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the nursing process

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الكلية كلية التمريض     القسم قسم التخصصات التمريضية     المرحلة 4
أستاذ المادة سلمى كاظم جهاد الابراهيمي       4/27/2011 8:27:06 AM


The Nursing Process:

 

 * An organizational framework for the practice of nursing
* Orderly, systematic
* Central to all nursing care
* Encompasses all steps taken by the nurse in caring for a patient

Definition of the Nursing Process:

* An organized sequence of problem-solving steps used to identify and to manage the health problems of clients
* It is accepted for clinical practice established by the American Nurses Association

Benefits of Nursing Process:

* Provides an orderly & systematic method for planning & providing care
* Enhances nursing efficiency by standardizing nursing practice
* Facilitates documentation of care
* Provides a unity of language for the nursing profession
* Is economical
* Stresses the independent function of nurses
* Increases care quality through the use of deliberate actions

The Nursing Process Utilizes The Following:

* Assessment
* Nursing Diagnosis
* Planning
* Implementation
* Evaluation

Characteristics of the Nursing Process:

* Within the legal scope of nursing
* Based on knowledge-requiring critical thinking
* Planned-organized and systematic
* Client-centered
* Goal-directed
* Prioritized
* Dynamic

Assessment of Well-Being:

* According to the World Health Organization is well-being in these domains:
* Emotional
* Physical
* Social
* Spiritual

Tools of assessment:

* Observation
* Interview
* Types of questions
* Environment (physical and emotional) Spiritual considerations
* Examination

Types of Data To Collect:

* Objective data-observable and measurable facts (Signs)
* Subjective data-information that only the client feels and can describe (Symptoms)

Sources of Data:

* Primary source: Client
* Secondary source: Client’s family, reports, test results, information in current and past medical records, and discussions with other health care workers

Disease Prevention:

* Primary prevention – protection from a disease while still in a healthy state.
* Secondary prevention – early detection and treatment of disease.
* Tertiary prevention – prevent complications and to maintain health once the disease process has occurred.
Planning:

* Establish the goals, interventions and outcomes

General Guidelines for Setting Priorities:
1. Take care of immediate life-threatening issues.
2. Safety issues.
3. Patient-identified issues.
4. Nurse-identified priorities based on the overall picture, the patient as a whole person, and availability of time and resources.

Nurse Identified Priorities:
* Composite of all patient’s strengths and health concerns.
* Moral and ethical issues.
* Time, resources, and setting.
* Hierarchy of needs.
* Interdisciplinary planning.

DIAGNOSIS:
* Sort, cluster, analyze information
* Identify potential problems and strengths
* Write statement of problem or strength
* Risk of infection related to compromised nutrition

Components of Outcomes:

* Subject: who is the person expected to achieve the outcome?
* Verb: what actions must the person take to achieve the outcome?
* Condition: under what circumstances is the person to perform the actions?
* Performance criteria: how well is the person to perform the actions?
* Target time: by when is the person expected to be able to perform the actions?

Nursing Interventions:

* Road maps directing the best ways to provide nursing care.
* Evidence based nursing.
1. Monitor health status.
2. Minimize risks.
3. Resolve or control a problem.
4. Assist with ADLs.
5. Promote optimum health and independence.

Interventions:

* Direct interventions:  actions   performed through interaction with clients.

* Indirect interventions:  actions performed away from the client, on behalf of a client or group of clients.
Documentation:

* Clear and concise
* Appropriate terminology
* Usually on a designated form
* Physical assessment
* Usually by Review of Systems
• Overview of symptoms
• Diet
• Each body system

Evaluation:

1. Determining outcome achievement
2. Identifying the variables affecting outcome achievement
3. Deciding whether to continue, modify, or terminate the plan

NANDA – North American Nursing Diagnosis Association

* Identifies nursing functions
* Creates classification system
* Establishes diagnostic labels

* Risk of infection related to compromised nutritional state
* Potential complication of seizure disorder related to medication compliance

Community as Client:
• A community-wide group of people as the focus of nursing service
– The community directly influences the health of individuals, families, groups, subpopulations, and populations who are a part of it.
– Provision of most health services occurs at the community level.
Dimensions of Community as Client:
• One perspective:
– Status: morbidity & mortality data identifying physical, emotional, and social determinants of health
– Structure: services and resources
– Process: ability to function effectively
• Another perspective:
– Location (community boundaries, location of health services, geographic features, climate, flora, fauna, human-made environment)
– Population (size, density, composition, rate of growth or decline, cultural characteristics, social class and educational level, mobility)
– Social system (variables, health care delivery system)

Nursing Process Characteristics & Community:
• Problem-solving process; management process; process for implementing change
• Characteristics:
– Deliberative; adaptable; cyclic
– Client-focused; need-oriented
– Interaction with community (communication, reciprocal interaction, paving way for helping relationship, aggregate application)
– Forming of partnerships and building of coalitions

Community Needs Assessment:

• Process of determining real or perceived needs of a defined community
• Types
– Windshield survey (familiarization assessment)
– Problem-oriented assessment
– Community subsystem assessment
– Comprehensive assessment (key informants)
– Community assets assessment

Community Assessment Methods:
• Surveys
• Descriptive epidemiologic studies
• Community forums/town hall meetings
• Focus groups


Sources of Community Data:

• Primary: gathered by talking to the people
• Secondary: records produced by people who know the community well
• International
• National
• State
• Local

Community Diagnoses:

• Portray a community focus
• Include community response and related factors that have potential for change via CHN; logically consistent; response and factors logically linked
• Include statements narrow enough to guide interventions
• Use a community response instead of a risk, goal, or need statement
• Include factors within the domain of community health nursing intervention
• Deficit and wellness diagnoses (include maintenance or potential change responses due to growth and development) when no deficit is present
 
Planning to Meet Community Health Needs; Implementing Plans:

• Planning
– Tools for assistance: operational definitions of objectives and activities, conceptual frameworks and models; systematic approach
– Health planning process
• Implementing
– Preparation
– Activities or actions

Evaluating Implemented Community Health Plan:
• Measuring or judging effectiveness of goal or outcome attainment
• Types of evaluation
– Formative: focus on process during actual interventions; development of performance standards
– Summative: focus on the outcomes of interventions; effect; impact

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

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المادة المعروضة اعلاه هي مدخل الى المحاضرة المرفوعة بواسطة استاذ(ة) المادة . وقد تبدو لك غير متكاملة . حيث يضع استاذ المادة في بعض الاحيان فقط الجزء الاول من المحاضرة من اجل الاطلاع على ما ستقوم بتحميله لاحقا . في نظام التعليم الالكتروني نوفر هذه الخدمة لكي نبقيك على اطلاع حول محتوى الملف الذي ستقوم بتحميله .
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