the nursing process shorter version

8/14/2019 The NURSING PROCESS Shorter Version

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The NURSING

Jeng P. Cuevas


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Nursing process

foundation of the nursing profession

central to nursing actions

a process to deliver care to patients

supported by nursing models orphilosophies.

systematic approach

enhances research opportunities adaptable to different clients in

different care settings

efficient method of organizing thought


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CRITICAL THINKING

Facione and Facione (1996) definecritical thinking as purposeful self-regulatory judgment that iscentrall evident in ex ert clinical

It is how thenurse uses theinformation toreason, makeinferences andform mentalpicture of what

Over time thenurse learns toalmostsimultaneouslyreview,interpret,analyze and


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To use this process, the nursemust demonstrate other

fundamental abilities of:

3. Knowledge

4. Creativity5. Adaptability

6. Commitment

7. Trust

8. Leadership

9. Intelligence

10.Inter ersonal and technical


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ASSESSMENT


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Client DataMr. Harold Simpson was admitted on Sunday morning witha medical diagnosis of swollen right knee and diabetes.Subjective DataFour children, ages 16, 14, 12,10.

Occupation: PainterUrinating about every two hours.Client states that he fell that morning from a ladder thatslipped while he was painting the neighbors house. Helater developed a headache. He admits that he didn't sleep

well the night before and he states that he is very upsetbecause he was supposed to take his children to abasketball game that day. He states that he is agnostic buthis wife and children are Protestants who go to churchregularly and they are trying to


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FUNCTIONAL HEALTHPATTERNS

Data According to


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MASLOWS HIERARCHY OFNEEDS

Data According to


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DIAGNOSIS


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Actual VS

Is aproblemthat is

identifiedduring theassessment

. It issupportedby obvious

Is aproblemthat the

nurse,throughknowledge

andexperience,perceives


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Writing the Nursing

It may be written as, Patientproblem+ Cause of the problem(etiology)

Example: >Impaired skin integrityr/t immobility

>Parental role conflict r/tdivorce

>Impaired verbalcommunication r/t

cultural differences


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Or, by using the PES format; Patientproblem + Etiology + Symptoms

Example:>Impaired skin integrity r/t

immobility as manifested by

Disruption of the skin surface overthe elbows and sacral area

>Parental role conflict r/t divorceas manifested by statements Ofunsatisfactory child care duringworking days


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Case Study

Mrs. Jones, 1 75-year old male, isadmitted to the unit with a medicaldiagnosis of lumbar pain. He statesthat the pain started 2 days ago. Hehas been in a wheelchair for 1 yearfollowing a stroke. He has had a foleycatheter in place for 3 months because ofincontinence. His urinary output is lessthan 30 cc per hour and is concentrated.

He is being fed through agastrostomytube that has been in placefor 6 months. He has one son who livesin Europe. He lost his wife a year ago. On


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PLANNING


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PLANNING

The resulting plan of nursing care isdesigned to help patients and theirfamilies;

Maintain their current level of healthand functioning if they are identifiedat risk for developing problems.

Reach an improvedlevel of health

functioning. Adjustto a reducedlevel of health

and functioning when improvementis not possible.

Adjustto aprogressively decreasing


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GUIDELINES FOR

Maslows hierarchy of basic needs canguide the selection of high priorityproblems.

Focus on the problems the patient feelare most important if this priority doesnot interfere with medical treatment.

Consider the effect of potential problemsin setting priorities.

For an actual nursing diagnosis, the goalstatement is a patient behavior thatdemonstrates reduction or alleviation ofthe problem.

For a potential nursing diagnosis, the


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IMPLEMENTATION


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Interventions:

Assessment is the FIRSTintervention!

Independent actions before

dependent actions. Refer to Standing Orders.

Refer to Physician.

Collaborate with othermembers of the health team.


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EVALUATION


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It has two parts; Evaluation ofoal achievement + Review of

Evaluation of goal statement The purpose of the first part isto decide whether the patienthas achieved the goal selected

during the planning phase ofthe nursing process.

The goal is evaluated at thetime or date specified in the

goal statement. It is written as:

Goal met Asevidenced


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Review of the Nursing

Review of the NCP keeps the plancurrent and responsive to thepatients changing needs.

The process of nursing is cyclicalin nature with that five stepsviewed as a circle with one stepleading to another.

the nursing process shorter version

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