NURSING PROCESS

68問 • 10ヶ月前

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

PROCESS

➢ 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

NURSING PROCESS

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

1955

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

1960

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

1966

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

1967

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.

1973

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

1973

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

1980

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

1982

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.

1984

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

CURRENT

THREE METHODS OF COLLECTING DATA ASSESSMENT =

ASSESSMENT, OBSERVATION, INTERVIEW, EXAMINATION

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.

ASSESSMENT

SOURCES OF DATA COLLECTION - patient

PRIMARY

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

SECONDARY

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.

SUBJECTIVE

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

OBJECTIVE

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

DIRECTIVE

COLLECTING DATA (rapport building interview)

NON DIRECTIVE

KINDS OF INTERVIEW restrictive, generally requiring short answer.

CLOSED QUESTIONS

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

OPEN ENDED QUESTIONS

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

NEUTRAL QUESTION

KINDS OF INTERVIEW directs the patients answer.

LEADING QUESTIONS

THE ASSESSMENT PROCESS

COLLECTING, ORGANIZE, VALIDATE, RECORDING

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

DIAGNOSIS

official working definition of Nursing Diagnosis

NANDA

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

ACTUAL NURSING DIAGNOSIS

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

RISK NURSING DIAGNOSIS

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.

POSSIBLE NURSING DIAGNOSIS

WRITING A NURSING DIAGNOSIS - ACTUAL NURSING DIAGNOSIS

PATIENT PROBLEM + CAUSE IF KNOWN

WRITING A NURSING DIAGNOSIS Nursing Diagnosis =

PROBLEM + ETIOLOGY + S/S

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

PROBLEM - less than 6 months

ACUTE

PROBLEM - more than 6 months

CHRONIC

PROBLEM - stopping or starting at intervals

INTERMITTENT

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

ETIOLOGY

PROBLEM - odors, lighting, and noises

ENVIRONMENTAL

PROBLEM - language, finances, support system

SOCIOLOGICAL

PROBLEM - fluid deficit/excess

PHYSIOLOGICAL

PROBLEM - rituals, practices, and beliefs

SPIRITUAL

PROBLEM - fear, anxiety, and low self esteem

PSYCHOLOGICAL

DEFINING CHARACTERISTICS - Clusters of cues

SIGNS AND SYMPTOMS

DEFINING CHARACTERISTICS - AEB

AS EVIDENCED BY

DEFINING CHARACTERISTICS - AMB

AS MANIFESTED BY

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.

PLANNING

WRITING A NURSING DIAGNOSIS - RISK NURSING DIAGNOSIS

PROBLEM + RISK FACTORS

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

HIGH PRIORITY

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

MEDIUM PRIORITY

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

LOW PRIORITY

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).

SHORT TERM GOAL

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

LONG TERM GOAL

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

NURSING INTERVENTIONS

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.

INDEPENDENT

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

DEPENDENT

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

IMPLEMENTATION

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

PRE IMPLEMENTATION PHASE

COMPONENTS OF IMPLEMENTATION PHASE - Documenting the implemented intervention.

POST IMPLEMENTATION PHASE

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

TECHNICAL SKILLS

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

INTERPERSONAL SKILLS

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

INTELLECTUAL SKILLS

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)

SOURCE-ORIENTED MEDICAL RECORD

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

PROBLEM ORIENTED MEDICAL RECORD

DIFFERENT WAYS OF NURSES PROGRESS NOTES/CHARTING - SOAPIE

SUBJECTIVE, OBJECTIVE, ANALYSIS, PLAN, INTERVENTION, EVALUATION

DIFFERENT WAYS OF NURSES PROGRESS NOTES/CHARTING - SOAPIER

SUBJECTIVE, OBJECTIVE, ANALYSIS, PLAN, INTERVENTION, EVALUATION, REVISION

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

NARRATIVE CHARTING

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

FOCUS CHARTING

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

EVALUATION

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JHAYS · 5問 · 1年前

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