The Nursing ProcessFelicel Barredo, RN
6 Characteristics• Cyclic and dynamic rather than static• Client centered – nurse organizes  plan of care according to cli...
• Universally applicable – can be used  with clients of any age at any point of  the wellness – illness continuum and  use...
ASSESSMENT
Assessment• Objective (physical exam) and subjective  (nursing history)SOURCES OF DATA• Primary – client• Secondary – rela...
GORDON’S TYPOLOGY OFFUNCTIONAL PATTERNS
• Health perception – health  management pattern – describes  clients perceived pattern of health  and well being and how ...
• Elimination – describes pattern of  excretory function (bowel, bladder  and skin).• Activity – exercise – describes  pat...
• Sleep rest – describes pattern of  sleep, rest and recreation.• Self perception – self concept – self  concept pattern a...
• Sexual reproductive – client  patterns of satisfaction and  dissatisfaction with sexuality:  describes reproductive patt...
NURSING DIAGNOSIS
NURSING DIAGNOSIS- Clinical judgment about an  individual, family or community  responses to actual and potential  health ...
NURSING                    MEDICAL      DIAGNOSIS                  DIAGNOSIS- Focus on identifying     - Identifies diseas...
OBJECTIVES
OBJECTIVES- Should be SMART- client centered- statement of a single human  response
EVALUATION
EVALUATION- Conclusion and supporting data- Goal met- Goal partially met- Goal not met
The nursing process
The nursing process
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The nursing process

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The nursing process

  1. 1. The Nursing ProcessFelicel Barredo, RN
  2. 2. 6 Characteristics• Cyclic and dynamic rather than static• Client centered – nurse organizes plan of care according to client problems rather that nursing goals• Interpersonal and collaborative – depends on open and meaningful communication between client and the nurse
  3. 3. • Universally applicable – can be used with clients of any age at any point of the wellness – illness continuum and useful in a variety of settings• Adaptation of problem solving techniques and system theory based on the scientific method• It can be viewed as parallel to but separate from the medical process
  4. 4. ASSESSMENT
  5. 5. Assessment• Objective (physical exam) and subjective (nursing history)SOURCES OF DATA• Primary – client• Secondary – relatives, members of health team
  6. 6. GORDON’S TYPOLOGY OFFUNCTIONAL PATTERNS
  7. 7. • Health perception – health management pattern – describes clients perceived pattern of health and well being and how health is managed.• Nutritional – metabolic pattern – describes pattern of food and fluid consumption relative to metabolic need and pattern indicators of local nutrient supply.
  8. 8. • Elimination – describes pattern of excretory function (bowel, bladder and skin).• Activity – exercise – describes pattern of exercise, activity, leisure and recreation• Cognitive perceptual – describes sensory perceptual and cognitive system
  9. 9. • Sleep rest – describes pattern of sleep, rest and recreation.• Self perception – self concept – self concept pattern and perceptions of self (body comfort, body image, feeling state).• Role relationship – describes pattern of role engagements and relationships
  10. 10. • Sexual reproductive – client patterns of satisfaction and dissatisfaction with sexuality: describes reproductive pattern• Coping stress tolerance – general coping pattern and effectiveness of the pattern in terms of stress tolerance.• Value belief – patterns of values, beliefs (including spiritual) or goals that guide choices of decisions.
  11. 11. NURSING DIAGNOSIS
  12. 12. NURSING DIAGNOSIS- Clinical judgment about an individual, family or community responses to actual and potential health problems- Professional nurses are responsible for making nursing diagnosis.- Nursing diagnosis describe a continuum of health states.
  13. 13. NURSING MEDICAL DIAGNOSIS DIAGNOSIS- Focus on identifying - Identifies diseasehuman responses to - Describe problems forhealth and illness which the physician- Describe problems directs the primarytreated by nurses treatmentwithin the scope ofindependent nursing - Remains the same forpractice as long as the disease is- Changes from day to presentday as client responseschange
  14. 14. OBJECTIVES
  15. 15. OBJECTIVES- Should be SMART- client centered- statement of a single human response
  16. 16. EVALUATION
  17. 17. EVALUATION- Conclusion and supporting data- Goal met- Goal partially met- Goal not met

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