nursing process
DESCRIPTION
nursing processTRANSCRIPT
The purposes of the Nursing Process
• Identify the client’s health care needs• Determine priority of care goals and
expected outcomes• Establish nursing care plan to meet
client-centered needs• Provide nursing interventions designed
to meet these needs• Evaluate the effectiveness of nursing
care
Components of nursing process
1. Assessment
2. Diagnosis
3. Planning
4. Implementation
5. evaluation
Nursing process
• Assessment: data collection:-– Subjective data … pain– Objective data …fever
• Diagnosis: determining the problem.
• Planning: developing a plan for care.
• Implementation: applying the plan.
• Evaluation: evaluating the outcomes.
1. Assessment
Steps:-
• Health history
• Physical examination
• Laboratory data & diagnostic procedures
• Validating data
• Documenting data
Sources of data
• Client
• Family
• Health care team
• Medical records
• Military records
Types of data
1- SUBJECTIVE DATA
Clients perception about his health problems usually includes
A - Presence of pain
B- Feeling of anxiety
C- Physical discomfort
D. Mental stress
Types of data
2- OBJECTIVE DATA
Observation or measurement made by the data collector includes
A – observation (body rash )
B- measured (BP , T , R , head circumference )
Methods of data collection
• Interview
• Nursing health history
• Physical examination
• Results of laboratory & diagnostic tests
Physical examination• Inspection, used to detect height,
weight, skin color, skin rash, scars,…• Palpation, used to detect tenderness,
temperature, texture, pulse,…• Percussion, used to detect the location
of organs.• Auscultation, used to listen to sounds
produced by cardiovascular, respiratory, gastrointestinal systems.
2. Diagnosis Steps:-• Interpreting data• Identify problems• Formulating nursing diagnosis• Documenting nursing diagnosisTwo types:-
- Actual- Potential
3. Planning
Steps:-
• Identify client’s goals
• Establish expected outcomes
• Selecting nursing actions
• Delegating action
• Writing nursing care plan
• Consulting
Types of goals:-
• short term goals– Achieved in a short period, usually less
than one week.
• Long term goals– Achieved over a long period, usually over
weeks or months.
4. Implementation
Steps:-
• Reassessing client
• Reviewing and modifying existing care plan
• Performing nursing action
5. Evaluation
Steps:-
• Comparing client response to criteria
• Analyzing reasons for results
• Modifying care plan