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NURSING PROCESS
Definition:
It is a systematic, client-centered method for structuring the delivery of
nursing care.
Phases:
1. Assessment
2. Diagnosing
3. Planning
4. Implementing
5. Evaluating
Characteristics:
1. It is cyclical and dynamic in nature.
2. It is client-centered.
3. It adapts problem solving.
4. Decision-making is involved in every phase.
5. It is interpersonal and collaborative.
6. It is universally applicable.
7. It uses variety of critical thinking skills.
-----------------------------------
ASSESSMENT
Definition: It is a systematic and continuous collection, organization, validation
and
documentation of data.
Characteristics:
1. It focuses on a clients responses to a health problem.
2. It should include the clients perceived needs, health problems, related
experience, health practices, values and lifestyle.
3. To be most useful, the data collected should be relevant to a particular
health problem.
Activities:
1. Collecting Data
2. Organizing data
3. Validating Data
4. Documenting Data
Concise
and
Descriptive
Judgmental
and
Conclusive
B. Interviewing
Non-directive
- rapport building interview
- uses open- ended questions, used for problem- solving counseling
and performance appraisal
(Rapport- is an understanding between 2 or more people)
Kinds of Interview Questions:
1. Closed question- used in directive interview, restrictive and generally
require only
short answers- giving specific information
2. Open-ended questions
- non-directive interview
- lead clients to explore their thoughts and feelings
disadvantages. The client may spend time
conveying irrelevant information.
3. Neutral Questions question that the client can answer without
direction or
pressure from the nurse
- is open-ended, and is used in non-directive interviews
4. Leading Questions is usually closed, used in directive interview and
thus directs
clients answer
Some hints to make patient comfortable before beginning the nursing history:
a.
b.
c.
d.
Time
Place- privacy
Seating arrangement- 45 degree angle to the bed
Distance-3 to 4 ft. apart
Language
Stages of Interview
1. The opening /introduction
steps: a. establishing rapport
b. orienting the interviewee
2. The body
3. The closing
Examination
- major method used in the physical health assessment
- done systematically, according to examiners preference
(head to toe or body systems)
a. Cephalo-caudal- head, neck, thorax, abdomen, and extremities and
ends at the toes
b. Body System approach- respiratory, circulatory, etc.
- datas obtained are measured against norms or standards (ideal
height/weight, temperature, Blood Pressure)
Techniques Used:
1. inspection
2. auscultation
3. palpation
4. percussion
INSPECTION- systematic- head to toe
PALPATION
- the nurse uses the hands and sense of touch to gather data
- used to detect tenderness, temp., texture, vibration, pulsations,
masess
- rules out/confirms suspicious raised during interview and inspection
PERCUSSION- is the tapping of the bodys surface to produce vibration and
sound
- sounds indicates the density of the underlying tissue
tympany-high-pitched-like sound over a hallow organ
dullness-low-pitched,thud-like soun over a dense organ
Technique: place the palmar surface of one hand against the clients body while
tapping with the other.
AUSCULTATION the process of listening to sounds produced by the body
- Systems involved:
Cardiovascular System
Respiratory System
Gastro-intestinal System
- Use: Stethoscope- an instrument that amplifies sounds
produced by i
nternal organs
- nurse uses written
systematically
ORGANIZING DATA
format that organizes
the
assessment
data
DOCUMENTING DATA
- to complete the assessment phase, the nurse records the data
----------------------------------------------------
NURSING DIAGNOSIS
- is a clinical Judgment about individual, family or community responses to
Actual or Potential health problems/ life process.
- It provides a basis for selection of nursing interventions to achieve
outcomes for which the N is Accountable
Advantages:
1. Ng Dx facilitates communication among Nurses and other health
team members.
2. Strengthen the Ng. Process and provide Direction for Planning
independent Ng. Actions
3. Health the nurse focus on independent Nursing Actions.
4. Help identify the focus of a Nursing Activity and thus facilitates peer
review and quality assurance program.
5. Facilitate Nursing intervention when a client moves from one hospital
unit to another.
6. They facilitate comprehensive health care by identifying, validating
and responding to specific health problems.
