Nursing Process
Fozia Ferozali RN.,MSN
Back Ground
The nursing process is based on a nursing theory developed by Ida Jean Orlando. She developed this theory in the late 1950's as she observed nurses in action. She saw "good" nursing and "bad" nursing. From her observations she learned that the patient must be the central character.
– Nursing care needs to be directed at improving outcomes for the patient, and not about nursing goals. – The nursing process is an essential part of the nursing care plan.
The Nursing Process is:
A systematic, rational method of planning and providing individualized nursing care.
Holistic
PhysicalEmotionalPsychosocialDevelopmentalSpiritual Being
Medical Diagnosis
Rheumatoid Arthritis
Nursing Diagnosis
Self-care deficit: bathing, related to joint stiffness
5 components of the Nursing Process:
1. 2. 3. 4.
Assessment Diagnosis Planning Implementing
5.
Evaluating
We will only focus on 4 components of the Nursing Process:
1. 2. 3. 4.
Assessment Diagnosis Planning Implementing
5.
Evaluating
1st Component of the Nursing ProcessASSESSMENT:
Data Collection
– Assessment involves taking vital signs (TPR BP & Pain assessment. – Performing a head to toe assessment – Listening to the patient's comments and questions about his health status – Observing his reactions and interactions with others. It involves asking pertinent questions about his signs (observable) and symptoms (Non-observable), and listening carefully to the answers.
During Assessment, the care provider:
A.
Establishes A Data Base Continuously Updates The Data Base Validates Data
B.
C.
D. Communicates Data
2nd component of the Nursing ProcessPlanning:
The establishment of client goals/outcomes
– Working with the client, to prevent, reduce, or resolve problems – To determine related nursing interventions (actions) that are most likely to assist client in achieving goals – This is about improving the quality of life for your patient. – This is about what your patient needs to do to improve his health status or better cope with his illness.
During Planning, the provider:
A. Establishes Priorities B. Writes Client Goals/Outcomes And Develops An Evaluative Strategy C. Selects Nursing Interventions D. Communicates The Plan
3rd Component of the Nursing Process-
Implementing:
The provider carries out the plan of care
During Implementing, the care provider:
Carries Out The Plan Of Nursing Care or Setting your plans in motion and delegating responsibilities for each step.
Continues Data Collection And Modifies The Plan Of Care As Needed Documents Care
4th Component of the Nursing Process-
Evaluating:
The measuring of the extent to which client goals have been met Evaluation involves not only analyzing the success of the goals and interventions, but examining the need for adjustments and changes as well. The evaluation incorporates all input from the entire health care team, including the patient.
During Evaluating, the care provider:
Measures The Clients Achievement Of Desired Goals/Outcomes Identifies Factors That Contribute To The Client’s Success Or Failure Modifies The Plan Of Care, If Indicated
Purpose of the nursing process:
To Achieve ScientificallyBased, Holistic, Individualized Care For The Client To Achieve The Opportunity To Work Collaboratively With Clients, Others To Achieve Continuity Of Care
Characteristics:
a.
Systematic
– The nursing process has an ordered sequence of activities and each activity depends on the accuracy of the activity that precedes it and influences the activity following it.
b.
Dynamic
– The nursing process has great interaction and overlapping among the activities and each activity is fluid and flows into the next activity
c.
Interpersonal
– The nursing process ensures that nurses are client-centered rather than task-centered and encourages them to work to enhance client’s strengths and meet human needs
d.
Goal-directed
– The nursing process is a means for nurses and clients to work together to identify specific goals (wellness promotion, disease and illness prevention, health restoration, coping and altered functioning) that are most important to the client, and to match them with the appropriate nursing actions
e.
Universally applicable
– The nursing process allows nurses to practice nursing with well or ill people, young or old, in any type of practice setting
The Whole Patient
The nursing process involves looking at the whole patient at all times. It personalizes the patient. He is not "the CVA in 214B."
It also forces the health care team to observe and interact with the patient, and not just the task they are performing such as a dressing change, or a bed bath. The process provides a roadmap that ensures good nursing care and improves patient outcomes.