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DESCRIPTION
XTRANSCRIPT
The Nursing ProcessThe Nursing Process
6 Characteristics• Cyclic and dynamic rather than
static• Client centered – nurse organizes
plan of care according to client problems rather that nursing goals
• Interpersonal and collaborative – depends on open and meaningful communication between client and the nurse
• Universally applicable – can be used with clients of any age at any point of the wellness – illness continuum and useful in a variety of settings
• Adaptation of problem solving techniques and system theory based on the scientific method
• It can be viewed as parallel to but separate from the medical process
ASSESSMENT
Assessment• Objective (physical exam) and
subjective (nursing history)
SOURCES OF DATA• Primary – client• Secondary – relatives, members of
health team
GORDON’S TYPOLOGY OF FUNCTIONAL PATTERNS
• Health perception – health management pattern – describes clients perceived pattern of health and well being and how health is managed.
• Nutritional – metabolic pattern – describes pattern of food and fluid consumption relative to metabolic need and pattern indicators of local nutrient supply.
• Elimination – describes pattern of excretory function (bowel, bladder and skin).
• Activity – exercise – describes pattern of exercise, activity, leisure and recreation
• Cognitive perceptual – describes sensory perceptual and cognitive system
• Sleep rest – describes pattern of sleep, rest and recreation.
• Self perception – self concept – self concept pattern and perceptions of self (body comfort, body image, feeling state).
• Role relationship – describes pattern of role engagements and relationships
• Sexual reproductive – client patterns of satisfaction and dissatisfaction with sexuality: describes reproductive pattern
• Coping stress tolerance – general coping pattern and effectiveness of the pattern in terms of stress tolerance.
• Value belief – patterns of values, beliefs (including spiritual) or goals that guide choices of decisions.
NURSING DIAGNOSIS
NURSING DIAGNOSISNURSING DIAGNOSIS- Clinical judgment about an
individual, family or community responses to actual and potential health problems
- Professional nurses are responsible for making nursing diagnosis.
- Nursing diagnosis describe a continuum of health states.
NURSING DIAGNOSIS
MEDICAL DIAGNOSIS
- Focus on identifying human responses to health and illness- Describe problems treated by nurses within the scope of independent nursing practice- Changes from day to day as client responses change
- Identifies disease- Describe problems for which the physician directs the primary treatment - Remains the same for as long as the disease is present
OBJECTIVES
OBJECTIVESOBJECTIVES- Should be SMART- client centered- statement of a single human
response
EVALUATION
EVALUATIONEVALUATION- Conclusion and supporting data
- Goal met
- Goal partially met
- Goal not met