NURSING PROCESS

NURSING PROCESSFGV Jaminit, RN, CNN, MADiabetes Care SpecialistHIV/AIDS Counselor

Lecturer, Foundations of NursingPamantasan ng Lungsod ng PasigNursing ProcessAn organizational framework for the practice of nursingAn organized sequence of problem-solving steps used to identify and to manage the health problems of clients

2NCM 100 - Nursing ProcessFGV Jaminit, BSN, RN, CNN, MANursing Process DevtIt is a systematic rational method of planning and providing individualized nursing careLydia Hall, originated the term Nursing Process in 1955. she introduced 3 steps: Note observation, Administration of care, Validation3NCM 100 - Nursing ProcessFGV Jaminit, BSN, RN, CNN, MANursing Process DevtDorothy Johnsons 3 steps Assessment, Decision, Nursing Action (1959)Ida Jean Orlando (1961): clients behavior, nurses reaction, nurses actions4NCM 100 - Nursing ProcessFGV Jaminit, BSN, RN, CNN, MANursing Process DevtWalsh (1967), 4 components: Assessing , Planning, Implementing, EvaluatingKnowles (1967), 5 Ds: Discover, Delve, Decide, Do, Discriminate5NCM 100 - Nursing ProcessFGV Jaminit, BSN, RN, CNN, MANursing Process DevtANA introduced innovations:Diagnosis distinguished as separate step (1973)Diagnosis of actual and potential health problems delineated as integral part of the nursing practice (1980)6NCM 100 - Nursing ProcessFGV Jaminit, BSN, RN, CNN, MANCM 100 - Nursing ProcessFGV Jaminit, BSN, RN, CNN, MA7Characteristics of NPProblem orientedGoal orientedOrderly, planned, step by step, and systematicOpen in accepting new information during its applicationIt is flexible to meet the unique needs of patient8NCM 100 - Nursing ProcessFGV Jaminit, BSN, RN, CNN, MACharacteristics of NPInterpersonal and collaborativePermits creativity among nurses an patientCyclical and dynamicUniversalBeneficial to the nurse and the client9NCM 100 - Nursing ProcessFGV Jaminit, BSN, RN, CNN, MACaseMr. Lucky Chan, 58 year-old male, was admitted at Jaminit Medical Centers Acute and Emergency Department. He is complaining of chest pain with pain score of 8/10. He looks pale and with some DOB upon Examination, oxygen saturation was 89%. 10NCM 100 - Nursing ProcessFGV Jaminit, BSN, RN, CNN, MAASSESSMENTCollecting, validating organizing, and recording data about the patients health statusIts purpose is to establish databaseIn the collection of data, the nurse does not make an interference but forces on establishing a comprehensive database that reflects the health status of the patient

11NCM 100 - Nursing ProcessFGV Jaminit, BSN, RN, CNN, MAASSESSMENTGoal is to establish baselineActivity on assessment: Data Collection12NCM 100 - Nursing ProcessFGV Jaminit, BSN, RN, CNN, MAASSESSMENTSubjectiveObjective13NCM 100 - Nursing ProcessFGV Jaminit, BSN, RN, CNN, MATypes of DataASSESSMENTPrimary SourceSecondary Source14NCM 100 - Nursing ProcessFGV Jaminit, BSN, RN, CNN, MASources of DataASSESSMENTInterviewObservationPhysical Assessment15NCM 100 - Nursing ProcessFGV Jaminit, BSN, RN, CNN, MAMethods of Collecting DataDiagnosingIs a process which results to a diagnostic statement or nursing diagnosisClinical act of identifying problemsAnalyze assessment information and derive meaning from this analysis16NCM 100 - Nursing ProcessFGV Jaminit, BSN, RN, CNN, MADiagnosingGoal is to identify the clients health care needs and to prepare diagnostic statements17NCM 100 - Nursing ProcessFGV Jaminit, BSN, RN, CNN, MADiagnosingIs a statement of clients potential or actual alteration of health statusIt is a clinical judgment about an individual, family, or community in response to actual and potential health problems and life process (NANDA, 1990)

18NCM 100 - Nursing ProcessFGV Jaminit, BSN, RN, CNN, MANursing DiagnosisDiagnosingA statement of a patients potential or actual health problems which nurses, by virtue of their education and experience are capable and licensed to treat (Gordon, 1976)19NCM 100 - Nursing ProcessFGV Jaminit, BSN, RN, CNN, MANursing DiagnosisDiagnosingOrganize cluster or group dataCompare data against standardsAnalyze data after comparing to standardsIdentify gaps and inconsistencies in data

20NCM 100 - Nursing ProcessFGV Jaminit, BSN, RN, CNN, MAActivities during diagnosingDiagnosingDetermine the clients health problems, risks, and strengthsFormulate nursing diagnoses statements (refer to NANDAs list)21NCM 100 - Nursing ProcessFGV Jaminit, BSN, RN, CNN, MAActivities during diagnosingDiagnosingActual nursing diagnosisRisk nursing diagnosisPossible nursing diagnosisSyndrome nursing diagnosisWellness nursing diagnosis

