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THE NURSING
PROCESS
A systemat ic , rati onal
method of pl anni ng
provi di ng nursi ng care .
Goal :
To identi fy a client’s hea lthcare
status, an d actu al or poten tial
heal th probl ems
To establ ish pl ans to meet the
identif ied needs
To del iv er speci fic nursi ng
inter venti ons to address those
needs MENU
ASSESSING
Collect data
Organize data
Validate data
O
Document data
DIAGNOSING
V Analyze data
Identify health problems, risk, and strengths
Formulate diagnostic statements
E
PLANNING
R Prioritize problems/diagnoses
Formulate goals/desired outcome
Select nursing interventions
V Write nursing orders
I IMPLEMENTATION
Reassess the client
Determine the nurse’s need for assistance
W EVALUATION
Collect data related to outcomes
Compare data with outcomes
Relate nursing actions to client goals/outcomes
Draw conclusions about problem status
HOME END Continue, modify, or terminate the client’s care plan
ASSESSMENT PHASE
The nurse carry out a
complete & holistic nursing
assessment of every
patient's needs
Utilizes an assessment
framework, based on a
nursing model or Waterlow
scoring wherein problems
are expressed as either
actual or potential
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ASSESSMENT PHASE
Assessing is a systematic and
continuous collection, organization,
validation,
and documentation of data
(information)
assessing is a continuous process
carried out during all phases of the
nursing process
Nursing assessments focus on a
client’s responses to a health
problem
should include the client’s perceived
needs, health problems, related
experience, health practices, values,
and lifestyles MENU
Types of Assessment
Initial Assessment
Problem-focused Assessment
Emergency Assessment
Time-lapsed Reassessment
The assessment process involves four
closely related activities: collecting data,
organizing data, validating data, and
documenting data.
1). Collecting Data
Data collection is the process of
gathering information about a client’s
health status. It must be both systematic
and continuous to prevent the omission of
significant data and reflect a client’s
changing health status.
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Types of Data
Interviewing
An interview is a planned communication or a
conversation with purpose, for example, to get or give
information, identify problems of mutual concern, evaluate
change, teach, provide support, or provide counseling or
therapy. There are two approaches to interviewing:
directive, is highly structured and elicits specific
information.
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The nurse establishes the purpose of the interview and
controls the interview, at least at the outset, and
nondirective interview, or rapport-building interview, by
contrast, the nurse allows the client to control the
purpose, subject matter, and pacing. Rapport is an
understanding between two or more people.
Examining
The physical examination or physical assessment is a
systematic data-collection method that uses observation
(i.e., the senses of sight, hearing, smell, and touch) to
detect health problems. To conduct the examination the
nurses uses techniques of inspection, auscultation,
palpation, and percussion.
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Validating data helps the nurse complete
these tasks:
Ensure that assessment information is complete.
Ensure that objective and related subjective data
agree.
Obtain additional information that may have been
overlooked.
Differentiate between cues and inferences. Cues
are subjective and objective data that can be
directly observed by the nurse; that is, what the
client says or what the nurse can see, hear, feel,
smell, or measure. Inferences are the nurse’s
interpretation or conclusions made based on the
cues.
Avoid jumping to conclusions and focusing in the
wrong direction to identify problems.
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4). Documenting Data
To complete the assessment phase,
the nurse records client data. Accurate
documentation is essential and should
include all data collected about the client’s
health status. Data are recorded in a
factual manner and not interpreted by the
nurse
MENU
ASSESSING
Collect data
Organize data
Validate data
O
Document data
DIAGNOSING
V Analyze data
Identify health problems, risk, and strengths
Formulate diagnostic statements
E
PLANNING
R Prioritize problems/diagnoses
Formulate goals/desired outcome
Select nursing interventions
V Write nursing orders
I IMPLEMENTATION
Reassess the client
Determine the nurse’s need for assistance
W EVALUATION
Collect data related to outcomes
Compare data with outcomes
Relate nursing actions to client goals/outcomes
Draw conclusions about problem status
HOME END Continue, modify, or terminate the client’s care plan
DIAGNOSING PHASE
The term diagnosing refers to the reasoning
process, whereas the term diagnosis is a
statement or conclusion regarding the nature of a
phenomenon. The standardized North American
Nursing Diagnosis Association (NANDA) names
for the diagnoses are called diagnostic labels;
and the client’s problem statement, consisting of
the diagnostic label plus etiology (causal
relationship between a problem and its related or
risk factors), is called nursing diagnosis.
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2).Identifying Health Problems, Risks,
and Strengths.
After data are analyzed, the nurse and
client can together identify strengths and
problems. This is primarily a decision-
making process.
Determining problems and risk
After grouping and clustering the data, the
nurse and client together identify problems that
support tentative actual, risk, and possible
diagnoses. In addition, the nurse must determine
whether the client’s problem is a nursing
diagnosis, medical diagnosis, or collaborative
problem.
