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N#316 lecture 1

Introduction to nursing process, diagnosis and professional Nursing

Intro 2 nursing ____, Nursing _____ and _______Nusing process diagnosis, professional nursing
Definition of Nursing .”(Roy, 1999 p.4) “A health care profession focuses human life processes patterns, emphasizes promotion health individuals, families, groups, and society as a whole.
Definition of Nursing .”(ANA 1998) diagnosis treatment human responses health illness
What is Nursing’s Role Today Caregiver Educator Advocate Manager Researcher Practitioner
What is Nursing’s Role Today care giver educator advocate manager researcher practitioner Promoter health illness prevention leader other
Guidelines for Nursing Practice American Nurse Association State nurse practice act
American Nurses Association code nurses, standards nursing practice
State nurse Practice Act State board nursing Nursing Licensure
Legal issues of nursing client rights, practice w/ in scope of licensure, negligence, malpractice, assult
ethical issues of nursing - clients rights cultural, confidentality, aids, Death and dying issues,
Nursing process must be? specific, individualized holistic
5 steps of nursing process ANPIE 1.Assessment 2.Nursing Diagnosis 3.Planning 4.Intervention 5.Evaluation
Assessment Create patient data base –systematic gather organize document
Assessment subjective data the patient's perspective
Assessment objective Data observeable Physical assessment diagnostic test
Assessment –con’t Components of the patient data base Cognitive Assessment developmental level, economic status, functional abalities, lifestyle, physical assessment, psychological assessment, socio-cultural assessment, spiritual assessment
Nursing Diagnosis statement,(pattern of cues or symptoms) Related to, or etiology (related cause or contributor to thye problem) As evidenced by (defining characteristics or symptoms identified by the nurse)
Nursing Diagnosis statement (pattern of cues or symptoms)
Nursing Diagnosis Related to , or etiology (related cause or contributor to the problem)
Nursing Diagnosis As evidenced by (defining characteristics or symptoms identified by the nurse)
Nursing diagnosis Example Impaired physical mobility related To limb immobilization as evidenced by inability to independently perform activities of daily living
Planning Chose the diagnosis that is the highest priority (maslow's Hierarchy of Needs) Develop outcomes ( Nursing outcomes classification (NOC) Develope interventioin to achieve outcomes (nursing intervention classifications (NIC) evidenced based nursing pract
steps in planning diagnosis w/ highest priority, develop outcomes, develop interventions to achieve outcomes
planning cont Nursing interventions any treatment that a nurse performs to enhance patient outcomes
examples of nursing interventions Direct care intervention indirect care intervention nurse initiated treatment physician initiated treatment (order) other provider initiated treatment
implementation just do it! Document it!
Physician Prescribed interventions ASA 325 mg. Q4 hours Prn Pain Activity-Bed rest Stool for O&P Low Fat Diet Diabetic management to see patient Initiate disharge planning
Evaluation Occurs throughout the process were the outcomes met? If no then..... were outcomes attainable? Was it the right diagnosis? Was it the wrong intervention? Make revisions where needed and try again.
teaching -Learning adult learning Mutual goal setting Identify outcome change (knlwledge, attitude or behavior change) Evaluate effectiveness
Nursing Prescribed interventions examples Administer aspirin for back pain, Reposition every 2 hours send a stool speciman to the laboratory explain ways to reduce dietary fat intake requesst that a clinical specialist see the client refer for discharge planning
Created by: garrowcousino