Fereshteh Mazhari RN.,MSN Nursing Process Fereshteh Mazhari RN.,MSN

Back Ground The nursing process is based on a nursing theory developed by Ida Jean Orlando. She developed this 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 must be the central character. Nursing care needs to be directed at improving outcomes for the patient, and not about nursing goals. The nursing process is an essential part of the nursing care plan.

تعریف فرآیند پرستاری فرآیند پرستاری چارچوبی برای برنامه ریزی و اجرای مراقبت های پرستاری برای بیمار و خانواده اش است. فرآیند پرستاری روشی سیستماتیک برای تفکر پرستار است. چارچوبی از فعالیت های مرتبط به هم، پویا، مداوم، علمی و مشکل مدار است. راهی سازمان یافته برای تشخیص عکس العمل های بیماران نسبت به بیماری و کاهش سلامتی یا درمان است.

Benefits of Nursing Process Provides an orderly & systematic method for planning & providing care Enhances nursing efficiency by standardizing nursing practice Facilitates documentation of care Provides a unity of language for the nursing profession Is economical Stresses the independent function of nurses Increases care quality through the use of deliberate actions

5 components of the Nursing Process: Assessment Diagnosis Planning Implementing Evaluating

We will only focus on 4 components of the Nursing Process: Assessment Diagnosis Planning Implementing Evaluating

Benefits of using the nursing process Continuity of care Prevention of duplication Individualized care Standards of care Increased client participation Collaboration of care

مراحل فرآیند پرستاری 1- ASSESSMENT در این مرحله که می توان آن را به شکل رابطه زیر نشان داد جمع آوری اطلاعات + تجزیه و تحلیل اطلاعات + تشخیص پرستاری اینکه هر گونه اطلاعاتی را جمع آوری کنیم درست نیست، بلکه پرستار باید در جمع آوری اطلاعات مهارت داشته باشد و فقط اطلاعات مربوط را جمع آوری کند.

جمع آوری اطلاعات بطور کلی از طریق دو فرم تاریخچه پرستاری و بررسی وضعیت سلامت انجام می شود. انواع داده ها عینی : علایم و رفتارهایی که پرستار مشاهده و بر اساس آن قضاوت می کند. objective data ذهنی : اطلاعاتی که بیمار به پرستار می دهد. Subjecthve data انواع روش های جمع آوری داده مشاهده : Observation مصاحبه : Interview معاینه : Examination (اندازه گیری) (Measurement)

ASSESSMENT: Observation Interview Types of questions Environment (physical and emotional) Spiritual conciderations Examination

Types of Data To Collect: Objective data-observable and measurable facts (Signs) Subjective data-information that only the client feels and can describe (Symptoms

Resources Client Other individuals Previous records Consultations Diagnostics studies Relevant literature

جمع آوری اطلاعات مهارت های لازم برای جمع آوری اطلاعات شامل : الف – مشاهده : تمرین و تکرار ب – مصاحبه گوش کنید و سئوال کنید. مشاهده کنید و تفسیر کنید. اطلاعات بدست آمده را با هم ترکیب کنید. اطلاعات را ثبت کنید. ج – بکار بردن قدرت تعقل (Wisdom )، قضاوت ( Judgment)، حضور ذهن ( Tact ) و استفاده از تجارب خود.

1st Component of the Nursing Process- ASSESSMENT: Data Collection Assessment involves taking vital signs (TPR BP & Pain assessment. Performing a head to toe assessment Listening to the patient's comments and questions about his health status Observing his reactions and interactions 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 provider: Establishes A Data Base Continuously Updates The Data Base Validates Data D. Communicates Data

Sources of Data Primary source: Client Secondary source: Client’s family, reports, test results, information in current and past medical records, and discussions with other health care workers

تجزیه و تحلیل اطلاعات این مرحله به منظور سازمان دادن به اطلاعات، پیدا کردن تناقض ها و درک اطلاعات از طریق رابطه زیر انجام می شود : مروری بر اطلاعات + تفسیر اطلاعات شناخت مشکل

