Nursing Process (Unit#01) PDF

Nursing Process ABIDA RAZZAQ  Objectives  At the end of the presentation students will be able to : 1. Define nursing process. 2. Describe the purposes of nursing process. 3. Identify the components of the nursing process 4. Discuss the requirements for effective use of th...

Nursing Process ABIDA RAZZAQ  Objectives  At the end of the presentation students will be able to : 1. Define nursing process. 2. Describe the purposes of nursing process. 3. Identify the components of the nursing process 4. Discuss the requirements for effective use of the nursing process 5. Describe the functional health approach to the nursing process 2 ABIDA RAZZAQ  Definition  Systematic, rational method of planning and providing individualized nursing care.  OR  Specific to the nursing profession and a framework for critical thinking. 3 ABIDA RAZZAQ Nursing Process  Organized framework to guide practice  Problem solving method - client focused  Systematic- sequential steps  Goal oriented- outcome criteria  Dynamic-always changing, flexible  Utilizes critical thinking processes 4 ABIDA RAZZAQ  Purposes “Diagnose and treat human responses to actual or potential health problems”.  To Achieve Scientifically- Based, Holistic, Individualized Care For The Client.  To Achieve The Opportunity To Work Collaboratively With Clients, Others 5 ABIDA RAZZAQ  Conti…  To Achieve Continuity Of Care ABIDA RAZZAQ  Advantages of Nursing Process  Provides individualized care  Develops a clear and efficient  Client is an active plan of care participant  Provides personal satisfaction  Promotes continuity of care as you see client achieve goals  Provides more effective  Professional growth as you communication among nurses evaluate effectiveness of your and healthcare professionals interventions ABIDA RAZZAQ   First step of the Nursing Process  Gather Information/Collect Data Assessment  Primary Source - Client / Family  Secondary Source - physical exam, nursing history, team members, lab reports, diagnostic tests….. ABIDA RAZZAQ  Conti…  Subjective -from the client (symptom) “I have a headache”  Objective - observable data (sign) Blood Pressure 130/80 ABIDA RAZZAQ Assessment-collecting data  Nursing Interview (history)  Health Assessment -Review of Systems  Physical Exam  Inspection  Palpation  Percussion  Auscultation ABIDA RAZZAQ  Assessment-collecting data  Make sure information is complete & accurate  Validate prn  Interpret and analyze data Compare to “standard norms”  Organize and cluster data ABIDA RAZZAQ  Example of Assessment  Obtain info from nursing assessment, history and physical (H&P) etc…...  Client diagnosed with hypertension B/P 160/90, 2 Gm Na diet and antihypertensive medications were prescribed  Client statement “ I really don’t watch my salt” “ It’s hard to justify and I just don’t get it” ABIDA RAZZAQ  Second step of the Nursing Process Nursing  Interpret & analyze clustered data Diagnosis  Identify client’s problems and strengths  Formulate Nursing Diagnosis (NANDA : North American Nursing Diagnosis Association)- Statement of how the client is RESPONDING to an actual or potential problem that requires nursing intervention ABIDA RAZZAQ  Medical Nsg Dx Dx Within the scope of Within the scope of nursing practice medical practice Identify responses Focuses on curing to health and illness pathology Stays the same as Can change from long as the disease is day to day present ABIDA RAZZAQ ABIDA RAZZAQ NURSING DIAGNOSIS TAXONOMY II. Taxonomy II for nursing diagnosis contains 13 domains and 47 classes. ABIDA RAZZAQ Nursing Diagnosis ABIDA RAZZAQ  Some more example of Nursing Dx  "Ineffective airway clearance related to gastroesophageal reflux as evidenced by retching, upper airway congestion, and persistent coughing.“  "Ineffective breathing patterns related to pulmonary hypoplasia as evidenced by tachypnea, abdominal breathing, and SPO2