nsg process
TRANSCRIPT
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Nursing
Process
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SERIES OF PLANNED ACTIONS OR OPERATIONS DIRECTEDTOWARD A PARTICULAR RESULT OR GOAL.
A SYSTEMATIC, RATIONAL METHOD OF PLANNING ANDPROVIDING INDIVIDUALIZED NURSING CARE.
ITS PURPOSE IS TO IDENTIFY A CLIENTS HEALTH STATUS,ACTUAL OR POTENTIAL HEALTH CARE PROBLEMS OR NEEDS,AND TO DELIVER SPECIFIC NURSING INTERVENTIONS TO
MEET THOSE NEEDS.
IT IS ALSO CYCLICAL. THAT IS, THE COMPONENTS OF THENURSING PROCESS FOLLOW A LOGICAL SEQUENCE, BUT MORETHAN ONE COMPONENT MAYBE INVOLVED AT ANY ONE TIME.
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ASSESSMENT
COLLECTING, ORGANIZING, VALIDATING AND RECORDINGDATA ABOUT A CLIENTS HEALTH STATUS. DATA ARE
OBTAINED FROM A VARIETY OF SOURCES AND ARE THEBASIS FOR ACTIONS AND DECISIONS TAKEN IN
SUBSEQUENT PHASES. NO CONCLUSIONS ABOUT THEDATA ARE DRAWN IN THIS PHASE.
DIAGNOSING
A PROCESS WHICH RESULTS IN A DIAGNOSTICSTATEMENT OR NURSING DIAGNOSIS. IN THIS PHASE,
THE NURSE SORTS, CLUSTERS, AND ANALYZES THE DATAAND ASKS, WHAT ARE THE ACTUAL AND POTENTIALHEALTH PROBLEMS FOR WHICH THE CLIENT NEEDS
NURSING ASSISTANCE? AND WHAT FACTORSCONTRIBUTED TO THIS PROBLEM? RESPONSES TO THOSE
QUESTIONS ESTABLISH THE NURSING DIAGNOSES.
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EVALUATING
ASSESSING THE CLIENTS RESPONSE TO NURSINGINTERVENTIONS AND THEN COMPARING THE RESPONSETO THE GOALS OR OUTCOME CRITERIA WRITTEN IN THEPLANNING PHASE. THE NURSE DETERMINES THE E TENTTO WHICH THE OUTCOMES/ GOALS OF CARE HAVE BEEN
ACHIEVED. THE CARE PLAN IS REASSESSED IN THISPHASE, WHICH MAY INVOLVE CHANGES IN ANY OR ALLOF THE PREVIOUS PHASES OF THE NURSING PROCESS.
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EVALUATION
IMPLEMENTING
PLANNING
DIAGNOSING
ASSESSINGEACH PHASEDEPENDS ON THE
ACCURACY OF
THE PRECEDING
PHASE.
EVALUATING
INVOLVES
EXAMINATION OF
ALL PREVIOUS
PHASES.
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The system is open and flexible to meet the unique
needs of the client, family, group or community.
It is cyclic and dynamic. Because all steps areinterrelated, there is no absolute beginning or end.
It is client centered; it individualizes the approach to
each clients particular needs.
It is interpersonal and collaborative. It requires the
nurse to communicate directly and consistently with
clients to meet their needs.
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It is planned.
It is goal directed.
It permits creativity for the nurse and client in
devising ways to solve the stated health problem.
It emphasizes feedback, which leads either to
reassessment of the problem or to revision of the
care plan.
It is universally applicable. The nursing process isused as a framework for nursing care in all types of
health care settings, with clients of all age groups.
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TO ESTABLISH A DATABASE ABOUT
THE CLIENTS RESPONSE TO HEALTH
CONCERNS OR ILLNESS AND THE
ABILTY TO MANAGE HEALTH CARE
NEEDS
ESTABLISH A DATABASE
* OBTAIN HEALTH HISTORY
* CONDUCT PHYSICAL ASSESSMENT
* REVIEW CLIENT RECORDS
* REVIEW LITERATUIRE
* CONSULT SUPPORT PERSONS
* CONSULT HEALTH PROFESSIONALS
UPDATE DATA AS NEEDED
ORGANIZE DATA
VALIDATE DATA
COMMUNICATE/DOCUMENT DATA
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OBSERVATION
INTERVIEWING
EXAMINING
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OBSERVATION
Gathering data using
the five senses
INTERVIEWING Planned communication orconversation with a purpose to
identify problems of mutual concern
EXAMINING
Physical examination is asystematic data-collection
method that uses
observational skills to
detect the health
problems
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Gathering information about a clientshealth status. It must be both
systematic and continuous to preventthe omission of significant data and
reflect a clients changing healthstatus.
