Nursing Process: A Clinical Guide Molly Sam
INDEX
A
Activity and exercise 87
nursing diagnoses under sleep and rest pattern 88
activity intolerance—high- risk/actual 88
altered growth and development 95
decreased tissue perfusion 100
fatigue 89
impaired gas exchange 102
impaired home maintenance management 103
impaired physical mobility 91
ineffective airway clearance 96
ineffective breathing pattern 98
self-care deficit 93
Approved nursing diagnoses— NANDA, 1990 12
Assessment guidelines 126
activity/rest reports 128
circulation 128
ego integrity 129
elimination 130
food/fluid 130
hygiene 131
medical/surgical assessment tool 127
neurosensory 132
pain/comfort 133
respiration 133
safety 134
sexuality 134
social interaction 135
teaching/learning 136
B
Body temperature 31
Bowel incontinence 31, 82
C
Cognition and perception 109
anxiety 119
expected outcomes 121
related clinical concerns 120
fear 123
clinical concerns 123
expected outcomes 123
related factors 123
nursing diagnosis 109
altered thought process 118
knowledge deficit 116
sensory perceptual alteration 112
Comparison of nursing models for data collection 5
D
Data collection and nursing diagnoses 11
cognition, reception and self- concept 21
NANDA approved nursing diagnosis according to human response patterns categories 14
NANDA list of nursing diagnoses organized according to Gordon's functional health patterns 17
nursing diagnoses classified under body systems 22
cardiovascular system 22
endocrine system 25
gastrointestinal system 23
genitourinary system 24
integumentary system 25
intensive cares 26
musculoskeletal system 24
nervous system 23
oncology 26
postoperative 26
preoperative 25
respiratory system 22
patterns and nursing diagnoses 20
activity-exercise sleep rest 21
elimination 21
health perception-health pattern management 20
nutrition metabolism 20
E
Elimination 78
nursing diagnosis 78
altered urinary elimination: incontinence 83
bowel incontinence 82
diarrhea 80
urinary retention 85
F
Fluid volume access 35
Fluid volume deficit – actual 34
Fluid volume deficit – potential 34
G
Gas exchange, impaired 35
Growth and development, altered 35
H
Health perception—health management pattern 50
I
Impaired swallowing 68
Impaired tissue/skin integrity-high risk for/actual 74
Infection potential for 38
Injury potential for 40
K
Knowledge deficit 40
M
Medical/surgical assessment tool 127
Mobility, impaired physical 38
Musculoskeletal system 24
N
Nursing care plan 138
Nursing diagnoses of health perception 50
altered health maintenance 50
clinical conditions 51
expected outcome 51
possibly evidenced 51
altered protection 57
clinical problems 58
possibly evidenced by 58
high-risk for infection 52
clinical conditions 53
expected outcome 53
high-risk for injury 55
clinical problems 56
expected outcome 56
possibly evidenced 56
in effective management of therapeutic regime 54
clinical concerns 54
expected outcome 54
Nursing diagnoses with defining characteristics and contributing factors 28
activity intolerance 28
activity intolerance potential 29
airway clearance, ineffective 29
anxiety 29
aspiration, potential for 30
body temperature, potential altered 31
bowel incontinence 31
breathing pattern, ineffective 31
constipation 32
diarrhea 32
fatigue 33
fluid volume deficit, actual 34
fluid volume deficit, potential 34
fluid volume excess 35
gas exchange, impaired 35
growth and development, altered 35
health maintenance, altered 36
home maintenance management impaired 37
infection, potential for 38
injury potential for 40
knowledge deficit 40
mobility, impaired physical 38
nutrition, altered: less than body requirements 39
nutrition, altered; more than body requirements actual and potential 41
pain 42
pain, chronic 42
self-care deficit, bathing/hygiene 42
self-care deficit, dressing/ grooming 43
self-care deficit, feeding 43
self-care deficit, toileting 44
sensory/perceptual alterations (specify): visual, auditory, kinesthetic gustatory, tactile, olfactory 40
skin integrity, impaired 44
skin integrity, potential impaired 44
sleep pattern disturbances 45
swallowing, impaired 45
tissue integrity, impaired 46
tissue perfusion, altered (specify) 47
trauma, potential for 46
urinary elimination, altered 48
urinary incontinence 48, 49
urinary retention 49
Nursing process 1
benefits 2
steps 3
assessment 3
diagnosis 7
expected outcome 9
implementation 8
planning 7
