Nursing Process. Associate Professor W. Kusoom

Transcription

1 Nursing Process By Associate Professor W. Kusoom

2 Nursing Process The nursing process enables the nurse to organize and deliver nursing care. The nursing process involves scientific reasoning. The nursing process is used to identify, diagnose and treat human responses to health and illness.

3 Nursing Process = Critical Thinking Approach

4 Nursing Process NURSING STANDARD PROCESS NURSING

5 Nursing Process Includes 5 steps Assessment Evaluation Nursing Diagnosis Analysis Implementation Planning

6 Assessment The assessment must be relevant to particular health problem. The nurse uses critical thinking to collect and analyze data to determine what is relevant for the assessment database.

7 Types of Data During assessment, the nurse must obtains two types of data. These are Subjective data Objective data

8 Subjective data Subjective data Are clients perception about their health problems. For example, the presence of pain or meaning of an illness.

9 Objective data Objective data are observation or measurements made by the data collector.

10 Method of data collection Interview, is a pattern of communication. Physical assessment Nursing assessment Medical record

11 ICU Patient& Environment

12 ICU Patient

13 Nursing diagnosis A nursing diagnosis is a statement that describes the client s s actual or potential response to health problem is licensed and competent to treat. Nursing diagnose provide the basis for selection of nursing interventions to achieve outcome for which the nurse is accountable.

14 Nursing Diagnosis Statement Diagnostic Label + Diagnostic = Label Related to (RT)

15 Nursing diagnosis Impaired skin integrity related to decreased mobility Risk for infection related to poor nutritional intake

16 Nursing Dx 1. Acute pain RT Tubal rupture 2. Risk for fluid volume deficit RT hemorrhagic loss, tricted fluid 3. Anxiety RT pain& threat of dead

17 Evolution of Nursing Diagnosis In 1973, the first national conference for the classification and of nursing diagnosis was held to identify nursing functions and established a classification system.

18 NANDA North American Nursing Diagnosis Association NANDA s work provides a common language for the health problems nurses deal with. ANA has officially sanctioned NANDA as the organization to govern the development of a classification system of nursing diagnosis.

19 3 Type of NANDA International Dx 1. Actual nursing diagnosis 2.Risk nursing diagnosis 3.Wellness nursing diagnosis=potential

20 Nursing Dx 1.Ineffective airway clearance RT thickened mucus secretion 2.Activity intolerance RT imbalance O2 supply and demand 3.Pain RT inflammation& effect of circulating toxin

21 Collaborative problem = Actual /potential problems = Nurses intervention with other health care Ineffective airway clearance RT tracheo bronchial secretion Wound infection RT.. Impaired gas exchange RT Decrease cardiac output RT preload

22 Planning for Nursing Care Planning for Nursing Care is a category of nursing behaviors in which client- centered goal and expected out comes are established and nursing intervention.

23 Planning for Nursing Care Nursing Dx Pain related to Incisional swelling Expect Outcome -Pain decrease by 3/10 -Respiratory expansion Nursing Plan/ Nursing Order 1.Drug administered (MO 4 mg dilute 1:1) V push slowly as order 2.Instruct patien in relaxation exercise. 3.Encourage patient to log roll when turning.

24 Implement Cognitive skills= know the rationale Interpersonal skills=clients Psychomotor skills= as level as level competence

25 Nursing Implementation

26 Nursing Dx is not Medical Dx Nursing Dx = is describes the response to health problem Medical Dx =is Diagnoses disease

27 Qualifiers for Diagnosis Acute= Severe but short duration Alter= a change from baseline Chronic= Lasting along time, recurring, constant Chronic= Decrease= lessened Increase = greater in size Deficient=inadequate in amount, not sufficient Depleted= empty, exhausted of.. Disturbed= agitated, interrupted Dysfunction=abnormal

28 Qualifiers for Diagnosis Excessive= Qualtity is greater Impaired =made worse, damage Ineffective =Not producing the desired effect Potential for =powerful Risk =hazard, chance of loss Hypothermia= body temperature is reduced below normal Hypothermia= Hyperthermia =body temperature is elevated above normal Enhanced = made greater, increase quality

29 Exercise.. Bronchitis? S&S :-: ก - 32 / Ronchi - ก - ก Please translate to Enghlish & Nursing diagnose and care plan