Unit 1Nursing Process

Nursing Process

Muhammad BaqarBscN DUHS Karachi

What is Process

It is a series of action.

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

Steps of nursing process

Assessment

Diagnosis

Planning

Implementation

Evaluation

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

Interview Orientation phase Working phase Termination

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.