Nursing process and conceptual framework 2
Nutrition metabolism 60
nursing diagnoses 61
altered body temperature 75
altered nutrition—less than body requirement 61
fluid volume deficit: actual or high-risk for 70
fluid volume excess 72
high-risk for/or potential for aspiration 66
impaired swallowing 68
impaired tissue/skin integrity- high-risk for/actual 74
O
Oncology 26
P
Place of nursing process in nursing education 2
R
Related clinical concerns 120
Respiratory system 22
S
Sleep-rest 106
sleep pattern disturbance 106
clinical conditions 106
expected outcome 107
possibly evidenced 106
T
Teaching/learning 136
Tissue integrity 46
Tissue perfusion 47
Trauma, potential for 46
U
Urinary retention 85
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Chapter Notes

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1Nursing Process: A Clinical Guide
2Nursing Process: A Clinical Guide
Second Edition
Molly Sam Assistant Professor MS Ramaiah Institute of Nursing MSR Nagar Bangalore, Karnataka India
3Published by
Jitendar P Vij
Jaypee Brothers Medical Publishers (P) Ltd
EMCA House, 23/23B Ansari Road, Daryaganj, New Delhi 110 002, India
Phones: +91-11-23272143, +91-11-23272703, +91-11-23282021, +91-11-23245672
Fax: +91-11-23276490, +91-11-23245683
Branches
Nursing Process—A Clinical Guide
© 2007, Molly Sam
All rights reserved. No part of this publication should be reproduced, stored in a retrieval system, or transmitted in any form or by any means: electronic, mechanical, photocopying, recording, or otherwise, without the prior written permission of the author and the publisher.
First Edition: 1997
Second Edition: 2007
9788184481310
Typeset at JPBMP typesetting unit
Printed at Gopsons Papers Ltd., A-14, Sector 60, Noida
4PREFACE TO THE SECOND EDITION
Nursing Process: A Clinical Guide is a pocket book specially designed for reference to help nursing students and practising nurses. It helps in assessing and planning the nursing care with current treatment plan.
This book is only using the most commonly used nursing diagnosis; and students and nurses are encouraged to further elaborate on their findings by more references.
In this edition, we have not changed much of what is in the first edition, but made lot of corrections of the mistakes which cropped up due to oversight, typing and printing errors.
I hope this book helps the beginners to prepare care plans.
Molly Sam
5PREFACE TO THE FIRST EDITION
The students have difficulty in writing individualized nursing actions as many of the books written by Indian authors for the nurses focuses on the disease condition relating to etiology, sign and symptoms and nursing care to treat the disease condition. Importance is given to medical care and medical diagnosis. It was more of helping the physician and other health professionals to achieve their goals. The nurse is a mediator, coordinator and organizer of care under them. No decisions are independently taken by the nurses.
The nursing education in India also continue to prepare students in the same line, while our counterparts in western countries have made enormous progress in the field of nursing. This book gives guidance to Nurses on what they can do independently and what they can do in collaboration with other professionals.
The purpose of nursing process is to plan, implement and evaluate care. It is important to understand the purpose of planning the care rendered. Most of the nursing care given in our country are unplanned. We look up on doctors to give us orders and instructions and then carry out those orders. This is convenient for physicians as they get some one to follow their directions and orders making their work simpler allowing them to spend less time with the patient and still getting all the credit for the services.
If we practice Nursing process it will lead to our professional identity and would increase ourself worth and job satisfaction. Nurses will have not only accountability but authority regarding what they can do independently without constant intrusion from other medical professionals.6
If care is not planned individual nursing needs of the patient will not be considered. The time nurses spend in the hospital will be utilized for house keeping and for carrying out orders given by other health professionals. To compound the problem no state or national agency has formulated any criteria for nursing care audit in India.
