a series of planned actions or operations directed toward a particular resulta series of planned actions or operations directed toward a particular result

➢ is a systematic, rational method of planning, and providing nursing care. Its goal is to identify a client's health status, actual or potential health problems, to establish plans to meet the identified needs and to deliver specific nursing interventions to meet those needs. ➢ It is the central/core to nursing actions in any setting because it is an efficient method of organizing thought processes for clinical decision making and problem solving. ➢ The basis of nursing actions/essence of nursing

EVOLUTION OF THE NURSING PROCESS The term nursing process was introduced by Lydia Hall Early

EVOLUTION OF THE NURSING PROCESS Dorothy Johnson, Orlando Ida, and Weidenback introduced 3 steps in nursing model: assess, implement, and evaluate

EVOLUTION OF THE NURSING PROCESS Virginia Henderson identified the Nursing Process model as : Observing, measuring, gathering data, and analyzing the findings.

EVOLUTION OF THE NURSING PROCESS 4 step model was proposed: Assessment, Planning. Intervention and Evaluation

EVOLUTION OF THE NURSING PROCESS The use of nursing process in clinical Practice continued to gain additional accuracy and recognition when the ANA published standard of Clinical Nursing Practice.

EVOLUTION OF THE NURSING PROCESS Classification of Nursing Diagnosis began by the NANDA ( North American Nursing Diagnosis Association)

EVOLUTION OF THE NURSING PROCESS ANA published a policy of statement which provided guidelines ( standard) for individual professional nurses to follow in practice.

EVOLUTION OF THE NURSING PROCESS NCLEX( National Council Licensure Examination) was revised to include the Nursing Process as a basis for organization.

EVOLUTION OF THE NURSING PROCESS JCAHO ( Joint commission On accreditation Of Health Organization launched the requirement for accredited hospitals to use the Nursing Process as a means of documenting all phases of client care.

EVOLUTION OF THE NURSING PROCESS The nursing Process is a Five steps Process: (A,Dx,PI,E)

THREE METHODS OF COLLECTING DATA ASSESSMENT =

ADPIE ➢ The collection of data about the health status of the client/patient is systematic and continuous. The data are accessible, communicated, and recorded. ( Standards of Nursing Practice, American Nurses Association, 1973) ➢ Data collection ➢ Process of collecting data for the purpose of identifying actual or potential patient health problems which the professional nurse licensed to treat. ➢ It is the basis of the patient care plan and later assessments contribute to revisions and updates in the plan as the patient’s condition changes. ➢ To establish a database. ➢ Collecting, validating, organizing, and recording data about the patient’s health status.

SOURCES OF DATA COLLECTION - patient

SOURCES OF DATA COLLECTION - records(chart), family members, and other persons giving care to patient, laboratory results,

TYPES OF DATA (symptoms, or covert data) can be described only by the person experiencing it using their own words which includes the individual’s perceptions.

TYPES OF DATA - can be observed and measured, qualitatively and quantitatively. - factual data that are observed by the nurse and could be noted by any other skilled observer. - seen, heard, felt or smelled by observer

COLLECTING DATA - highly structured and elicits specific information.(e.g.emergency situation)

COLLECTING DATA (rapport building interview)

KINDS OF INTERVIEW restrictive, generally requiring short answer.

KINDS OF INTERVIEW lead patient to discover, explore their thoughts and feelings.

KINDS OF INTERVIEW patient can answer without direction or pressure from the nurse.(ex. How do you feel about that?)

KINDS OF INTERVIEW directs the patients answer.

THE ASSESSMENT PROCESS

ADPIE - interpret assessment data - identify client’s strength - identify client’s problems

official working definition of Nursing Diagnosis

TYPES OF NURSING DIAGNOSIS - refer to a problem that exists at the present moment in reality. - client’s response to a health problem that is present at the time of the nursing assessment. It is based on actual presence of signs and symptoms. - EX: Ineffective breathing pattern

TYPES OF NURSING DIAGNOSIS is a clinical judgment that an individual, family, or community is more vulnerable to develop the problem than are others in the same or similar situation. - EXAMPLE: people admitted to a hospital have more possibility of acquiring infection, * High risk for infection

TYPES OF NURSING DIAGNOSIS - the nurse may decide to formulate a tentative - evidence about a health problem is unclear; causative factor is unknown; this requires more data - this is compared to “rule out” of Medical Diagnosis - EX: A woman lives alone-admitted to hospital-nurse notice nobody visits the patient.

