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Unformatted text preview: Nursing Process Fozia Ferozali RN.,MSN Back Ground The nursing process is based on a nursing theory The developed by Ida Jean Orlando. She developed this Ida She theory in the late 1950's as she observed nurses in action. She saw "good" nursing and "bad" nursing. From her observations she learned that the patient From must be the central character. – Nursing care needs to be directed at improving outcomes Nursing for the patient, and not about nursing goals. – The nursing process is an essential part of the nursing care The plan. The Nursing Process is: A systematic, rational method of planning and systematic, providing individualized nursing care. providing Holistic PhysicalEmotionalPsychosocialDevelopmentalSpiritual Being Medical Diagnosis Rheumatoid Arthritis Nursing Diagnosis Self-care deficit: bathing, related to joint stiffness 5 components of the Nursing Process: 1. Assessment 1. Diagnosis 1. Planning 1. Implementing 1. Evaluating We will only focus on 4 components of the We Nursing Process: Nursing 1. Assessment 1. Diagnosis 1. Planning 1. Implementing 1. Evaluating 1st Component of the Nursing ProcessASSESSMENT: Data Collection – Assessment involves taking vital signs Assessment (TPR BP & Pain assessment. (TPR – Performing a head to toe assessment – Listening to the patient's comments and Listening questions about his health status questions – Observing his reactions and interactions Observing with others. It involves asking pertinent questions about his signs (observable) and symptoms (Non-observable), and listening carefully to the answers. During Assessment, the care During Assessment the provider: provider: A. Establishes A Data Base A. Continuously Updates Continuously The Data Base The A. Validates Data D. Communicates Data D. Communicates 2nd component of the Nursing ProcessPlanning: Planning The establishment of client The goals/outcomes goals/outcomes – Working with the client, to prevent, Working reduce, or resolve problems – To determine related nursing interventions (actions) that are most likely to assist client in achieving goals likely – This is about improving the quality of This life for your patient. – This is about what your patient needs to This do to improve his health status or better cope with his illness. During Planning, the provider: During Planning A. Establishes Priorities B. Writes Client Goals/Outcomes And Writes Develops An Evaluative Strategy Develops C. Selects Nursing Interventions D. Communicates The Plan 3rd Component of the Nursing Process3rd Implementing: The provider carries out the plan of care During Implementing, the care During the provider: provider: Carries Out The Plan Of Nursing Care or Carries Setting your plans in motion and delegating responsibilities for each step. Continues Data Collection And Modifies The Continues Plan Of Care As Needed Plan Documents Care 4th Component of the Nursing Process4th Evaluating: Evaluating The measuring of the extent to which The client goals have been met client Evaluation involves not only analyzing Evaluation the success of the goals and interventions, but examining the need for adjustments and changes as well. The evaluation incorporates all input from the entire health care team, including the patient. including During Evaluating, the care provider: During Evaluating Measures The Clients Achievement Of Measures Desired Goals/Outcomes Desired Identifies Factors That Contribute To Identifies The Client’s Success Or Failure Client’s Modifies The Plan Of Care, If Modifies Indicated Indicated Purpose of the nursing process: To Achieve ScientificallyTo Based, Holistic, Individualized Care For The Client Care To Achieve The Opportunity To To Work Collaboratively With Clients, Others Clients, To Achieve Continuity Of Care Characteristics: a. Systematic Systematic – The nursing process has an ordered sequence of activities and each The activity depends on the accuracy of the activity that precedes it and influences the activity following it. influences b. Dynamic – The nursing process has great interaction and overlapping among the The activities and each activity is fluid and flows into the next activity activities c. c. Interpersonal Interpersonal – The nursing process ensures that nurses are client-centered rather The than task-centered and encourages them to work to enhance client’s strengths and meet human needs strengths d. Goal-directed – The nursing process is a means for nurses and clients to work The together to identify specific goals (wellness promotion, disease and illness prevention, health restoration, coping and altered functioning) that are most important to the client, and to match them with the appropriate nursing actions with e. Universally applicable Universally – The nursing process allows nurses to practice nursing with well or ill The people, young or old, in any type of practice setting people, The Whole Patient The nursing process involves looking at the whole The patient at all times. It personalizes the patient. He is not "the CVA in 214B." not It also forces the health care team to observe and It interact with the patient, and not just the task they are performing such as a dressing change, or a bed bath. The process provides a roadmap that ensures good nursing care and improves patient outcomes. nursing ...
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