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SUBJECTIVE DATA
Data belong under subjective if
The patient or family member tells the history.
The patient or family member tells about lifestyle or home
situation.
The patient or family member tells emotions or attitudes.
The patient states his or hergoals.
The patient voices a complaint.
The patient reports a response to treatment.
It is anything that the patient tells which is relevant to his
case or present condition.
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OBJECTIVE DATA
Data belong under objective if
It is part of the patients history taken from medical recordand relevant to the current problem.
It is a result of the therapists objective measurements or
observations.
It is part of the treatment given to a patient.
Hx: ASHD, CHF, COPD, S/P fx L Hip prosthesis insertion
AROM: WNL throughout UEs & LEs except 120
shoulder flexion noted
L
Tolerated 3 repetitions of ROM exercises of UEs & LEs
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Types of data: SUBJECTIVE DATA OBJECTIVE DATA
SUBJECTIVE OBJECTIVE
I feel pain at my right
knee.
BP 90/50
Apical Pulse 104
Skin pale and
diaphoretic
I have difficulty
breathing.
Lung sounds are diminished in
the left lower lobe of the lung
RR 25/min
Leans forward
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Sources of data:
Primary data: patient
Secondary data: support people, other health
professionals, records and reports,literature
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Using an organized assessmentframework, often referred to as a
nursing history or nursing assessment.
FRAMEWORKS
NURSING CONCEPTUAL MODELSWELLNESS MODELS
NONNURSING MODELS
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HEALTH PERCEPTION-HEALTH MANAGEMENTPATTERN. Describes clients perceived pattern ofhealth and well-being and how health ismanaged.
NUTRITIONAL-METABOLIC PATTERN. DescribesPATTERN OF FOOD AND FLUID CONSUMPTIONRELATIVE TO METABOLIC NEED AND PATTERNINDICATORS OF LOCAL NUTRIENT SUPPLY.
NURSING CONCEPTUAL MODELS
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ELIMINATION PATTERN. Describes patterns ofexcretory function (bowel, bladder, skin)
ACTIVITY-EXERCISE PATTERN. Describes patternof exercise, activity leisure, and recreation
COGNITIVE-PERCEPTUAL PATTERN. Describessensory- perceptual and cognitive pattern.
SLEEP-REST PATTERN. Describes patterns of sleep,rest and relaxation.
SELF-PERCEPTION-SELF-CONCEPT PATTERN.Describes self-concept pattern and perceptions
of self (eg, body comfort. Body image, feelingstate).
ROLE RELATIONSHIP PATTERN. Describes thepattern of role-engagements and relationships.
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SEXUALITY-REPRODUCTIVE PATTERN. Describesclients patterns of satisfaction anddissatisfaction with sexuality; describes
reproductive patterns.
COPING-STRESS-TOLERANCE PATTERN. Describesgeneral coping pattern and effectiveness of thepattern in terms of stress tolerance.
VALUE-BELIEF PATTERN. Describes patterns ofvalues, beliefs (including spiritual), or goals thatguide choices or decisions.
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Universal Self-Care Deficits
1. The Maintenance of a sufficient intake of air.
2. The Maintenance of a sufficient intake of water.
3. The Maintenance of a sufficient intake of food.
4. The Provision of care associated with elimination
processes and increments.
5. The Maintenance of a balance between activity and rest.
6. The Maintenance of a balance between solitude and social
interaction
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7. The prevention of hazards to human life, human
functioning, and human well-being.
8. The promotion of human functioning and development within
social groups in accord with human potential, known human
limitations, and human desire to be normal.
