Nursing Process

Fozia Ferozali RN.,MSN

Back Ground

The nursing process is based on a nursing theory developed by Ida Jean Orlando. She developed this theory in the late 1950's as she observed nurses in action. She saw "good" nursing and "bad" nursing. From her observations she learned that the patient must be the central character.
Nursing care needs to be directed at improving outcomes for the patient, and not about nursing goals. The nursing process is an essential part of the nursing care plan.

The Nursing Process is:

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

Holistic

PhysicalEmotionalPsychosocialDevelopmentalSpiritual Being

Medical Diagnosis
Rheumatoid Arthritis

Nursing Diagnosis
Self-care deficit: bathing, related to joint stiffness

5 components of the Nursing Process:

1. 2. 3. 4. 5.

Assessment Diagnosis Planning Implementing Evaluating

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

1. 2. 3. 4. 5.

Assessment Diagnosis Planning Implementing Evaluating

1st Component of the Nursing ProcessASSESSMENT:

Data Collection
Assessment involves taking vital signs (TPR BP & Pain assessment. Performing a head to toe assessment Listening to the patient's comments and questions about his health status Observing his reactions and interactions with others. It involves asking pertinent questions about his signs (observable) and symptoms (Non-observable), and listening carefully to the answers.

During Assessment, the care provider:

A. B.

Establishes A Data Base Continuously Updates The Data Base Validates Data

C.

D. Communicates Data

2nd component of the Nursing ProcessPlanning:

The establishment of client goals/outcomes

Working with the client, to prevent, reduce, or resolve problems To determine related nursing interventions (actions) that are most likely to assist client in achieving goals This is about improving the quality of life for your patient. This is about what your patient needs to do to improve his health status or better cope with his illness.

During Planning, the provider:

A. Establishes Priorities B. Writes Client Goals/Outcomes And Develops An Evaluative Strategy C. Selects Nursing Interventions D. Communicates The Plan

3rd Component of the Nursing Process-

Implementing:
The provider carries out the plan of care

During Implementing, the care provider:

Carries Out The Plan Of Nursing Care or Setting your plans in motion and delegating responsibilities for each step. Continues Data Collection And Modifies The Plan Of Care As Needed Documents Care

4th Component of the Nursing Process-

Evaluating:

The measuring of the extent to which client goals have been met Evaluation involves not only analyzing the success of the goals and interventions, but examining the need for adjustments and changes as well. The evaluation incorporates all input from the entire health care team, including the patient.

During Evaluating, the care provider:

Measures The Clients Achievement Of Desired Goals/Outcomes Identifies Factors That Contribute To The Clients Success Or Failure Modifies The Plan Of Care, If Indicated

Purpose of the nursing process:

To Achieve ScientificallyBased, Holistic, Individualized Care For The Client To Achieve The Opportunity To Work Collaboratively With Clients, Others To Achieve Continuity Of Care

Characteristics:

a. b.
c.

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

Dynamic
The nursing process has great interaction and overlapping among the activities and each activity is fluid and flows into the next activity

Interpersonal
The nursing process ensures that nurses are client-centered rather than task-centered and encourages them to work to enhance clients strengths and meet human needs

d.

Goal-directed
The nursing process is a means for nurses and clients to work together to identify specific goals (wellness promotion, disease and illness prevention, health restoration, coping and altered functioning) that are most important to the client, and to match them with the appropriate nursing actions

e.

Universally applicable
The nursing process allows nurses to practice nursing with well or ill people, young or old, in any type of practice setting

The Whole Patient

The nursing process involves looking at the whole patient at all times. It personalizes the patient. He is not "the CVA in 214B."

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