WRITING NURSING DIAGNOSIS
1. ACTUAL NURSING DIAGNOSIS
a. Ng. Dx = PATIENT PROBLEM AND ETIOLOGY
Ex. Impaired skin integrity r/t immobility
Prental role conflict r/t divorce
Impaired verbal r/t cultural
Communication differences
b. Ng. Dx = P + E + S
Impaired skin integrity r/t immobility
Manifested by disruption of skin
Surface over the elbows and coccyx
Prental role conflict r/t divorce as manifested by statement or
unsatisfactory child care during working hours
Impaired verbal r/t cultural differences as Communication manifested
by inability to Speak English.
r/t
r/t
MEDICAL DX
Describe a specific do
Is oriented to pathology
Remains
constant
Guides medical
management, some
which may be carried out
the nurse.
Is complementary to
Has well developed
classification
system
of 2 or 3 words
1. Organized Data
2. Compare data against standard -------- normal health patterns
-------- normal vital signs
-------- lab values
3. Cluster data
NCP-Importance
1. they individualize care to clients
2. Healps in setting priorities by providing information about the client as well as
the nature of his problems
3. Promotes systematic communication among those involved in the health care
effort
4. Continuity of care facilitated
5. Facilitates the coordination of care
STEPS IN DEVELOPING FNCP:
1.
2.
3.
4.
the
the
the
the
problem definition
goals and objectives of care
plan of intervention
plan for evaluating care
ESTABLISHING GOALS:
Goal - is a general statement of purpose
- it is the end toward which all efforts are directed
S
specific
M
A
R
T
measurable
attainable
realistic
time bounded
D. Diet
The client will be able to:
Describe the purpose of his or her prescribed diet
Plan several typical menus using prescribed diet
PLANNING
Definition- is the process of designing the Ng. Strategies or interventions
required to prevent, reduced opr eliminate those client health problems
identified and validated during the diagnostic phase.
-
the process in which problem solving and decision- making are carried out.
Uses:
6 Compaonents of P:
1. setting priorities
2. establishing client goals and outcome criteia
3. planning Ng Strategies
4. writing Ng orders
5. writing the NCP
6. Consulting
I.
Setting Priorities
Determined by the following factors:
1.
2.
3.
4.
5.
6.
II.
Purposes:
1. provide direction of planning nursing intervention
2. provide direction for establishing evaluation
Types of Goals
a. long term- client living at home or having chronic health problems, in NG.
Homes and rehab center.
b. short term- clients requiring short term care
- persons who are frustrated by long term goals
Establishing goals for Fr Ng Dx
Nursing Diagnosis- Impaired Physcial Mobility r/t pain
Client problems- Impaired physical mobility
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Ng. Dx
Client problems
Client goals
OUTCOME CRITERIA:
4 purposes:
1. provide direction for nursing intervention
2. provide a time spab for planned activities
3. serve as criteria for evaluation of progress toward goal achievement
COMPONENTS OF OUTCOME CRITERIA:
1.
2.
3.
4.
subject
verb
condition or modifier
criterion
SUBJECT
VERB
Standard
Client
Client
Drinks
List
Client
Identifies
Client
States
Cleint
Identifies
CONDITION
100 ml of fluid
Three hazards of
Smoking
Advance of
Immunization
The purpose of his
medication
Importance of
eating right kind
of food
DESIRED
PERFORMANCE
Q 4 hours
(three)
On the next visit
Before discharge
On the next visit
GUIDELINES:
1. Write goals and outcome criteria in term of client behavior- focus on the client
not nursing action.
2. Avoid statement that short and enable, facilitate, allow, let, permit followed
by the word client
3. Make sure the goal statement is appropriate for the NG. Dx and those
outcome criteria are appropriate for goal
4. Make sure the client considers the goals important and values them.
5. Ensure that the (goals) (client) goals and outcome criteria are compatible with
the word and therapies of other professionals
6. Make sure that each goals is derived from only on NG Dz
7. When writing outcome criteia, use observable, measurable terms (smart)
III.
PLANNING NG STRATEGIES:
1. generating alternative nursing strategies
a. brainstorming
b. Hypothesizing
c. Extrapolating
2. considering the consequences of each strategies
3. choosing nursing strategies
IV.