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WELLNESS MODELS
GENERALLYINCLUDES:
^^^ HEALTH HISTORY^^^
^^^ PHYSICAL FITNESS EVALUATION^^^
^^^ NUTRITIONAL ASSESSMENT^^^
^^^ LIFE-STRESS ANALYSIS^^^^^^ LIFE-STYLE AND HEALTH HABITS^^^^^^ HEALTH BELIEFS^^^^^^ SE UAL HEALTH^^^
^^^ SPIRITUAL HEALTH^^^^^^ RELATIONSHIPS^^^
^^^ HEALTH RISKS APPRAISALS^^^
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NONNURSING MODELS
BODY SYSTEMS MODEL
MASLOWS HIERARCHY OFNEEDS
DEVELOPMENTAL THEORIES
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1. Physiologic Needs
* Activity and rest
* Nutrition
* Elimination* Fluid and Electrolytes
* Oxygenation
* Protection
* Regulation:temperature* Regulation:the senses
* Regulation:endocrine system
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2. Self-concept
* Physical Self
* Personal Self
3. Role Function
4. Interdependence
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Act of double-checking or verifyingdata (cues) to confirm that they are
accurate and factual.
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Data are documented in factualmanner and are not interpreted by the
nurse.
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TO IDENTIFY CLIENT STRENGTHS AND
HEALTH PROBLEMS THAT CAN BE
PREVENTED OR RESOLVED BY
COLLABORATIVE AND INDEPENDENT
NURSING INTERVENTIONS
TO DEVELOP A LISTING OF NURSING
DIAGNOSES AND COLLABORATIVE
PROBLEMS
INTERPRET & ANALYZE DATA
* COMPARE DATA AGAINST STANDARDS
* CLUSTER OR GROUP DATA
* IDENTIFY GAPS AND INCONSISTENCIES
DETERMINE CLIENTS STRENGTHS, RISKS
AND PROBLEMS
FORMULATE NURSING DIAGNOSIS AND
COLLABORATIVE PROBLEM STATEMENTS
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A CLINICAL JUDGEMENTABOUTINDIVIDUAL, FAMILY OR COMMUNITY
RESPONSES TOACTUAL ANDPOTENTIAL HEALTH PROBLEMS/LIFE
PROCESSES.
IT PROVIDES THE BASIS FOR
SELECTIO
NO
F NUR
SINGINTERVENTIONS TOACHIEVEOUTCOMES FOR WHICH THE NURSE IS
ACCOUNTABLE.
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STATEMENT OF NURSING JUDGMENT AND REFERS TOA CONDITION THAT NURSES ARE LICENSED TO
TREAT; DECRIBES A CLIENTS PHYSICAL,SOCIOCULTURAL, PSYCHOLOGIC AND SPIRITUAL
RESPONSES TO AN ILLNESS OR POTENTIAL HEALTH
PROBLEM.
MADE BY THE PHYSICIAN AND REFERS TO A CONDITION
ONLY A PHYSICIAN CAN TREAT; REFERS TO DISEASE
PROCESSES THAT ARE FAIRLY UNIFORM FROM ONE
CLIENT TO ANOTHER.
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PROBLEM STATEMENT (DIAGNOSTIC LABEL)
ETIOLOGY (RELATED FACTORS & RISK FACTORS)
DEFINING CHARACTERISTICS
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ActivityIntolerance/ relatedto/prolonged
bedrest/ asmanifestedby/ body
weaknessandfatigue
P E
S
1. PROBLEM (P) --- STATEMENT OF THE CLIENTS
RESPONSES
2. ETIOLOGY (E) --- FACTORS CONTRIBUTING TO OR
PROBABLE CAUSES OF THE RESPONSE
3. SIGNS & SYMPTOMS (S) --- DEFININGCHARACTERISTICS MANIFESTED BY THE CLIENT
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Alterationincomfort, pain/
associatedwith/ abdominalincision/ asmanifestedby/ muscle
guardingandgrimace
Alteredthermoregulation, / related
toinfection/ asmanifestedby/ high
gradefeverandexcessiveperspiration
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TO DEVELOP AN INDIVIDUALIZED CARE
PLAN THAT SPECIFIES CLIENT
GOALS/EXPECTED OUTCOMES ANDRELATED NURSING INTERVENTIONS
SET PRIORITIES AND GOALS/OUTCOMES IN
COLLABORATION WITH THE CLIENT
WRITE GOALS/OUTCOME CRITERIA
SELECT NURSING STRATEGIES/INTERVENTIONS
CONSULT OTHER HEALTH PROFESSIONALS
WRITE NURSING ORDERS AND NURSING CARE
PLAN
COMMUNICATE CARE PLAN TO RELEVANT
HEALTH CARE PROVIDERS
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TO ASSIST THE CLIENT TO MEET
DESIRED GOALS/OUTCOMES,
PROMOTE HEALTH AND WELLNESS;
PREVENT ILLNESS AND DISEASE; AND
FACILITATE COPING WITH HEALTH
PROBLEMS.
