CHARACTERISTICS OF NURSING PROCESS

CHARACTERISTICS OF NURSING PROCESS

1. Cyclic and dynamic rather than static
2. Client centered – nurse organizes plan of care according to client problems rather that nursing goals
3. Interpersonal and collaborative – depends on open and meaningful communication between client and the nurse
4. 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
5. Adaptation of problem solving techniques and system theory based on the scientific method
6. It can be viewed as parallel to but separate from the medical process

ASSESSMENT

-       Objective (physical exam) and subjective (nursing history)

SOURCES OF DATA

1. Primary – client
2. Secondary – relatives, members of health team, tests

FOR NURSING HISTORY USE GORDON’S TYPOLOGY OF 11 FUNCTIONAL PATTERN

1. Health perception – health management pattern – describes client perceived pattern of health and well being and how health is managed.
2. Nutritional – metabolic pattern – describes pattern of food and fluid consumption relative to metabolic need and pattern indicators of local nutrient supply.
3. Elimination – describes pattern of excretory function (bowel, bladder and skin).
4. Activity – exercise – describes pattern of exercise, activity, leisure and recreation
5. Cognitive perceptual – describes sensory perceptual and cognitive system
6. Sleep rest – describes pattern of sleep, rest and recreation.
7. Self perception – self concept – self concept pattern and perceptions of self (body comfort, body image, feeling state).
8. Role relationship – describes pattern of role engagements and relationships
9. Sexual reproductive – client patterns of satisfaction and dissatisfaction with sexuality: describes reproductive pattern
10. Coping stress tolerance – general coping pattern and effectiveness of the pattern in terms of stress tolerance.
11. Value belief – patterns of values, beliefs (including spiritual) or goals that guide choices of decisions.

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.

           

Actual            Potential Health   Problem         Healthy  Responses                                                                                                         

                                                 

NURSING DIAGNOSIS	MEDICAL DIAGNOSIS
- Focus on identifying human responses to health and illness - Describe problems treated by nurses within the scope of independent nursing practice - Changes from day to day as client responses change	- Identifies disease - Describe problems for which the physician directs the primary treatment - Remains the same for as long as the disease is present

6 TYPES OF NURSING DIAGNOSIS

1. Actual nursing diagnosis – judgment about a clients response to a health problem at the time of assessment and is signified by the presence of associated signs and symptoms.

            Format: 2 part (problem related to etiology)

                          3 part (problem, etiology and signs and symptoms format)

2. Risk nursing diagnosis – clinical judgment about a clients vulnerability to develop a problem

            Format: 2 part statement (diagnostic label related to risk factors)

3. Possible nursing diagnosis – evidence about a certain problem is unclear and need to gather more data to support it

            Format: 2 part statement

4. Wellness nursing diagnosis – clinical judgment about an individual, family and community in transition from a specific level of wellness to a higher level of wellness

            Format: potential + desired higher level of wellness

                         Readiness for + higher level of wellness

5. Syndrome nursing diagnosis – comprises of a cluster of problems

            Format: 1 part statement (rape trauma syndrome)

6. Alfaro’s rule for a collaborative problem –  focus on potential complications

            Format: potential problem + related to + list of complications that may occur

First Priority – is any threat to the vital functions of breathing, heart beat, blood pressure.

Medium Priority – health-threatening problems that may result in delayed development or cause destructive physical or emotional changes.

Low Priority – problems that arise from normal development needs or those that require minimal nursing support.

OBJECTIVES

- Should be SMART, client centered, statement of a single human response

EVALUATION

- Conclusion and supporting data

- Goal met

- Goal partially met

- Goal not met

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Posted in: Fundamentals of Nursing