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The nursing process copy

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  • 1. The Nursing Process Kalyani Mohanraj Associate Professor CCN
  • 2. Planning • Deliberate systematic phase of the nursing process that involves problem solving and decision making. – Prioritizing problems (nursing diagnosis) – Formulate goals/desired outcomes – Select nursing interventions – Write nursing orders
  • 3. Types of Planning • Initial planning – Initiated soon after the initial assessment – Comprehensive plan based on the data • Ongoing planning/daily planning – Individualize the initial plan – Modified every shift – Evaluate effectiveness of care • Discharge planning – Deals with care needs at home/hospice
  • 4. Setting Priorities • Establishing preferential sequence of addressing nursing diagnoses and interventions. – High priority – life threatening conditions – Medium priority – health threatening problems – Low priority – minimum nursing interventions
  • 5. Guide Lines to Set Priorities • Abraham Maslow’s hierarchy of needs • Clients preference • Resources available • Health beliefs and values of client • Medical treatment plan
  • 6. Setting Outcome Criteria • They describe in observable client responses what the nurse hopes to achieve by implementing the nursing interventions. – Goals/desired outcome/objective/outcome criteria/expected outcome all these terms are used interchangeably.
  • 7. Components of Goals • Derived from the problem in the nursing diagnoses • It is stated as the opposite healthy client response • Must have the following clauses – Subject – client/part or attribute of client – Verb – action the client is expected to perform – Conditions/modifiers – what/when/where/how – Criterion of performance – standard/quality of perfomance
  • 8. Guide Lines for Writing Goals • In terms of client responses • Realistic/Achievable • Address one nursing diagnosis • Observable and measurable terms • In collaboration with client
  • 9. Samples Nursing Diagnoses Goals/desired outcome Impaired physical mobility Improved mobility - Ambulates with crutches by the end of this week Ineffective airway clearance Effective airway clearance – coughs and deep breathes every two hours
  • 10. Subje ct Verb Conditions/ Modifiers Criterion Client Drinks 2500ml of fluid Daily (time) Client Admini sters Correct insulin dose Using aseptic technique (quality standard) Client Lists 3 hazards of smoking Accuracy
  • 11. Nursing Interventions • Actions taken by the nurse to achieve the goals/expected outcome • Focus on eliminating/reducing/modifying the etiology of the nursing diagnosis • If not possible, to treat the signs and symptoms (defining characteristics) – E.g. • Anxiety related to hospitalization • Pain related to surgical incision
  • 12. Types of Nursing Interventions • Independent interventions – Activities the nurses are licensed to initiate on the basis of their knowledge and skills • Dependent interventions – Activities carried out under the physicians’ orders or supervision or according to specified routines • Collaborative interventions – With other health team members e.g. physiotherapists, social workers dieticians etc.,
  • 13. Criteria for selecting the Interventions • Safe and appropriate • Achievable with the resources available • Congruent with the client’s values and beliefs • Compatible with other therapies • Based on nursing knowledge or experience • Within established standards of care
  • 14. Formats of Care Plans • Student care plans • Computer generated care plans – Standardized care plans – Individualized care plans • Concept maps • Collaborative care plans/Critical path ways
  • 15. Student care plan Asse ssme nt data Nursi ng diagn osis Goals Plann ing Ratio nale Imple ment ation Evalu ation
  • 16. Implementing • The phase in which the nurse carries out or delegates the planned interventions. – Reassess the client – Determine the need for assistance – Implement the intervention – Supervise delegated care – Document nursing activities