REASSESS THE CLIENT TO UPDATE THE
DATABASE
DETERMINE THE NEED FOR NURSINGASSISTANCE
PERFORM OR DELEGATE PLANNED NURSING
INTERVENTIONS
COMMUNICATE NURSING ACTIONS
IMPLEMENTED
* DOCUMENT CARE AND CLIENT RESPONSES
TO CARE
* GIVE VERBAL REPORTS AS NECESSARY
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TO DETERMINE THE EXTENT TO WHICH
CLIENT GOALS/OUTCOMES HAVE BEEN
ACHIEVED AND TO DETERMINEWHETHER TO CONTINUE, MODIFY OR
TERMINATE THE PLAN OF CARE
COLLABORATE WITH THE CLIENT AND COLLECT
DATA RELATED TO EXPECTED OUTCOMES
JUDGE WHETHER GOALS/OUTCOMES HAVEBEEN ACHIEVED
RELATE NURSING ACTIONS TO CLIENT
OUTCOMES
MAKE DECISIONS ABOUT PROBLEM STATUS
REVIEW AND MODIFY THE CARE PLAN ASINDICATED OR TERMINATE NURSING CARE
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(JUSTIFIES THE USE OF
THE NURSING DIAGNOSIS)
RATIONALE
(S.M.A.R.T. GOALS
OF CARE)
E PECTEDOUTCOME
(PRIORITIZED)
INTERVENTION/IMPLEMENTATION
(EXAMINES THE
PREVIOUS PHASES)
EVALUATION
(JUSTIFIES THE USE OF
THE NURSING DIAGNOSIS)
RATIONALE
CUES
(Subjective
and
objective
cues)
NURSINGDIAGNOSIS
(Using
NANDA list)
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CUES NURSING
DIAGNOS
IS
RATIONALE EXPECTED
OUTCOMES
INTERVE
NTIONS
RATIONA
LE
EVALUATI
ON
Subjective:
I have been
feeling so
weak and
exhausted
for the last
four days
Decreased
appetite;have eaten
only small
amounts
during meal
time
Objective:
Temp = 38
C
Pulse =
85/min
Altered
thermoreg
ulationrelated to
infection
Invasion of the
body by the
Corona viruscompromised the
bodys immune
system as it
attacks the
respiratory
system. The body
attempts to get rid
of thesemicroorganisms by
releasing
pyrogens causing
the elevation of
body temperature
At the end of 8
hours nursing
intervention,the patient will
be able to:
Have lowered
temp to 37 -
37.5C
Eat at least 3times during
the day in
satisfactory
amounts
Resume
ADLs
Perform
TSB
Give small
frequent
feedings,
then
gradually
increase
Encourage
increased
fluid intake
Loosen
clothings
TSB lowers
down body
temperature
Gradually
increasing
the intake
will
promote
tolerance of
foods
Fluids help
lower down
body
temperatur
e
Promoting
airflow
assist in
lowering
body
temperatur
e
Afebrile
37.6C
Ate two full
meals, no
leftovers
Was able to
take a bath,
move around
Appeared
cheerful and
conversant
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CUES NURSING
DIAGNOSIS
RATIONALE EXPECTED
OUTCOMES
INTERVE
NTIONS
RATIONA
LE
EVALUATI
ON
flushed
face
diaphoretic
teary-eyed
Provide
ventilationbut kept on
isolation
* Isolation
preventsspread of
the virus
thereby
minimizing
contaminati
on
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Thankyou!