The Nursing Process Shorter Version

The NURSING PROCESS Jeng P. Cuevas

Nursing process • • • • • • • •

foundation of the nursing profession central to nursing actions a process to deliver care to patients supported by nursing models or philosophies. systematic approach enhances research opportunities adaptable to different clients in different care settings efficient method of organizing thought processes or clinical decision-making

CRITICAL THINKING • It is how the • Over time the nurse uses the nurse learns to information to almost reason, make simultaneously inferences and review, form mental interpret, picture of what analyze and is happening to evaluate • Facione and Facione (1996) define critical thinking as purposeful selfregulatory judgment that is centrally evident in expert clinical

To use this process, the nurse must demonstrate other fundamental abilities of: 3. Knowledge 4. Creativity 5. Adaptability 6. Commitment 7. Trust 8. Leadership 9. Intelligence 10.Interpersonal and technical

ASSESSMENT

Client Data Mr. Harold Simpson was admitted on Sunday morning with a medical diagnosis of swollen right knee and diabetes. Subjective Data Four children, ages 16, 14, 12,10. Occupation: Painter Urinating about every two hours. Client states that he fell that morning from a ladder that slipped while he was painting the neighbor’s house. He later developed a headache. He admits that he didn't sleep well the night before and he states that he is very upset because he was supposed to take his children to a basketball game that day. He states that he is agnostic but his wife and children are Protestants who go to church regularly and they are trying to

Data According to

FUNCTIONAL HEALTH PATTERNS

Data According to

MASLOW’S HIERARCHY OF NEEDS

DIAGNOSIS

Actual Risk

Is a problem that is identified during the assessment . It is supported by obvious signs and

VS Is a problem that the nurse, through knowledge and experience, perceives will

Writing the Nursing Diagnosis

• It may be written as, Patient problem+ Cause of the problem (etiology) Example: >Impaired skin integrity r/t immobility >Parental role conflict r/t divorce >Impaired verbal communication r/t cultural differences

Or, by using the PES format; Patient problem + Etiology + Symptoms Example: >Impaired skin integrity r/t immobility as manifested by Disruption of the skin surface over the elbows and sacral area >Parental role conflict r/t divorce as manifested by statements Of unsatisfactory child care during working days >Impaired verbal communication

Case Study Mrs. Jones, 1 75-year old male, is admitted to the unit with a medical diagnosis of “lumbar pain”. He states that “the pain started 2 days ago”. He has been in a wheelchair for 1 year following a stroke. He has had a foley catheter in place for 3 months because of incontinence. His urinary output is less than 30 cc per hour and is concentrated. He is being fed through a gastrostomytube that has been in place for 6 months. He has one son who lives in Europe. He lost his wife a year ago. On admission, his vital signs were: T-38

PLANNING

PLANNING The resulting plan of nursing care is designed to help patients and their families; • Maintain their current level of health and functioning if they are identified at risk for developing problems. • Reach an improved level of health functioning. • Adjust to a reduced level of health and functioning when improvement is not possible. • Adjust to a progressively decreasing

GUIDELINES FOR SETTING PRIORITIES: • Maslow’s hierarchy of basic needs can guide the selection of high priority problems. • Focus on the problems the patient feel are most important if this priority does not interfere with medical treatment. • Consider the effect of potential problems in setting priorities. • For an actual nursing diagnosis, the goal statement is a patient behavior that demonstrates reduction or alleviation of the problem. • For a potential nursing diagnosis, the goal statement is a patient behavior that

IMPLEMENTATION

Interventions: • Assessment is the FIRST intervention! • Independent actions before dependent actions. • Refer to Standing Orders. • Refer to Physician. • Collaborate with other members of the health team. • Write only when performed.

EVALUATION

It has two parts; Evaluation of goal achievement + Review of – Evaluation of goal statement • The purpose of the first part is to decide whether the patient has achieved the goal selected during the planning phase of the nursing process. • The goal is evaluated at the time or date specified in the goal statement. • It is written as: Goal met As evidenced Goal unmet +

Review of the Nursing Care plan •

•

Review of the NCP keeps the plan current and responsive to the patient’s changing needs. The process of nursing is cyclical in nature with that five steps viewed as a circle with one step leading to another.