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The Nursing ProcessThe Nursing Process

6 Characteristics• Cyclic and dynamic rather than

static• Client centered – nurse organizes

plan of care according to client problems rather that nursing goals

• Interpersonal and collaborative – depends on open and meaningful communication between client and the nurse

• Universally applicable – can be used with clients of any age at any point of the wellness – illness continuum and useful in a variety of settings

• Adaptation of problem solving techniques and system theory based on the scientific method

• It can be viewed as parallel to but separate from the medical process

ASSESSMENT

Assessment• Objective (physical exam) and

subjective (nursing history)

SOURCES OF DATA• Primary – client• Secondary – relatives, members of

health team

GORDON’S TYPOLOGY OF FUNCTIONAL PATTERNS

• Health perception – health management pattern – describes clients perceived pattern of health and well being and how health is managed.

• Nutritional – metabolic pattern – describes pattern of food and fluid consumption relative to metabolic need and pattern indicators of local nutrient supply.

• Elimination – describes pattern of excretory function (bowel, bladder and skin).

• Activity – exercise – describes pattern of exercise, activity, leisure and recreation

• Cognitive perceptual – describes sensory perceptual and cognitive system

• Sleep rest – describes pattern of sleep, rest and recreation.

• Self perception – self concept – self concept pattern and perceptions of self (body comfort, body image, feeling state).

• Role relationship – describes pattern of role engagements and relationships

• Sexual reproductive – client patterns of satisfaction and dissatisfaction with sexuality: describes reproductive pattern

• Coping stress tolerance – general coping pattern and effectiveness of the pattern in terms of stress tolerance.

• Value belief – patterns of values, beliefs (including spiritual) or goals that guide choices of decisions.

NURSING DIAGNOSIS

NURSING DIAGNOSISNURSING DIAGNOSIS- Clinical judgment about an

individual, family or community responses to actual and potential health problems

- Professional nurses are responsible for making nursing diagnosis.

- Nursing diagnosis describe a continuum of health states.

NURSING DIAGNOSIS

MEDICAL DIAGNOSIS

- Focus on identifying human responses to health and illness- Describe problems treated by nurses within the scope of independent nursing practice- Changes from day to day as client responses change

- Identifies disease- Describe problems for which the physician directs the primary treatment - Remains the same for as long as the disease is present

OBJECTIVES

OBJECTIVESOBJECTIVES- Should be SMART- client centered- statement of a single human

response

EVALUATION

EVALUATIONEVALUATION- Conclusion and supporting data

- Goal met

- Goal partially met

- Goal not met