The Nursing Process
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Definition of Nursing Process
serves as an organizational framework for the practice of
nursing.
it encompasses all of the steps taken by the nurse in caring
for a patient
The process requires a systematic approach to the person's
situation
4 phases: assessment, nursing diagnosis, planning,
implementation, and evaluation.
Framework- means basic structure, serve as supporting
structure. 2
Characteristics of the Nursing Process
Open and Flexible
Cyclic and dynamic
Client Centered
Individualized to meet the client’s needs
Interpersonal and Collaborative
Planned
Goal-directed
Permits creativity
Emphasizes Feedback
Universally accepted
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Characteristics of Nursing Process (explantion)
1)The system is open and flexible to meet the unique needs of client,
family group, or community
2)It is cyclic and dynamic (active )---. Because all phases are
interrelated. There is no absolute beginning or end
3)It is client centered; it individualizes the approach to each client’s
particular needs.
4)It is interpersonal and collaborative. It requires the nurse to
communicate directly and consistently with clients to meet their
needs.
5)It is planned.
6)It is goal-directed.
7)It permits creativity for the nurse and client in devising ways to solve
the stated health problem
8)It emphasizes feedback, which leads either to reassessment of the
problem or to revision of the care plan.
9)It is universally applicable. The Nursing Process is used as a
framework for nursing care in all types of health care settings, with 4
clients of all age groups.
ANA’s Standards of Clinical Nursing
Standard I. The nurse collects client health data
Assessment :
Standard II. The nurse analyzes the assessment data
Diagnosis : determining diagnosis
Standard III. The nurse identifies expected outcomes
Outcome individualized to the client.
Identification :
Standard IV. The nurse develops a plan of care prescribes
Planning : interventions to attain expected outcomes.
Standard V. The nurse implements the interventions identified
Implementation : in the plan of care
Standard VI. The Nurse evaluates the client’s progress toward
Evaluation : attainment of outcomes.
From American Nurses Association:
Standards of Clinical nursing practice,
Washington, DC, 1991, The Association 5
Assessing Diagnosing
Assessing Collect data Analyze data
Organize data Identify health problems, risks and
Validate data strengths
DiagnosisDocument data Formulate diagnostic statements
Planning
Prioritize problem/Nursing Diagnoses
Planning Evaluating
Formulate goals/ desired outcomes
SelectCollect data related to outcomes
nursing interventions
WriteCompare data with outcomes
nursing orders
Implementing Implementing
Relate nursing actions to client goals or
outcomes
Reassess the client
Draw conclusions about problem status
Determine the nurse’s need for assistance
Continue,
Implement modify
the nursing ordersor terminate client’s
Evaluating care
Delegate and supervise
Document nursing actions 6
ASSESSMENT
Nursing Health History
The Interview Process
• Establish rapport.
• Establish the agenda of the interview.
• Expand and clarify the health history.
.
• Identify the possible nursing diagnoses.
• Create a shared understanding of the nursing problem.
• Plan for follow-up and closing
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ASSESSMENT
Biographic Data
1. Name
2. Address
3. Age
4. Gender
5. Race
6. Marital status
7. Occupation
8. Religious orientation
9. Health care financing
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ASSESSMENT
Chief Complaint
• What brought you to the clinic or hospital?
• What is troubling you?
• Told in the client’s own words, the chief complaint
establishes the purpose of the contact, provides
direction for the assessment, and establishes the
nurse-client relationship
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ASSESSMENT
Chief Complaint
• Gather information to fully describe the client’s
problem.
• Ask questions that help the client describe the specific
signs and symptoms associated with the problem and
provide a history to the present illness
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