Nursing ProcessNursing Process

Back GroundBack Ground

The nursing process is based on a nursing theory The nursing process is based on a nursing theory developed by developed by Ida Jean OrlandoIda Jean Orlando. She developed this . She developed this theory in the late 1950's as she observed nurses in theory in the late 1950's as she observed nurses in action. She saw "good" nursing and "bad" nursing. action. She saw "good" nursing and "bad" nursing.

From her observations she learned that the patient From her observations she learned that the patient must be the central character. must be the central character. – Nursing care needs to be directed at improving outcomes Nursing care needs to be directed at improving outcomes

for the patient, and not about nursing goals. for the patient, and not about nursing goals. – The nursing process is an essential part of the nursing care The nursing process is an essential part of the nursing care

plan. plan.

The Nursing Process is:The Nursing Process is:

A systematic, rational method of planning and A systematic, rational method of planning and providing individualized nursing care.providing individualized nursing care.

HolisticHolistic Physical-Physical- Emotional-Emotional- Psychosocial-Psychosocial- Developmental-Developmental- Spiritual BeingSpiritual Being

Medical Medical DiagnosisDiagnosis

Nursing Nursing DiagnosisDiagnosis

Rheumatoid Rheumatoid ArthritisArthritis

Self-care deficit: Self-care deficit: bathing, related bathing, related to joint stiffnessto joint stiffness

5 components of the Nursing Process:5 components of the Nursing Process:

1.1. AssessmentAssessment

2.2. DiagnosisDiagnosis

3.3. PlanningPlanning

4.4. ImplementingImplementing

5.5. EvaluatingEvaluating

We will only focus on 4 components of the We will only focus on 4 components of the Nursing Process:Nursing Process:

1.1. AssessmentAssessment

2. Diagnosis

3.3. PlanningPlanning

4.4. ImplementingImplementing

5.5. EvaluatingEvaluating

11stst Component of the Nursing Process- Component of the Nursing Process- ASSESSMENT:

Data CollectionData Collection– Assessment involves taking vital signs Assessment involves taking vital signs

(TPR BP & Pain assessment.(TPR BP & Pain assessment.

– Performing a head to toe assessmentPerforming a head to toe assessment

– Listening to the patient's comments and Listening to the patient's comments and questions about his health statusquestions about his health status

– Observing his reactions and interactions Observing his reactions and interactions with others. It involves asking pertinent with others. It involves asking pertinent questions about his signs (observable) questions about his signs (observable) and symptoms (Non-observable), and and symptoms (Non-observable), and listening carefully to the answers. listening carefully to the answers.

During During AssessmentAssessment, the care , the care provider:provider:

A.A. Establishes A Data BaseEstablishes A Data Base

B.B. Continuously Updates Continuously Updates The Data BaseThe Data Base

C.C. Validates DataValidates Data

D. D. Communicates DataCommunicates Data

22ndnd component of the Nursing Process- component of the Nursing Process- PlanningPlanning::

The establishment of client The establishment of client goals/outcomesgoals/outcomes– Working with the client, to prevent, Working with the client, to prevent,

reduce, or resolve problems reduce, or resolve problems

– To determine related nursing To determine related nursing interventions (actions) that are most likely interventions (actions) that are most likely to assist client in achieving goalsto assist client in achieving goals

– This is about improving the quality of life This is about improving the quality of life for your patient. for your patient.

– This is about what your patient needs to This is about what your patient needs to do to improve his health status or better do to improve his health status or better cope with his illness. cope with his illness.

During During PlanningPlanning, the provider:, the provider: A.A. Establishes PrioritiesEstablishes Priorities

B.B. Writes Client Goals/Outcomes And Writes Client Goals/Outcomes And Develops An Evaluative StrategyDevelops An Evaluative Strategy

C.C. Selects Nursing InterventionsSelects Nursing Interventions

D.D. Communicates The PlanCommunicates The Plan

3rd Component of the Nursing Process- 3rd Component of the Nursing Process- Implementing:

The provider carries out the plan of careThe provider carries out the plan of care

During During Implementing, the care , the care provider:provider:

Carries Out The Plan Of Nursing Care or Carries Out The Plan Of Nursing Care or Setting your plans in motion and delegating Setting your plans in motion and delegating responsibilities for each step. responsibilities for each step.

