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Nursing Process is:
A systematic rational method of planning and providing individualized nursing care.
A problem solving approach to patient care
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The Five Steps to the Nursing Process
- Assessment
- Diagnosis
- Planning
- Implementation
- Evaluation
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Characteristics of the Nursing Process
- Dynamic, cyclic
- Patient Centered
- Interpersonal
- Collaborative
- Goal Directed
- Creative Feedback
- Universally applicable
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Purpose of the Nursing Process
- Identifying the patients health status.
- Identifying actual or potential health problems.
- Est. a plan of care to meet the patients needs.
- Developing specific nursing interventions to meet the needs of the pt.
- Taking care of the pt family
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History of the Process:
Nanda - stands for
est?
What do they do?
- North America Nursing Dx Assoc.
- 1982
- Continually develp the nursing dx we use
- Develop terminaology
- Provide a common language.
- Allows nurses to communicate with each other.
- Helps Nurses to Focus on the scope of the nursing practice.
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Nusing Process in relationship to Humoan Response
focuses the nurses atten on individual human responses to a given health situation.(stressors)
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Nursing Process
Patient Centered Care
- promotes the involvement of the patient in their health care.
- Increases sense of control.
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Evidence Based Practice
- Problem solving process for clinical practice
- Helps nurse provide quality care.
- *It's been tesed and trialed*
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Quality Improvement
- continous improving of processes in providing health care
- focuses on identifying problems in efficancy and safety problems like duplicate hospital services.
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Assessment
Continouse process carried out during all phases of the nursing process.
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Sources of Data
- Patient
- family
- health history
- physical assessment
- record review
- consultation
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Levels of Prevention:
PRIMARY
- Health promotion
- specific protection against disease
- precedes disease or disability
- generally healthy individuals or groups.
- example - health education, diet, exercise, brushing teeth and not smoking
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Levels of Prevention:
SECONDARY
- Health Maintenence of individuals experiencing health problems or illness
- Early detection of disease (screening or risk assessment
- Prompt, effective treatment to prevent complications & disabilities for those at risk.
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Levels of Prevention:
TERTIARY
- Managing a disease to prevent a disease to be chronic
- Rehab and Restoration
- Chronic illness Management
- - support groups or rehab
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Cues
- directily obeserved by the nurse
- piece of information that influences a decision
- what the patient says or what the nurse can see, hear, feel, smell or measure
- example: crying
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PES FORMAT
- Problem Dx
- Etiolgy - R/T
- Supporting Data AEB as evidence by
- example: impaired gas exchange r/t increased bronchial secretions aeb shortness of breath, cough, crackles and rales in upper lobes of lungs bilaterally
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Types of Dx
- Actual
- Risk
- Collaborative / PC potential complication
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PC Dx
PC of CHF: pulmonary edema
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Risk is a two part statement of what?
The Risk, R/T
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