The Nursing Process:
An organizational framework for the practice of nursing
Orderly, systematic
Central to all nursing care
Encompasses all steps taken by the nurse in caring for a patient
Definition of the Nursing Process:
An organized sequence of problem-solving steps used to identify and to manage the health problems of clients
It is accepted for clinical practice established by the American Nurses Association
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
Is economical
Stresses the independent function of nurses
Increases care quality through the use of deliberate actions
The Nursing Process Utilizes The Following:
Assessment
Nursing Diagnosis
Planning
Implementation
Evaluation
Characteristics of the Nursing Process:
Within the legal scope of nursing
Based on knowledge-requiring critical thinking
Planned-organized and systematic
Client-centered
Goal-directed
Prioritized
Dynamic
Assessment of Well-Being:
According to the World Health Organization is well-being in these domains:
Emotional
Physical
Social
Spiritual
Tools of assessment:
Observation
Interview
Types of questions
Environment (physical and emotional) Spiritual considerations
Examination
Types of Data To Collect:
Objective data-observable and measurable facts (Signs)
Subjective data-information that only the client feels and can describe (Symptoms)
Sources of Data:
Primary source: Client
Secondary source: Client’s family, reports, test results, information in current and past medical records, and discussions with other health care workers
Disease Prevention:
Primary prevention – protection from a disease while still in a healthy state.
Secondary prevention – early detection and treatment of disease.
Tertiary prevention – prevent complications and to maintain health once the disease process has occurred.
Planning:
Establish the goals, interventions and outcomes
General Guidelines for Setting Priorities:
Take care of immediate life-threatening issues.
Safety issues.
Patient-identified issues.
Nurse-identified priorities based on the overall picture, the patient as a whole person, and availability of time and resources.
Nurse Identified Priorities:
Composite of all patient’s strengths and health concerns.
Moral and ethical issues.
Time, resources, and setting.
Hierarchy of needs.
Interdisciplinary planning.
DIAGNOSIS:
Sort, cluster, analyze information
Identify potential problems and strengths
Write statement of problem or strength
Risk of infection related to compromised nutrition
Components of Outcomes:
Subject: who is the person expected to achieve the outcome?
Verb: what actions must the person take to achieve the outcome?
Condition: under what circumstances is the person to perform the actions?
Performance criteria: how well is the person to perform the actions?
Target time: by when is the person expected to be able to perform the actions?
Nursing Interventions:
Road maps directing the best ways to provide nursing care.
Evidence based nursing.
Monitor health status.
Minimize risks.
Resolve or control a problem.
Assist with ADLs.
Promote optimum health and independence.
Interventions:
Direct interventions: actions performed through interaction with clients.
Indirect interventions: actions performed away from the client, on behalf of a client or group of clients.
Documentation:
Clear and concise
Appropriate terminology
Usually on a designated form
Physical assessment
Usually by Review of Systems
Overview of symptoms
Diet
Each body system
Evaluation:
Determining outcome achievement
Identifying the variables affecting outcome achievement
Deciding whether to continue, modify, or terminate the plan
NANDA – North American Nursing Diagnosis Association
Identifies nursing functions
Creates classification system
Establishes diagnostic labels
Risk of infection related to compromised nutritional state
Potential complication of seizure disorder related to medication compliance
Community as Client:
A community-wide group of people as the focus of nursing service
The community directly influences the health of individuals, families, groups, subpopulations, and populations who are a part of it.
Provision of most health services occurs at the community level.
Dimensions of Community as Client:
One perspective:
Status: morbidity & mortality data identifying physical, emotional, and social determinants of health
Structure: services and resources
Process: ability to function effectively
Another perspective:
Location (community boundaries, location of health services, geographic features, climate, flora, fauna, human-made environment)
Population (size, density, composition, rate of growth or decline, cultural characteristics, social class and educational level, mobility)
Social system (variables, health care delivery system)
Nursing Process Characteristics & Community:
Problem-solving process; management process; process for implementing change
Characteristics:
Deliberative; adaptable; cyclic
Client-focused; need-oriented
Interaction with community (communication, reciprocal interaction, paving way for helping relationship, aggregate application)
Forming of partnerships and building of coalitions
Community Needs Assessment:
Process of determining real or perceived needs of a defined community
Types
Windshield survey (familiarization assessment)
Problem-oriented assessment
Community subsystem assessment
Comprehensive assessment (key informants)
Community assets assessment
Community Assessment Methods:
Surveys
Descriptive epidemiologic studies
Community forums/town hall meetings
Focus groups
Sources of Community Data:
Primary: gathered by talking to the people
Secondary: records produced by people who know the community well
International
National
State
Local
Community Diagnoses:
Portray a community focus
Include community response and related factors that have potential for change via CHN; logically consistent; response and factors logically linked
Include statements narrow enough to guide interventions
Use a community response instead of a risk, goal, or need statement
Include factors within the domain of community health nursing intervention
Deficit and wellness diagnoses (include maintenance or potential change responses due to growth and development) when no deficit is present
Planning to Meet Community Health Needs; Implementing Plans:
Planning
Tools for assistance: operational definitions of objectives and activities, conceptual frameworks and models; systematic approach
Health planning process
Implementing
Preparation
Activities or actions
Evaluating Implemented Community Health Plan:
Measuring or judging effectiveness of goal or outcome attainment
Types of evaluation
Formative: focus on process during actual interventions; development of performance standards
Summative: focus on the outcomes of interventions; effect; impact
ACROSS THE COUNTRY STATE HEALTH ORGANIZATIONS NURSING HOMES PRIVATE
ADMINISTRATOR ANDOR DIRECTOR OF NURSING CHANGE THIS FORM IS
AL ALBAYT UNIVERSITY FACULTY OF NURSING ACADEMIC STAFF NAME
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