planning 1– the plan is individualized to the client’s condition. 2- the plan is developed with the client’s and significant others if appropriate. 3-The plan reflects current nursing practice 4-The plan is documented 5-The plan provides for continuity of care  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. There are three type of nursing intervention 1-Specific order written by physician 2-Standing order 3-Protocol ‘’ a series of standing orders or procedures’’  Implementation This fourth step of the nursing process involves the execution of the nursing care plan derived during the planning phase  Examples of Nursing Implementation Supervise the patient performing active range- of-motion exercises three times a day. Administer sublingual nitroglycerin as prescribed to the patient who complains of angina. Change patient position who complains loss of Concioussness  Evaluation the final step of the nursing process, allows the nurse to determine the patient’s response to the nursing interventions and the extent to which the objectives have been achieved. The plan of nursing care is the basis for evaluation.  Example of Evaluation Example 1: Patient with Impaired Skin Integrity Goal: Prevent skin breakdown. Evaluation: Patient demonstrates intact skin without any signs of redness, warmth, or breakdown. Example 2: Patient with Ineffective Breathing Patterns Goal: Improve oxygenation. Evaluation: Patient's oxygen saturation remains above 95% on room air. Example 3: Patient with Impaired Mobility Goal: Increase range of motion in affected joints. Evaluation: Patient is able to perform active range of motion exercises with minimal discomfort.  Example 4: Patient with Anxiety Goal: Reduce anxiety levels. Evaluation: Patient reports decreased anxiety symptoms and is able to participate in activities without excessive distress. Example 5: Patient with Deficient Knowledge Goal: Improve knowledge of diabetes management. Evaluation: Patient accurately demonstrates blood glucose monitoring and can identify signs and symptoms of hypoglycemia and hyperglycemia.  Summary Assessment –the nurse collects client’s health data Diagnosis –the nurse analyzes assessment data and determines diagnosis Outcome identification –the nurse identify expected outcomes individualized to the patient Planning –the nurse develops a plan of care the prescribes interventions to attain expected outcomes Implementation – the implements the intervention identified in the plan of care. Evaluation –the nurse evaluates the patient progress toward attainment of outcomes.  Task Lecture 2 Write the steps of the nursing process for specific disease you are choose?