unit 1nursing process
TRANSCRIPT
Nursing process
The nursing process used to identify, diagnose, and treat human responses to health and illness.( ANA 2003).
The nursing process is a systematic, rational method of planning and providing individualized nursing care.
Nursing Care Plan (NCP)
The NCP is a written plan of action that quickly provides information to all care gives about what individual nursing care is needed and why.
Benefits of Nursing Process1-Provides an orderly & systematic method
for planning & providing care
2-Enhances nursing efficiency by standardizing nursing practice
3-Facilitates documentation of care
4-Provides a unity of language for the nursing profession
5-Stresses the independent function of nurses
6-Increases care quality through the use of deliberate actions
ASSESSMENT
Assessment is the deliberate and systematic collection of data to determine a clients current and past health status and functional status and to determine the clients present and past coping patterns.
(Carpenito 2000).
Assessment: Phase One of the Nursing Process
Purpose: Establish a baseline of information on the client
and develop a data base Determine client’s normal function Determine client’s risk for dysfunction Determine presence or absence of dysfunction Determine client’s strengths Provide data for diagnostic phase
Unique Focus of Nursing Assessment
Nursing assessments do not duplicate medical assessments
Medical assessments target data pointing to pathologic conditions
Nursing assessments focus on the patient’s responses to health problems or potential health problems
Assessment
The purpose is to establish a database by: Collecting data
Subjective versus objective
Interviewing and taking a health history Subjective and organized
Performing a physical examination Vital signs, patient’s behavior, diagnostic and
laboratory data, medical records
Gordon’s 11 Functional Health Patterns
Uses a series of questions which assist in formulating a nursing diagnosis
Problem focused assessment Focuses on the patient’s problem and develop
you plan of care around the problem
Approaches for Data Collection
Types of Nursing Assessments
Initial assessmentFocused assessmentEmergency assessmentTime-lapsed assessment
Types of Data
Subjective Data Information perceived only the affected
person Cannot be perceived or verified by another
person Examples: feeling nervous, pain
Objective Data Observable and measurable data Data that can be see, heard or felt by someone
other than the person experiencing it Examples: elevated temperature (>101 F),
moist skin, refusal to eat, vital signs
Types of Data
Components of Data Collection
Nursing History Biographical information Reasons for seeking healthcare Present illness or health concern Health history Environmental history Psychosocial and cultural history Review of systems or functional health
patterns
Sources of Data
Primary patient
Secondary Family members Significant other Other healthcare professionals Health records
Nursing Diagnose
A clinical judgment about individual, family, or community responses to actual and potential health problems or life processes
The goal of a nursing diagnosis is to identify actual and potential responses
Medical Diagnosis
Identification of a disease condition based on a specific evaluation of physical signs, symptoms, history, diagnostic tests, and procedures
The goals of a medical diagnosis is to identify the cause of a illness or injury and design a treatment plan
Nursing Diagnosis vs. Medical Diagnosis
Medical diagnosis Identify disease
Nursing diagnosis Focus on unhealthy response to health or illness
Medical diagnosis Physician directs treatment
Nursing diagnosis Nurse treats problem within scope of independent
nursing practice
Nursing Diagnosis vs. Medical Diagnosis
Medical Diagnosis Remains the same as long as the disease is
present
Nursing Diagnosis May change from day to day as the patient’s
responses change
Nursing Diagnosis
Medical Diagnosis Myocardial infarction
Nursing Diagnosis Fear Altered health maintenance Knowledge deficit Pain Altered tissue perfusion
NANDA
• NANDA: North American Nursing Diagnosis Association
• Established in 1973 to identify standards and classify health problems treated by nurses
NANDA
NANDA conferences are held every two years to continue progress in defining, classifying and describing diagnoses
Types of Nursing Diagnosis
NANDA International has identified three types of nursing diagnosis
Actual Nursing DiagnosisIs a client problem that is present at the
time of the nursing assessment.
Example: Ineffective Breathing pattern, Anxiety.
Risk nursing diagnosis
Describes human responses to health conditions/life processes that may be develop in vulnerable individual, family, and community.
Example: Risk for Infection….Wellness Nursing Diagnosis
Describes human responses to level of wellness in an individual, family, community that have readiness for enhancement. (NANDA International 2005, p. 277 )
Example: Readiness for enhanced spiritual well-being
Component of Nursing Diagnosis
Problem( Diagnostic Label) and Definition
The diagnostic label is the name of the nursing diagnosis as approved by NANDA International.
Etiology (Related Factors)Are causative or other contributing factors
that have influenced the clients actual or potential responses to the health problem and can be changed by nursing interventions.
Defining Characteristics
Are the cluster of signs and symptoms that indicate the presence of a particular diagnostic label.
References:
Kozier, Barbara, et al. (2004) Assessing, Fundamentals of Nursing: concepts,
process and practice, 2nd ed .Kozier& Erb‘s. Fundamentals of Nursing:
concepts, process and practice, 8th ed.