Continues Data Collection And Modifies Continues Data Collection And Modifies The Plan Of Care As NeededThe Plan Of Care As Needed

Documents CareDocuments Care

4th Component of the Nursing Process- 4th Component of the Nursing Process- EvaluatingEvaluating::

The measuring of the extent to which The measuring of the extent to which client goals have been metclient goals have been met

Evaluation involves not only Evaluation involves not only analyzing the success of the goals and analyzing the success of the goals and interventions, but examining the need interventions, but examining the need for adjustments and changes as well. for adjustments and changes as well.

The evaluation incorporates all input The evaluation incorporates all input from the entire health care team, from the entire health care team, including the patient.including the patient.

During During EvaluatingEvaluating, the care provider:, the care provider:

Measures The Clients Achievement Of Measures The Clients Achievement Of Desired Goals/OutcomesDesired Goals/Outcomes

Identifies Factors That Contribute To Identifies Factors That Contribute To The The Client’s Success Or FailureClient’s Success Or Failure

Modifies The Plan Of Care, If Modifies The Plan Of Care, If IndicatedIndicated

Purpose of the nursing process:Purpose of the nursing process:

To Achieve Scientifically- To Achieve Scientifically- Based, Holistic, Individualized Based, Holistic, Individualized Care For The ClientCare For The Client

To Achieve The Opportunity To To Achieve The Opportunity To Work Collaboratively With Work Collaboratively With Clients, OthersClients, Others

To Achieve Continuity Of CareTo Achieve Continuity Of Care

Characteristics:Characteristics: a.a. SystematicSystematic

– The nursing process has an ordered sequence of activities and each The nursing process has an ordered sequence of activities and each activity depends on the accuracy of the activity that precedes it and activity depends on the accuracy of the activity that precedes it and influences the activity following it.influences the activity following it.

b.b. DynamicDynamic– The nursing process has great interaction and overlapping among the The nursing process has great interaction and overlapping among the

activities and each activity is fluid and flows into the next activityactivities and each activity is fluid and flows into the next activity c.c. InterpersonalInterpersonal

– The nursing process ensures that nurses are client-centered rather The nursing process ensures that nurses are client-centered rather than task-centered and encourages them to work to enhance client’s than task-centered and encourages them to work to enhance client’s strengths and meet human needsstrengths and meet human needs

d.d. Goal-directedGoal-directed– The nursing process is a means for nurses and clients to work The nursing process is a means for nurses and clients to work

together to identify specific goals (wellness promotion, disease and together to identify specific goals (wellness promotion, disease and illness prevention, health restoration, coping and altered illness prevention, health restoration, coping and altered functioning) that are most important to the client, and to match them functioning) that are most important to the client, and to match them with the appropriate nursing actionswith the appropriate nursing actions

e.e. Universally applicableUniversally applicable– The nursing process allows nurses to practice nursing with well or ill The nursing process allows nurses to practice nursing with well or ill

people, young or old, in any type of practice settingpeople, young or old, in any type of practice setting

The Whole PatientThe Whole Patient The nursing process involves looking at the whole The nursing process involves looking at the whole

patient at all times. It personalizes the patient. patient at all times. It personalizes the patient.

It also forces the health care team to observe and It also forces the health care team to observe and interact with the patient, and not just the task they are interact with the patient, and not just the task they are performing such as a dressing change, or a bed bath. performing such as a dressing change, or a bed bath. The process provides a roadmap that ensures good The process provides a roadmap that ensures good nursing care and improves patient outcomes.nursing care and improves patient outcomes.