22NCM 100 - Nursing ProcessFGV Jaminit, BSN, RN, CNN, MATypes of Nursing DiagnosesDiagnosingClient problem that is present at the time of the nursing assessment23NCM 100 - Nursing ProcessFGV Jaminit, BSN, RN, CNN, MAActual Nursing DiagnosisDiagnosingA clinical judgment that a problem does not exist, but the presence of risk factors indicates that a problem is likely to develop unless nurses intervene24NCM 100 - Nursing ProcessFGV Jaminit, BSN, RN, CNN, MARisk Nursing DiagnosisDiagnosingEvidence about health problem is unclear or incompleteIt requires more data, either to support or refute it25NCM 100 - Nursing ProcessFGV Jaminit, BSN, RN, CNN, MAPossible Nursing DiagnosisDiagnosingDescribes human responses to levels of wellness in an individual, family, or community that have a readiness for enhancement (NANDA, 2003)26NCM 100 - Nursing ProcessFGV Jaminit, BSN, RN, CNN, MAWellness Nursing DiagnosisDiagnosing2 cues must pre present:A desire for higher level of wellnessAn effective present status or function27NCM 100 - Nursing ProcessFGV Jaminit, BSN, RN, CNN, MAWellness Nursing DiagnosisDiagnosingAssociated with a cluster of diagnosesComprised a cluster of actual or risk nursing diagnoses that are predicted to be resent because of a certain event or situation28NCM 100 - Nursing ProcessFGV Jaminit, BSN, RN, CNN, MASyndrome Nursing DiagnosisDiagnosingDiagnostic statement for wellness diagnoses if one part statement that contains the label readiness for enhanced, followed by the desired higher level wellnessRelated factors are not included29NCM 100 - Nursing ProcessFGV Jaminit, BSN, RN, CNN, MAWellness Nursing DiagnosisFormula in diagnosingActual nursing diagnosisP+E+SRisk nursing diagnosisP+Risk factorsPossible nursing diagnosisData but inadequate and with need for further investigationWellness diagnosisHealthy response, high level of wellness30NCM 100 - Nursing ProcessFGV Jaminit, BSN, RN, CNN, MAComponents of a Nursing DiagnosesProblemDeficient, impaired, decreased, ineffective, compromisedEtiologyDefining characteristics31NCM 100 - Nursing ProcessFGV Jaminit, BSN, RN, CNN, MADiagnosingOne-part statementTwo-part statementThree-part statement

32NCM 100 - Nursing ProcessFGV Jaminit, BSN, RN, CNN, MAFormulating Diagnostic StatementsGuidelines for setting priorities Take care of immediate life-threatening issues.Safety issues.Patient-identified issues.Nurse-identified priorities based on the overall picture, the patient as a whole person, and availability of time and resources.33NCM 100 - Nursing ProcessFGV Jaminit, BSN, RN, CNN, MAPlanningInvolves determining beforehand the strategies or course of actions to be taken before implementation of nursing careTo be effective, involve the client and his family in planning.34NCM 100 - Nursing ProcessFGV Jaminit, BSN, RN, CNN, MAPlanningNursing plan of care is a written summary of the care that a client is to receiveIt is the blue print of the nursing process35NCM 100 - Nursing ProcessFGV Jaminit, BSN, RN, CNN, MAPlanningTo identify the clients goals and appropriate nursing interventionsTo direct client car activitiesTo promote continuity of careTo focus charting requirementsTo allow delegation of spec. acts.36NCM 100 - Nursing ProcessFGV Jaminit, BSN, RN, CNN, MAPurposesPlanningS-M-A-R-T37NCM 100 - Nursing ProcessFGV Jaminit, BSN, RN, CNN, MACharacteristicsCase (Remember Mr. Chan?)After assessment, oxygen therapy was started at 4 LPM via nasal cannula; Isosorbide dinitrate 10mg SL was given as stat dose. One hour after the intervention chest pain was relieved with pain score of 3/10,O2 sat of 95% and non-pale looking skin.38NCM 100 - Nursing ProcessFGV Jaminit, BSN, RN, CNN, MAImplementationIs putting the nursing care plan into actionPurpose: carry out planned nursing interventions to help the client goals and achieve optimal level of health39NCM 100 - Nursing ProcessFGV Jaminit, BSN, RN, CNN, MAImplementationReassessingSet prioritiesPerform nursing interventionsRecord actions40NCM 100 - Nursing ProcessFGV Jaminit, BSN, RN, CNN, MAActivitiesEvaluationAssessing the clients response to nursing interventions and then comparing the response to predetermined standard or outcome criteriaPurpose: appraise the extent to w/c goals and outcome criteria have been achieved41NCM 100 - Nursing ProcessFGV Jaminit, BSN, RN, CNN, MAEvaluationCollect data about the clients responseCompare the clients response to goals and outcome criteriaJudgmentAnalyze reasons of outcomeModify care plan as needed42NCM 100 - Nursing ProcessFGV Jaminit, BSN, RN, CNN, MAActivitiesJudgment:Goal was completely metGoal was partially metGoal was completely unmetNew problems or nursing diagnoses have developed4243NCM 100 - Nursing ProcessFGV Jaminit, BSN, RN, CNN, MA