nadersmadi@hotmail.

com

The purposes of the Nursing Process Identify the clients health care needs Determine priority of care goals and expec ted outcomes Establish nursing care plan to meet client-centered needs Provide n ursing interventions designed to meet these needs Evaluate the effectiveness of nursing care

Components of nursing process 1. Assessment 3. Diagnosis 5. Planning 7. Implementation 9. evaluation

Nursing process Assessment: data collection: Subjective data pain Objective data fever Diagnosis: determining the problem. Planning: developing a plan for care. Implem entation: applying the plan. Evaluation: evaluating the outcomes.

1. Assessment Steps: Health history Physical examination Laboratory data & diagnostic procedure s Validating data Documenting data

Sources of data Client Family Health care team Medical records Military records

Types of data 1- SUBJECTIVE DATA Clients perception about his health problems usually includes A - Presence of pain B- Feeling of anxiety C- Physical discomfort D. Mental str ess

Types of data 2- OBJECTIVE DATA Observation or measurement made by the data collector includes A observation (body rash ) B- measured (BP , T , R , head circumference )

Methods of data collection Interview Nursing health history Physical examination Results of laboratory & di agnostic tests

Physical examination Inspection, used to detect height, weight, skin color, skin rash, scars, Palpatio n, used to detect tenderness, temperature, texture, pulse, Percussion, used to de tect the location of organs. Auscultation, used to listen to sounds produced by cardiovascular, respiratory, gastrointestinal systems.

2. Diagnosis Steps: Interpreting data Identify problems Formulating nursing diagnosis Document ing nursing diagnosis Two types:- Actual - Potential

3. Planning Steps: Identify clients goals Establish expected outcomes Selecting nursing action s Delegating action Writing nursing care plan Consulting

Types of goals: short term goals Achieved in a short period, usually less than one week. Long term goals Achieved over a long period, usually over weeks or months.

4. Implementation Steps: Reassessing client Reviewing and modifying existing care plan Performing n ursing action

5. Evaluation Steps: Comparing client response to criteria Analyzing reasons for results Modify ing care plan