prepared by Mrs.Hamdia Mohammed

1-Define nursing process 2-Define nursing care plan 3- List the basic components of the Nursing Process. 3-Enumerate items of planning process. 4- Apply nursing process on situation. 5- Explain 2 different example from nursing care plan.

The Nursing Process is : A systematic, rational method of planning and providing individualized nursing care.

A written guide, organizing client data into a formal statements of strategies to assist the client achieve optimal health

 Assessment  Diagnosis  Planning  Implementing  Evaluating

The Planning process:- In the process of developing client care plans, the nurse engages in the following activities: 1- Setting Priorities. 2- Establishing client goals /desire outcomes 3- Selecting nursing interventions 4- Writing individualized nursing interventions on care plans.

Mrs. Mona Ali have 43 years old, admitted to hospital in H. She complain from sharp chest pain when coughing and dyspnea on exertion. States unable to carry out regular daily exercise for past week.Nausea & vomiting associated with coughing. Assesses own supports as good (e.g. relationship with husband) is worried about daughter. States husband will be out of town until tomorrow. Concerned too about her work and worry about it.

Evaluati on InterventionGoal/Desired outcomes Nursing diagnosis The pt Do coughing & breathing exercise And breaths effectively 1- Assess airway for patency. 2-Auscultate lungs for presence of normal or abnormal breathing sounds 3-Assess changes in V.S 4-Assess cough for effectiveness & productivity ( color, amount odor& consistency). Long term goal:- Respiratory status : Gas exchange. Short term goal:- -Absence of pallor and cyanosis - Pt will be able to use of correct breathing /coughing technique -Productive cough -Lung clear 1- Ineffective airway clearance Related to viscous secretions as evidenced by pain and fatigue.

5-Assist pt in performing coughing & breathing exercise( chest physiotherapy ). 6-Put pt in sitting position ( optimal position)& use of abdominal muscles for more forceful cough. 7-Encourage oral intake of fluids. 8- Administer medications( e.g antibiotic, bronchodilators, expectorants) as ordered. 9- Give pt nebulizer treatment if indicated.

EvaluationInterventionGoal/Desire d outcomes Nursing diagnosis Pt demonstrate That he is increase oral fluid intake & return to normal skin turgor. 1- Assess characteristic of vomiting (amount, odor, color,...). 2- Evaluate fluid status in relation to dietary intake. 3- Check V.S 4-Assess skin turgor for signs of dehydration. Long term goal:- Fluid balance. Short term goal:- -Good skin turgor -Moist mucous membranes. -Stating the need for oral fluid intake. 2-Deficient fluid volume: intake insufficient to replace fluid loss R/T vomiting aeb poor skin turgor

5-Assess intake & output. 6- Monitor serum electrolytes & report abnormal value. 7-Administer antiemetic drug as order. 8- Give pt I.V fluid as replacement therapy if indicate as doctor ordered.

Evaluatio n InterventionGoal/Desired outcomes Nursing diagnosis Pt verbalize that she or he return to normal psycholo- gical status 1- Reassure the pt. 2- Maintain a calm manner while interacting with pt. 3- Provide a quite environment. 4- Encourage her to talk about anxious feeling Long term goal:- Anxiety control. Short term goal:- Freely expressing concerns and possible solutions about work and parenting roles. 3-Anxiety R/T family and work problems aeb concerns about work and parenting roles.

5- Assist the pt in developing anxiety- reducing skills ( e.g, relaxation, deep breathing, positive visualization ). 6- Assist pt in developing problem solving abilities. - Emphasize the logical strategies pt can use when experiencing anxious feelings.

Evaluati on InterventionGoal/Desired outcomes Nursing diagnosis Pt verbalize that she or he return to normal psycholo -gical status 1- Assess for precipitating events ( illness, life transition, crisis). 2- Assess family member’s perceptions of the problem. 3- Evaluate strengths, coping skills & current support systems. Long term goal:- Family coping. Short term goal:- Client and husband communicating effectively and working together to solve problems. 4-Risk for interrupted family processes R/Tmother's illness and temporary unavailability of father to provide child care, AEB concerns about parenting roles.

EvaluationinterventionPatient goalNursing diagnosis Patient list the time of washing arms and legs 1-talking with patient 2-reassure him 3-tell the importance of hygiene ……. Will experience no self care hygiene deficit by 4 days Self Care Deficit: Bathing /Hygiene R/T lack of motivation secondary to depression AEB Unwilling to wash body parts Example of writing nursing care plan

EvaluationInterventionsPatient goalNursing diagnosis Pt increase daily exercise & change his position continuous. 1- change position frequently 2-back rub 3-skin care 4-increase fluid intake 5- increase protein intake……. Pt. will experience no any signs of skin breakdown Risk for impaired skin integrity r/t decreased mobility Example of writing nursing care plan cont.