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Nursing Process

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Nursing Orders Directions for a ... Times New Roman Arial Fundamental Nursing Skills and Concepts 1 Definition of the Nursing Process ... – PowerPoint PPT presentation

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Title: Nursing Process


1
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  • Nursing Process
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  • www.palnurse.com

2
Definition of the Nursing Process
  • An organized sequence of problem-solving steps
    used to identify and to manage the health
    problems of clients
  • It is accepted for clinical practice established
    by the American Nurses Association

3
Characteristics of the Nursing Process
  • Within the legal scope of nursing
  • Based on knowledge-requiring critical thinking
  • Planned-organized and systematic
  • Client-centered
  • Goal-directed
  • Prioritized
  • Dynamic

4
Steps of the Nursing Process
  • Assessment
  • Diagnosis
  • Planning
  • Implementation
  • Evaluation

5
Assessment
  • Systematic collection of facts or data

6
Types of Data
  • Objective data-observable and measurable facts
    (Signs)
  • Subjective data-information that only the client
    feels and can describe (Symptoms)

7
Sources of Data
  • Primary source Client
  • Secondary source Clients family, reports, test
    results, information in current and past medical
    records, and discussions with other health care
    workers

8
Types of Assessments
  • Data base assessment
  • Focus assessment

9
Organization of Data
  • Grouping of related information
  • Organization of assessment data into small groups
    to be analyzed

10
Nursing Diagnosis
  • Health issue that can be prevented, reduced,
    resolved, or enhanced through independent nursing
    measures
  • Nursing Diagnosis Caregories
  • Actual
  • Risk
  • Possible
  • Syndrome
  • Wellness

11
Diagnostic Statements
  • Name of the health-related issue or problem as
    identified in the NANDA list
  • Etiology (its cause)
  • Signs and Symptoms
  • The name of the nursing diagnosis is linked to
    the etiology with the phrase related to, and
    the signs and symptoms are identified with the
    phrase as manifested (or evidenced) by

12
Collaborative Problems
  • Physiologic complications whose treatment
    requires both nurse- and physician-prescribed
    interventions.
  • They are an interdependent domain of nursing
    practice

13
Collaborative Problems-Nurses Responsibility
  • Correlating medical diagnoses or medical
    treatment measures with the risk for unique
    complications
  • Documenting the complications for which clients
    are at risk
  • Making pertinent assessments to detect
    complications
  • Reporting trends that suggest development of
    complications
  • Managing the emerging problem with nurse- and
    physician-prescribed measures
  • Evaluating the outcomes

14
Planning
  • The process of prioritizing nursing diagnoses and
    collaborative problems, identifying measurable
    goals or outcomes, selecting appropriate
    interventions, and documenting the plan of care.
  • The nurse consults with the client while
    developing and revising the plan.

15
Setting Priorities
  • Determine problems that require immediate action
  • Maslows Hierarchy of Human Needs

16
Short-Term Goals
  • Outcomes achievable in a few days or 1 week
  • Developed form the problem portion of the
    diagnostic statement
  • Client-centered
  • Measurable
  • Realistic
  • Accompanied by a target date

17
Long-Term Goals
  • Desirable outcomes that take weeks or months to
    accomplish for clients with chronic health
    problems

18
Goals for Collaborative Problems
  • Goals for collaborative problems are written from
    a nursing rather than from a client perspective.
  • The focus on what the nurse will monitor, report,
    record, or do to promote early detection and
    treatment.

19
Selecting Nursing Interventions
  • Planning the measures that the client and nurse
    will use to accomplish identified goals involves
    critical thinking.
  • Nursing interventions are directed at eliminating
    the etiologies.
  • The nurse selects strategies based on the
    knowledge that certain nursing actions produce
    desired effects.
  • Nursing interventions must be safe, within the
    legal scope of nursing practice, and compatible
    with medical orders.

20
Nursing Orders
  • Directions for a clients care
  • Identifying what, when, where, and how for
    performing nursing interventions
  • Nursing orders are signed to be accountable

21
Communicating The Plan
  • The nurse shares the plan of care with nursing
    team members, the client, and clients family.
  • The plan is a permanent part of the record.

22
Implementation
  • Carrying out the plan of care
  • The nurse implements medical orders and nursing
    orders
  • Implementation involves the client and one or
    more health care team
  • The information in the chart shows a correlation
    between the plan and the care that has been
    provided.
  • Nurses are accountable for carrying out nursing
    orders and physician orders.

23
Evaluation
  • The way nurses determine whether a client has
    reached a goal.
  • It is the analysis of the clients response,
    evaluation helps to determine the effectiveness
    of nursing care.

24
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  • WWW.PALNURSE.COM
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