Nurses have to realize that if they continue to be medical assistants the profession is not going to have an identity of its own. We can be the coordinator, mediators and organizers for the holistics care of patients. In the process of doing all these we have neglected our own profession and its growth and the very purpose of nursing itself. The situation has deteriorated to the extend that other medical professionals and administrators have difficulty in accepting the assertiveness of few nurses as they are used to the submissive and subordinate role of the nurses. The nurse is appreciated only when she carries out their orders efficiently and obediently.
The work of nurses have increased enormously but they are not recognized for the responsibility they take. The salary, promotion and her position in the society has not improved due to their subordination to medical profession. This is the very reason why nursing care has not improved over the years in spite of having postgraduate and doctoral level education in nursing.
By documenting nursing process, it is possible to evaluate and audit nursing care which will help in determining the need and importance of nurses and then, other medical professionals will be forced to accept nursing at par with them.
Chapter 1 gives a detailed description of nursing process and its steps. Chapter 2 gives data collection which is explained in the introduction with the nursing diagnoses under them. Chapter 3 explains nursing diagnoses in alphabetical order with defining characteristics and contributing factors. Chapter 4 7to 8 gives nursing diagnoses under different patterns. Two patterns are combined together in seventh and eighth chapters to reduce the number of chapters. Only selected nursing diagnoses which could be frequently used by the student nurses and nurses for adult patients are included. Appendices give different assessment guides, Nursing care plan and glossary.
Molly Sam
8FOREWORD
You know – you need to provide individualized care required by your client/patient.
You feel – you have an identity of your own as a nurse. You are skillful and capable of planning and implementing the care required by your clients independently.
You need – Practical approach to identify and meet your clients needs/problems
You deserve – To achieve job satisfaction, enhance self-worth and accomplish professional identity and autonomy.
Nurses have seen many changes in their profession over the last few decades, although one thing has not changed much, that is the need for the nurses to become more aware of the importance of nursing process and its uses in providing quality assurance Nursing care services to the clients.
“Nursing Process” is series of activities which are undertaken to identify the nursing care needs/problems, plan, implement and evaluate the care provided. The nursing process requires nurse to engage in many decision-making activities during each of the five phases, i.e. Assessment, Diagnosis, Planning, Implementation and Evaluation. Nursing process is quite similar to problem solving approach and is closely related to Nursing Research. As nursing process presents a model that nurses in practice may use to develop research project by applying the problem solving approach of Nursing process. Both Nursing process and Nursing research begins with a problem in Nursing practice and both are used to improve the patient care. Nursing process guides the nurses in better understanding of the client and his/her problems, establish and maintain contact and continuity in the care and to act in 9the best interest of the client. It aids in documenting and auditing the care provided and thus maintain as expected level of performance as per the nursing care standards.
The use of Nursing process in nursing practice is important to achieve independence and autonomy of Nursing profession
Using her nursing background and experience the author has worked hard to untangle misconceptions, dispel fears and pinpoint priorities in the use of Nursing process. The goal of this book is to accelerate the learning and use of Nursing process in the nursing practice and support the nurses in making significant changes that last.
The contents included in the book are:
  1. Relevant to nursing practice at all levels and settings
  2. Language is simple and easy to understand
  3. Illustrations and examples are stimulating
  4. Concepts are well explained
  5. Provides useful appendices as guidelines and models
In each chapter the author has presented the materials in such a way which will help the nurses to become familiar with steps of Nursing process
Chapter 1 gives a detailed description of Nursing process and its steps.
Chapter 2 gives the steps of date collection and making Nursing Diagnoses.
Chapter 3 further explains Nursing Diagnoses in alphabetical order with defining characteristics and contributing factors.
Chapter 4 to 8 gives Nursing Diagnosis under different patterns, that is related to the clients health, his family, environments and his clinical condition. It also explains the expected outcome of the Nursing actions/interventions with the rationale for each action. These few selected nursing diagnosis given in these chapters are based on the basic human needs and the ones which are commonly used by the nurses in their daily nursing practice.10
Appendices give assessment guidelines, Nursing care plan and glossary.
This book is intensively alive with the examples to clarify the concepts of the various phases of nursing process. This book should be like a ball of light in the hands of the nurses who are truly interested in providing scientific and efficient nursing care services in their clients and in achieving professional autonomy.
Uma Handa msc n