NURSING PROCESS

Systematic method of planning and providing care to clients

  • Orderly thoughts - before interven conduct assessment

  • Analysis and planning

  • Designed to be used with client throughput the life span and any care setting - applicable to all types and ages of patient womb to tomb

  • Applicable in any setting

  • Pediatric

  • Obstetric

Purpose

  • Provide client care that is individualized holistic and effective and efficient

  • Some maybe same but not truly the same therefore if we used the nursing process we can provide nursing care holistically

  • Ex. Hypertensive not only concern how to lower BP but also emotionally

  • Effective in the sense ma Gina based mo a imo assessment that can fit to r suitable to the problem of the patient

ASSESSMENT

  • First step in the nursing process

  • And includes the systematic collection verification organization interpretation

  • And documentation of client data

    • Purpose of assessment is to establish DATABASE

  • COLLECTING DATA IN A VARIETY OF SOURCE

    • SUBJECTIVE

    • From the client

    • Verbalize by patient and significant others

    • Gathered from the patient that you cannot used your 5 senses

    • OBJECTIVE

    • Observable

    • Measurable

    • Used 5 senses

      Headache- subjective

      Facial grimace- objective

      Dizzenes - subj

    • BP 90/60 mmHg - obj

  • Primary source

    • Halinnsa patient

  • Secondary source

    • Family, diagnostic, laboratory

SUBJECTIVE

  • I HAVE FEVER

  • I FEEL SUCKE TO MY STOMACHS

  • I FEEL WEAK ALL OVER MY BODY

OBJECTIVE

  • Body temp tachy cradia skin warnm to touch

  • Abdomen from and slightly distended active bowel movement auscultated in all 4 quads

  • BP

VALIDATING DATA

  • objective data should be validated subjected data

  • Validate prevents omission

  • Double checking

Organization of data

  • In order to identify ar easbof the client problems and strength

  • Interpret data, para ma distinguish between irrelevant and relevant

Document data

  • Must be recorded and reported

  • Last step in the assessment

Essential for communication

Complain pain conduct assessment

DIAGNOSIS

  • Further analysis and synthesis

  • Clinical judgement about individuals family and community responsesnto actual or potential health conditions

  • You ,ake decision baased on your nursing knowledge

  • Based in assessment

  • Gathers Tanana tanan na assessment

  • Maganhalinnina simo assessment

  • Must be prudent

PLANNING

  • Involves several steps

  • The nurses sets measurable and achievable short term and long term goals

Ex fluid and electrolyte balance

What is the aims -ntonreyurn back tehnloss fluid and electrolyte balance

Within the 8 hrs of rendering nursing care the fluid and electrolyte would return to normal

  • Record the emtir enurismg plam in the client record

đŸ˜­đŸ˜­đŸ˜­đŸ€ Small notebook

  • Independent nursing interventions - that do not require permision of the physiciqn

Ex hapo - orthopneic position

  • Dependent nursing interventions

  • Collaborative nursing interventions

  • Ga tudlo physical therapies

INTERVENTIONS

  • Execution of the nursing care plan and drive from the planning phase

  • The doing ohas and action phase

  • Though we are in the steps of the implementation it involves many skills

  • Hapo2 equals cpt

  • Why implementation is to mportant I'm implementation

To asses the result

Before magninflatensangbbalon wait for the urine flow

EVALUATION

  • It helps determine whether the goal has been meet partially met or not

  • Therefore if wla na net gala back to the assessment and reaases

Possible eradeons why goals have not met

  • Data wee incompletes

  • Nursing Diagnosis were inappropriate