Nursing diagnosis “A clinical judgment about individual, family or community responses to actual or potential heal problems / life processes. A nursing diagnosis provides the basis for selection of nursing interventions to achieve outcomes for which the nurse is accountable

تشخیص پرستاری NURSING DIAGNPSIS تشخیص پرستاری مشکل بالفعل و یا بالقوه بیمار است و برای حل، کاهش یا سازش بیمار ضرورت دارد. بالفعل (موجود) : Present N.D انواع تشخیص های پرستاری بالقوه (احتمالی) : Potential N.D ممکن : N.D Tentative or Possible

Medical vs. Nursing diagnosis Medical diagnosis Nursing diagnosis Identifies conditions the MD is licensed & qualified to treat Identifies situations the nurse is licensed & qualified to treat

Medical vs. Nursing diagnosis Medical diagnosis Nursing diagnosis Identifies conditions the MD is licensed & qualified to treat Identifies situations the nurse is licensed & qualified to treat Focuses on illness, injury or disease processes Focuses on the clients responses to actual or potential health / life problems

Medical vs. Nursing diagnosis Medical diagnosis Nursing diagnosis Remains constant until a cure is effected Changes as the clients response and/or the health problem changes

Medical vs. Nursing diagnosis Medical diagnosis Nursing diagnosis Remains constant until a cure is effected Changes as the clients response and/or the health problem changes i.e. Breast cancer i.e. Knowledge deficit Powerlessness Grieving, anticipatory Body image disturbance Individual coping, ineffective

Diangosis Nursing diagnosis Medical diagnosis Breathing patterns, ineffective Chronic obstructive pulmonary disease Activity intolerance Cerebro vascular accident Pain Appendectomy Body image disturbance Amputation Body temperature, risk for altered Strep throat

NURSING DIAGNPSIS Present N.D Potential N.D Tentative or PossibleN.D Risk of infection related to compromised nutrition Tentative or PossibleN.D Potential for effective breastfeeding related to knowledge level and support system Problem + Etiology + Sign & Symptom

Problem + Etiology + Sign & Symptom تشخیص پرستاری نحوه نگارش انواع تشخیص های پرستاری : Problem + Etiology + Sign & Symptom باید دقت نمود که تشخیص ذکر شده مختصر، اختصاصی، مربوط به یک مشکل و با توجه به اطلاعات به دست آمده باشد. مثال: یبوست در رابطه با کاهش فعالیت که مشخص شده با کاهش دفعات مدفوع

تشخیص موجود: مثال : تخلیه غیر موثر راه هوایی در رابطه با ضعف شدید که مشخص شده است با سرفه غیر موثر. تشخیص احتمالی: خطر آسیب در رابطه با تغییر در حرکت و حالت گیجی در این تشخیص قسمت سوم (علائم) وجود ندارد. تشخیص ممکن: احتمال کاهش حجم مایعات در رابطه با استفراغ مکرر برای سه روز که مشخص شده با افزایش ضربان قلب

مراحل فرآیند پرستاری (برنامه ریزی) 2- PLANING از طریق رابطه زیر نشان داده می شود : تعیین اولویت ها + تعیین اهداف + برنامه تدابیر پرستاری

تعیین اولویت ها منظور این نیست که یک مشکل به طور کامل حل شود بدون اینکه مشکلات دیگر در نظر گرفته نشوند. نیازهای حیاتی مشکلاتی که بیمار اظهار می کند نکات ضروری مشکلات بالقوه منابع قابل دسترس، پرسنل و زمان مورد نیاز

Prioritizing the nursing diagnosis Maslow’s hierarchy of needs

Maslow’s Hierarchy of Needs

تعیین اهداف در واقع منظور از هدف، نتایج مراقبت پرستاری یا تغییر در وضعیت سلامت بیمار یا عملکرد اوست. کوتاه مدت ( مراقبت های ویژه، اورژانس و ریکاوری) انواع هدف بلند مدت (پیشگویی برای مددجو) معیار : رفتار بیمار + معیار انجام دادن کار + زمان + موقعیت

Planning & Outcome identification Identifying outcomes Goals An aim, intent or end. Short term goals Hours to days (less than a week) Long term goals Weeks to months

General Guidelines for Setting Priorities Take care of immediate life-threatening issues. Safety issues. Patient-identified issues. Nurse-identified priorities based on the overall picture, the patient as a whole person, and availability of time and resources.

