nursing process

Nursing processNs. Djolly sambeka

THE NURSING PROCESS

The nursing process is based on theory developed by Ida Jean Orlando[1950]She observb nurses in action and she saw[good and bad nursing] Patient must be the central character; -.Nursing care needs to be directed at improving, out comes for the patient. not about nursing goals -.the nursing process is essential part of the nursing care planning.

• The nursing Process• The nursing process is a systematiec,decision

making process that involves Assess ment [data collection] nursing diagnosis ,planning,,and implementation and uses evaluation

• The process as a whole is cyclic,the steps being interrelated,interdependent and recurrent

• The nursing process is asystematic, rational method of planning and providing Individualized nursing care

• OR The nursing process is good orented method or caring the provides a frame

Work to nursing care.

5 Steps of Nursing Process Assessment,Nursing Diagnosis, Planning,

Implementation and evaluation

1.Assessment• The nurse completes an holistic nursing

assessment of the needs of the [individual/Family/ community,regardless of the ratio for the encounter

• Holistic;Physical,emotional,phychosocial,developmental,sp

iritual being• Nursing assessment provide the starting poin

for determining nursing diagnosis it is vital a recognized

• To identifythe patient Problem,Risk.

• Data subjective• -.client interview [name ID]GENERAL INFORMATION.• -.client perception of stressor or problem• -.current occupational or work situation• -.any somatic complaints• -.or defficulties sexual activity• • Data objective• -.Physical examination• -.Taking V/S [T,P,R,BP,Pain assessment]• -.Performing a head to toe assessment• -.listen patient comment and question about health status [• family history report including dietary• -.Observing reaction,interaction with others,it involves asking • pertinent questions about his signs• Any symtoms and lestening carefully to the answer

• During Assessment the care provider;• A.Established a data base• B.Continuously updates the data • C.Validates data • D.Comunicates data

2.NURSING DIAGNOSIS

• Is the nurse,s clinical judgment about the client respon to actual or potential health condition the dx not only the pain but the caused other problem

such as anxiety,poor nutrition,conflict With family or potential complication ;respiratory

infection So nursing diagnosis is the basic for the nurse,s care

plan [multiple nursing diagnosis maybe more for one klien]

3.PLANNINGIn agreement with the client[nurse addresses

each problem identified nursing diagnosing]– Multiple nursing DX [The nurse prioritizes which te

most attention according to;– Severity,potential causing more serious harm– For each problem a measurable goal/outcome is set– THE ESTABLISHMENT OF CLIENT GOAL/OUTCOMES.– WORKING WITH CLIENT,to prevent,reduce,or

resolved problem

– to determine related nursing intervention[action ]that are most likely to assist client in achieving Goals

– This is about improving the quality of life for your client

– This is about what your client needs to do to improved health status or better cope with his illness

• 4.Implementation - the implementation phase of of the nur- sing process is the actual initiation of the care plan - patient outcome/ goalare achieved by nur- se performance of nursing intervention - during the phase the nurse continues to assess the patient to determine or whe- ther intervention are effective

- or carries out the plan of nursing care or setting your plans in motion and delega- ting responsibilities for each step - continues data collection and modifies the plan of care as needed - documents care.[an important part of this phase is documentation ,

• -documention is necessary for legal reason• because in legal dispute’’ If it wasn’t • charted, it wasn’t done or no documen-• tion you do nothing

5. Evaluation -the measuring of the extend to which client goals have been met or the nurse

– evaluates the progress towar the goal– outcome identified in the previous phase– if progress towars hthe goal is slow or regression

has occurred the nurse must change the plan of care accordingly

– evaluation involves not only analysing success of the goals and intervention,but examining the need for adjustments and changes as wel

– if the goal has been achieved then the are can cease.

– the evaluation incorporates all input from the entire health care team,including the patient.

– and during evaluathing the care provider– [measures the patients achievement of desire

gaols /outcome,identifies factors that contribute to the patients successor failure]

– modifies the plan of care,if indicated new

problems may be identified at this stage and thus the process will start all over again.

Thank You