Nursing process Unit two 9/14/2018

Nursing process: Definition: Is a systematic process, rational method of planning which nurses deliver care to individual, families and community. 9/14/2018

The goal of nursing process: Identify client health care status. Actual and potential health problem. Establish plan to meet the need. 9/14/2018

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. 9/14/2018

Stages of the nursing process: Assessment Diagnosis Planning Implementation Evaluation 9/14/2018

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Characteristic of nursing process: Provide the framework for care. It is client center. Adapted of problem solving technique. It has planned. It is cyclic and dynamic. 9/14/2018

1) Assessment: Definition: Is the systematic and continuous collection, organization, validation, documentation of data. 9/14/2018

Initial assessment: to establish complete data base after admission. Type of assessment: Initial assessment: to establish complete data base after admission. Problem focused assessment: to determine the status of specific problem integrated with nursing care. Emergency assessment: identify the life-threatening problem. Time lapsed assessment: several month, to compare the client status. 9/14/2018

Is the process of gathering information about client health status. Data collection: Is the process of gathering information about client health status. The collection of patient data is vital steps in nursing process because the remaining steps depend on these steps. Characteristic of data: Complete. Accurate Relevant. 9/14/2018

The data will collect through: Nursing history physical examination Lab results. Review records and literature 9/14/2018

Nursing health history: Biographic data: Client name, address, age, sex, marital satus, occupation, religious, assurance, Date and time of history. 2. Chief complain: The answer given to question "what brought you to the hospital? The chief complain should record in own patient word. Ex: my stomach hurts or I have come for my regular check up. 9/14/2018

History of present pain: Location. Radiation. frequency Timing and duration. Quality Factors aggravated or alleviated. Associated symptoms 9/14/2018

Allergy ( drug, egg, animals and insect). Surgeries Hospitalization. Past History: Immunization. Childhood illness( measles, mumps, streptococcal infection and rheumatic fever). Allergy ( drug, egg, animals and insect). Surgeries Hospitalization. Medication ( aspirin, laxatives, antihypertensive) 9/14/2018

Risk factor certain disease Family history: Risk factor certain disease Cancer, hypertension. Angina, bleeding tendency. Life style: Personal habits: tobacco, alcohol, coffee, tea. Diet description: high fat diet. High salt. sleep pattern. Hoppies. 9/14/2018

Example Blood pressure reading, pulse, redness, cyanosis.. Type of data: Subjective data: (symptoms), only client can be described. Such as itching, pain, feeling, I feel weak all over. Objective data: (signs ) are detectable by observe or can be measured, it can be seen, heard. Example Blood pressure reading, pulse, redness, cyanosis.. 9/14/2018

Primary: always the patient Source of data: Primary:  always the patient Secondary: family, other health care personnel, medical records, lab reports. 9/14/2018

Data collection method: Observing: is the conscious use of the five senses to gather information. Example: flushed face. 2. Interview: Is a planned communication or conversation with purpose for example to get or to give information or to identify problem. 9/14/2018

There are two approaches to interview: Directive interview: is highly structured and elicit specific information. Non directive interview: the nurse allow the client to control the purpose. 9/14/2018

physical examination: Techniques of Physical Assessment: 1) Inspection 2) Palpation 3) Percussion 4) Auscultation 9/14/2018

visual exam e.g.: flush, cyanosis. 2) Palpation: Inspection : visual exam e.g.: flush, cyanosis.  2) Palpation: gather data with hands via sense of touch feel skin and underlying tissue to detect/describe: temp, texture, vibration, pulsation, mass, size, tenderness. 3) Percussion: Tap body surfaces to produce vibration and sound  4) Auscultation Listen to sounds produced by body heart, lung , bowel sounds, BP 9/14/2018

Nursing Diagnosis: A statement that describes actual or potential health problems that can be prevented or resolved by independent nursing intervention NANDA Definition: (North America Nursing Diagnosis Associate) Nursing diagnosis is a clinical judgment about individual, family, or community responses to actual and potential health problems/life processes. 9/14/2018

Purpose: Nursing Diagnosis “provides the basis for selection of nursing interventions to achieve outcomes for which the nurse is accountable” 9/14/2018

Difference Between Nursing and Medical Diagnosis Nursing Diagnosis- statement used to describe the client’s actual or potential response to a health problem that a nurse is licensed and competent to treat i.e.-Impaired skin integrity, Risk for Infection, etc. Medical Diagnosis-physician’s clinical judgment of the disease- i.e. diabetes mellitus, give insulin, 9/14/2018

It contains three parts: Problem: 1) Identifies unhealthy response 2) Indicates what should change Etiology: 1) Identifies causative or contributing factors Sign and symptom: redness, cyanosis, loss of appetite. It called PES system. 9/14/2018

The words ‘related to’ are used to identify the cause of the problem. Example: problem Etiology Sign Ex:  Anxiety related to Fear of death manifested by patient verbalization.   Ex: Activity intolerance related to obesity manifested by body weight 140 KG. The words ‘related to’ are used to identify the cause of the problem. . 9/14/2018

Select nursing intervention. Write nursing order. Record and modify. Planning: Is systematic phase of the nursing process that involves decision making. Planning process: Prioritize problem. Formulate goal. Select nursing intervention. Write nursing order. Record and modify. 9/14/2018

Implementation: is the phase in which the nurse puts the nursing care plan in to action. Process of implementation: Reassessing the client. Determine the nurse need for assistance. Implementing. Supervising. Document the action. 9/14/2018

Evaluation: Determine the client progress to ward goals achievement and effectiveness of the nursing care plan. Examples: The goal met. The goal not met. The goal partially met. 9/14/2018

On chest, auscultation reveals respiratory crackles. Case study: Mrs. A 23 years old admitted to the hospital, married, the temperature is elevated, productive cough, rapid respiration with difficulty. 1) Assessment: V/S are temperature 39.1C, pulse 92 b/m, respiration rate 28 b/m and blood pressure 122/80 mmhg. nurse observe that Mrs. A is dry skin, her cheeks are flushed, she is experience of chill. On chest, auscultation reveals respiratory crackles. 9/14/2018

respiration with difficulty. 3) Planning: Goal: 2) Diagnosis: Ineffective breathing pattern related to accumulation of secretion as manifested by productive cough, rapid respiration with difficulty. 3) Planning: Goal: The patient will able to breath normally within hours . Restore effective breathing pattern. Interventions: Deep breathing exercise. Increase fluid intake, Bronchodilator medications. 9/14/2018

4) Implementation: 5) Evaluation: Mrs. A agree to practice: Deep breathing exercise . Increase the fluid intake. Take bronchodilator medications. 5) Evaluation: (The goal not met) the nurse detects failure of the client to breath normally, the plan modify to reach normal breathing and then reevaluation. 9/14/2018