برنامه تدابیر پرستاری این مرحله با توجه به اولویت های تعیین شده و اهداف در نظر گرفته شده طراحی می شود . در واقع در نظر گرفته می شود چه فعالیتی، چه وقت، چه مدت و چگونه باید انجام شود. همچنین تاریخ و زمان انجام فعالیت ها هم باید قید گردد.

Planning & Outcome identification Developing specific nursing interventions Independent nursing interventions No order needed Elevate edematous legs Interdependent nursing interventions In conjunction with an interdisciplinary team member Assist client with physical therapy exercises Dependent nursing interventions Require an order Administering of medications

The provider carries out the plan of care Implementing: The provider carries out the plan of care

Nursing Interventions Road maps directing the best ways to provide nursing care. Evidence based nursing. Monitor health status. Minimize risks. Resolve or control a problem. Assist with ADLs. Promote optimum health and independence.

Interventions Direct interventions: actions performed through interaction with clients. Indirect interventions: actions performed away from the client, on behalf of a client or group of clients.

During Implementing, the care provider: Carries Out The Plan Of Nursing Care or Setting your plans in motion and delegating responsibilities for each step. Continues Data Collection And Modifies The Plan Of Care As Needed Documents Care

Documenting the Plan of Care To ensure continuity of care, the plan must be written and shared with all health care personnel caring for the client. Consists of: Prioritized nursing diagnostic statements. Outcomes. Interventions.

مراحل فرآیند پرستاری (ارزشیابی) 4- EVALUATION تعیین واکنش بیمار نسبت به تدابیر پرستاری از طریق رابطه زیر نشان داده می شود ارزشیابی دستیابی به هدف + مروری بر فرآیند پرستاری چه مراقبت هایی انجام شده . اطلاع از کیفیت مراقبت (مروری بر گزارشات بیمار و مقایسه با استانداردها راهی برای بررسی کیفیت مراقبت های انجام شده است). منبعی برای تحقیق. مورد استفاده دیگران بودن.

Evaluating: The measuring of the extent to which client goals have been met Evaluation involves not only analyzing 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.

During Evaluating, the care provider: Measures The Clients Achievement Of Desired Goals/Outcomes Identifies Factors That Contribute To The Client’s Success Or Failure Modifies The Plan Of Care, If Indicated

Evaluation 5th step Determining whether the clients goals have been met, partially met or not met.

Purpose of the nursing process: To Achieve Scientifically- Based, Holistic, Individualized Care For The Client To Achieve The Opportunity To Work Collaboratively With Clients, Others To Achieve Continuity Of Care

Characteristics: a. Systematic b. Dynamic d. Goal-directed The nursing process has an ordered sequence of activities and each activity depends on the accuracy of the activity that precedes it and influences the activity following it. b. Dynamic The nursing process has great interaction and overlapping among the activities and each activity is fluid and flows into the next activity c. Interpersonal The nursing process ensures that nurses are client-centered rather than task-centered and encourages them to work to enhance client’s strengths and meet human needs d. Goal-directed The nursing process is a means for nurses and clients to work 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 e. Universally applicable The nursing process allows nurses to practice nursing with well or ill people, young or old, in any type of practice setting

مزیت فرآیند پرستاری اطمینان و اعتماد رضایت شغلی برای پرستاران رشد و پیشرفت حرفه پرستاری تعیین استانداردهایی برای پرستاری بالینی شرکت بیمار در مراقبت از خود برای بیماران تداوم مراقبت ها افزایش کیفیت مراقبت های انجام شده

The Whole Patient The nursing process involves looking at the whole patient at all times. It personalizes the patient. It also forces the health care team to observe and 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.