WRITING A NURSING DIAGNOSIS - ACTUAL NURSING DIAGNOSIS

WRITING A NURSING DIAGNOSIS Nursing Diagnosis =

WRITING A NURSING DIAGNOSIS Identified label of client’s health condition or response to the Medical illness or therapy for which nursing may intervene. Also Known as “Nursing Diagnosis”

PROBLEM - less than 6 months

PROBLEM - more than 6 months

PROBLEM - stopping or starting at intervals

PROBLEM - Or Cause. One or more probable causes of health problems.

PROBLEM - odors, lighting, and noises

PROBLEM - language, finances, support system

PROBLEM - fluid deficit/excess

PROBLEM - rituals, practices, and beliefs

PROBLEM - fear, anxiety, and low self esteem

DEFINING CHARACTERISTICS - Clusters of cues

DEFINING CHARACTERISTICS - AEB

DEFINING CHARACTERISTICS - AMB

ADPIE - Involves determining beforehand the strategies or course of actions to be taken before implementation of nursing care. - Is a mental formulation of a proposed method of doing or making something in achieving a given end.

WRITING A NURSING DIAGNOSIS - RISK NURSING DIAGNOSIS

MASLOW’S HIERARCHY OF NEEDS - life threatening problems. (loss of cardiac or respiratory functions)

MASLOW’S HIERARCHY OF NEEDS - health threatening problems (acute illness)

MASLOW’S HIERARCHY OF NEEDS one that arises from normal developmental needs or that requires only minimal nursing support.

GOAL is a statement identifying a change in behavior that can be achieved fairly, quickly, usually within a few hours or days (2-3 days).

GOAL indicates an objective to be achieved over a longer period usually over a week or months.

are activities that the nurse plans and must be implemented to help the patient to achieve goals.

TYPES OF NURSING INTERVENTIONS These are those activities that nurses are licensed to initiate on the basis of their knowledge and skills. - Ex. Physical care, Ongoing assessment, Emotional support, and Comfort, teaching, Counselling, Environmental management.

TYPES OF NURSING INTERVENTIONS is those activities carried out under the physician’s order or supervision or according to specified routines.

ADPIE This is the “DOING” phase of the nursing process. Actual implementation of nursing care.

COMPONENTS OF IMPLEMENTATION PHASE - Knowledge of the NCP - Validating the NCP - Knowledge, and skills to implement the nursing intervention competently and efficiently.

COMPONENTS OF IMPLEMENTATION PHASE - Documenting the implemented intervention.

IN PRE-IMPLEMENTATION PHASE (SKILLS) - ability to perform a procedure competently and safely

IN PRE-IMPLEMENTATION PHASE (SKILLS) - communicating with the client and to other members of the health team.

IN PRE-IMPLEMENTATION PHASE (SKILLS) - ability to reason and understand.

TYPES OF RECORDING/DOCUMENTATION a. Admission sheet b. Physician orders sheet c. Medical history sheet d. Nurses notes e. Special records and report (referral form, lab diagnostic/findings)

TYPES OF RECORDING/DOCUMENTATION a. Data base b. Doctor’s order sheet c. Progress notes d. Care plans - Nurse’s progress notes

DIFFERENT WAYS OF NURSES PROGRESS NOTES/CHARTING - SOAPIE

DIFFERENT WAYS OF NURSES PROGRESS NOTES/CHARTING - SOAPIER

DIFFERENT WAYS OF NURSES PROGRESS NOTES/CHARTING notes written in paragraph of 4 hours, patient body temperature will subside from 39-37

DIFFERENT WAYS OF NURSES PROGRESS NOTES/CHARTING (DAR) DATA, ACTION, RESPONSE

ADPIE is assessing the patient’s response to nursing interventions and then comparing the response to predetermined standards or outcome criteria.