Nursing processAn over view

Nursing process:
Definition:
Is a systematic process, rational method of planning which nurses deliver care to individual, families and community
The Nursing process is often remembered by the acronym ADPIE
Assessment of patient s needs
Diagnosis (of human response needs that nursing can assist with
Planning (of patient s care
Implementation of care
Evaluation (of the success of the implemented care
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
Assessment:
Definition: Is the systematic and continuous collection, organization, validation, documentation of data.
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
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.Biographic data:
Client name, address, age, sex, marital status, 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.
History of present pain:
Location.
Radiation.
frequency
Timing and duration.
Quality and quantity.
Factors aggravated or alleviated.
Associated symptoms
Past History:
Immunization.
Childhood illness( measles, mumps, streptococcal infection and rheumatic fever).
Allergy ( drug, egg, animals and insect).
Surgeries
Hospitalization.
Medication ( aspirin, laxatives, antihypertensive)
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.
Hopis.
Type of data:
Subjective data: (symptoms, covert data), the client only client can be described. Such as itching, pain, feeling, I feel weak all over.
Objective data: referred to as (signs or overt data) are detectable by observe or can be measured, it can be seen, heard.
Example Blood pressure reading, pulse, redness, cyanosis.
Blood pressure: 90/ 50 mmHg
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
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, 1800 caloric diet and moderate exercise.
Diagnosis is the second phase of the nursing process.
Analyze data
Identify health problem and risk.
Identify the characteristic of nursing problem.
state nursing diagnosis in concise way and precisely
It contains three parts:
Problem:
1) Identifies unhealthy response
2) Indicates what should change
Etiology:
1) Identifies causative or contributing factors
suggests nursing interventions
Sign and symptom: redness, cyanosis, loss of appetite.
It called PES system.
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.
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.
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.