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5 components:
1. date
2. action verb
3. time element
4. signature
Relationship of OC Vs CG
1. OC- outcome criteria are derived from and relate to the client goals CG from
1st clause of the Ng Dx
Ng Dx- POTENTIAL IMPIARED SKIN INTERITY r/t imposed bed rest.
Client goal- maintain intact ski, particular over bony prominence
Outcome Criteria- demonstrate correct techniques for positioning and
turning
Note: 3-6 outcome criteia are neede to each goal
Characteristics of a well stated outcome criteria:
1. each outcome criteria related to the established goals
2. the outcome stated in the criteria is possible to achieve
3. each criteria is a specific and concrete as possible, to facilitate
measurement
4. each criteria is appraisable or measurable
V.
WRITING NCP
Ng. Dx
Fears r/t cardiac
catherterization,
possible
heart
surgery and its
outcome
Goals
Experience
increased
emotional comfort
and feelings of
control
Ng. Orders
Establish
a
trusting
relationship
with
the
client
and
family to express
feelings
and
concern
discuss
the cardiac cath
procedure
and
what is expected
of him before and
after
the
procedure
Outcome criteria
Verbalizes
specified concerns
communicate
thoughts clearly
and logically facial
expressions, voice
tone, and body
posture
correcpond to
verbal expressions
and increased
emotional comfort
after instruction,
describe cath
procedure and
what is expected
of him.
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2.
3.
4.
5.
6.
Discharge Planning- the process of anticipating and planning for needs after
discharge form a Hospital or other facility.
IMPLEMENTING- Intervening
- putting the nursing strategies listed in the hrsing care plan into action
by: Belucheck and Mc Closkey
Nursing Intervention- an autonomous action based on scientific rationale that is
executed to benefit the client in a predicted way related to the Nursing diagnosis
and stated goals.
TYPES OF NURSING ACTIONS:
1. Independent Nursing Action- an activity that the nurse initiates as a result
of the nurses own knowledge and skill autonomous nursing practice.
Taxonomy- is a set of classification that are ordered and arranged on the
basis of a single principle or consistent set of principle.
2. Dependent Nursing Action- are those activities carried out in the order of
the physician, under the physicians supervision or according to specified
routines.
3. Interdependent Interventions- is completed with our without a physicians
order or is written at a nurse suggestion
COLLABORATION- a ture partnership, in which power on both sides in valued
by both, with recognition and acceptance of separate and combined spheres
of activity and responsibility, mutual safe guarding of legitimate interests of
each party and a commonality of goals that is recognized by both parties.
PROTOCOLS- is a written plan specifying the procedure to be followed in a
particular situation.
STANDING ORDER- is a written document about policies, rules, regulations
or orders regarding client care.
6 COMPONENTS OF IMPLEMENTING
1. Reassessing the client
- focuses on more specific needs
- N- determine whether planned nursing strategies are appropriate for the
client.
2. Validating the NCP
N reviews the NCP in 4 areas:
a. safety
b. appropriateness
c. effectiveness
d. individualize nursing care
to validate the plan- to request another appropriate professional and patient
iif possible to give plan approved or implementation
3. Determining the Needs for Assistance
2 Reasons:
a. the N unable to implement the nursing strategies safety alone
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IMPLEMENTING ACTIVITIES
1. Caring
2. Communicating
3. Helping
4. Teaching
5. Counseling
6. Client advocate
GUIDELINES FOR IMPLEMENTING NURSING STRATEGIES
1. Nursing action are based on scientific knowledge
2. Nursing actions resulting from a physicians order must be understood by the
N
3. Nursing actions are adapted to the individual
4. Nursing actions should always be safe
5. Nursing actions often require teaching, supportive and comfort components
6. Nursing actions should be holistic
7. Nursing action should respect the dignity of the client and enhance clients
self-esteem
8. The clients active participation in implementing nursing actions should be
encouraged as health permits.
EVALUATING
To evaluate- to identify whether or to what degree to clients goals have been
met
6 Components
1. Identifying Outcome Criteria
2 purposes
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