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NURSING PROCESS AND CARE PLANS

NURSING PROCESS AND CARE PLANS. HNI 364 PROFESSOR PATRICIA VOELPEL. WHAT IS THE NURSING PROCESS??????. Systematic and rational method of planning and providing care for individuals, families, groups, and communities!!!. Requires critical thinking Identify actual and potential problems

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NURSING PROCESS AND CARE PLANS

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  1. NURSING PROCESS AND CARE PLANS HNI 364 PROFESSOR PATRICIA VOELPEL

  2. WHAT IS THE NURSING PROCESS?????? • Systematic and rational method of planning and providing care for individuals, families, groups, and communities!!!

  3. Requires critical thinking Identify actual and potential problems Define goals Establish a plan of care Implement the plan Provides framework for responsibility and accountability ADPIE (assessment, diagnosis, planning, implementation, and evaluation). NURSING PROCESS

  4. CHARACTERISTICS • Person centered • Emphasizes feedback • Facilitates creativity • FOUNDATION OF NURSING PRACTICE

  5. ASSESSMENT • Review the clinical record • Interview • Nursing history • Physical assessment • Psychological assessment • Consultation • Review of literature

  6. DIAGNOSING • Analyze data • Identify health problems, risks, and strengths • Formulate diagnostic statements

  7. TYPES OF DIAGNOSES • Actual • High-risk • Wellness • Collaborative problems

  8. PLANNING • Prioritize problems/diagnoses • Formulate goals/desired outcomes • Select nursing interventions • Write nursing orders

  9. SMART METHOD FOR GOALS • S = Specific • M = Measurable • A = Appropriate • R = Realistic • T = Timely

  10. NURSING INTERVENTIONS

  11. Independent Interdependent Should contain date when started The verb should be precise Based on nursing science Prescribed activity Time frequencies Signature of nurse Realistic and safe Achievable Congruent with beliefs and values Legal NURSING INTERVENTIONS

  12. EVALUATING • Collect data related to outcomes • Compare data with outcomes • Relate nursing actions to outcomes • Draw conclusions about problem status • Continue, modify, or terminate

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