The Nursing Process

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
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

ASSESSMENT
Assessment
Objective (physical exam) and subjective
(nursing history)


SOURCES OF DATA
Primary client
Secondary relatives, members of health
team

GORDONS TYPOLOGY OF
FUNCTIONAL PATTERNS
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.
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
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
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.

NURSING DIAGNOSIS
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.


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
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