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Determining strengths
At this stage, the nurse and client also establish
the client’s strengths, resources, and abilities to
cope. Most people have a clearer perception of
their problems or weakness than of their
strengths and assets, which they often take for
granted. A client’s strengths can be found in the
nursing assessment record (health, home life,
education, recreation, exercise, work, family and
friends, religious beliefs, and sense of humor).
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Basic two-part statements
The basic two-part statement includes the
following:
Problem (P): statement of the client’s response.
Etiology (E): factors contributing to or probable
cause of the responses.
MENU
ASSESSING
Collect data
Organize data
Validate data
O
Document data
DIAGNOSING
V Analyze data
Identify health problems, risk, and strengths
Formulate diagnostic statements
E
PLANNING
R Prioritize problems/diagnoses
Formulate goals/desired outcome
Select nursing interventions
V Write nursing orders
I IMPLEMENTATION
Reassess the client
Determine the nurse’s need for assistance
W EVALUATION
Collect data related to outcomes
Compare data with outcomes
Relate nursing actions to client goals/outcomes
Draw conclusions about problem status
HOME END Continue, modify, or terminate the client’s care plan
PLANNING PHASE
The third phase of the nursing process, in
which the nurse and client develop client
goals/desired outcomes and nursing interventions
to prevent, reduce, or alleviate the client’s health
problems.
Planning is a deliberative, systematic phase of
the nursing process that involves decision making
and problem solving. In planning, the nurse refers
to the client’s assessment data and diagnostic
statements for direction in formulating client’s
goals and designing the nursing interventions
required to prevent, reduce, or eliminate the
client’s health problems. A nursing intervention is
“any treatment, based upon clinical judgment and
knowledge that a nurse performs to enhance
patient/client outcomes”
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Types of Planning
Planning begins with the first client contact and
continues until the nurse-client relationship ends,
usually when the client is discharges from the
health care agency.
Initial Planning
The nurse perform the admission assessment
usually develops the initial comprehensive plan of
care. This nurse has the benefit of the client’s
body language as well as some intuitive kinds of
information that are not available solely from the
written database. Planning should be initiated as
soon as possible after the initial assessment,
especially because of the trend toward shorter
hospital stays.
Ongoing Planning
Is done by all nurses who work with the client.
As nurses obtain new information evaluate the
client’s responses to care, they can individualize
the initial care plan further. Ongoing planning also
occurs at the beginning of a shift as the nurse
plans the care to be given that day.
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Discharge Planning
The process of anticipating and planning for
needs after discharge, is a crucial part of
comprehensive health care and should be
addressed in each client’s care plan.
O
Document data
DIAGNOSING
V Analyze data
Identify health problems, risk, and strengths
Formulate diagnostic statements
E
PLANNING
R Prioritize problems/diagnoses
Formulate goals/desired outcome
Select nursing interventions
V Write nursing orders
I IMPLEMENTATION
Reassess the client
Determine the nurse’s need for assistance
W EVALUATION
Collect data related to outcomes
Compare data with outcomes
Relate nursing actions to client goals/outcomes
Draw conclusions about problem status
HOME END Continue, modify, or terminate the client’s care plan
IMPLEMENTATION PHASE
The methods by which the goal will be
achieved are also recorded at this stage.
The methods of implementation must be
recorded in an explicit and tangible
format in a way that the patient can
understand should he wish to read it.
Clarity is essential as it will aid
communication between those tasked
with carrying out patient care.
Implementing consists of doing and
documenting the activities that are
specific nursing actions needed to carry
out the interventions that were developed
in the planning step and then concludes
the implementing step by recording
nursing activities and the resulting client
responses.
MENU
Implementing Skills
To implement the care plan successfully, nurses
need cognitive, interpersonal, and technical skills.
These skills are distinct from one another; in
practice, however, nurses use them in various
combinations and with different emphasis,
depending on the activity. Having these skills
contributes to the greater improvement of the
nurse's delivery of health care to the patient,
including the patient's level of health, or health
status.
Process of Implementing
The process of implementing normally
includes:
1). Reassessing the Client
Just before implementing an
intervention, the nurse must reassess the
client to make sure the intervention is still
needed. Even though an order is written
on the care plan, the client’s condition
may have changed.
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2). Determining the Nurse’s Need for
Assistance
When implementing some nursing
interventions, the nurse may require
assistance for one of the following
reasons:
-The nurse is unable to implement the
nursing activity safely alone (e.g.,
ambulating an unsteady obese client).
-Assistance would reduce stress on the
client (e.g., turning a person who
experiences acute pain when moved).
-The nurse lacks the knowledge skills to
implement a particular nursing activity
(e.g., a nurse who is not familiar with a
particular model of traction equipment
needs assistance the first time it is
applied). MENU
3). Implementing the Nursing
Interventions
It is important to explain to the client what
interventions will be done, what
sensations to expect, what the client is
expected to do, and what the expected
outcome is. For many nursing activities it
is important to ensure the client’s privacy,
for example by closing doors, pulling
curtains, or draping the client. When
implementing interventions, nurses
should follow these guidelines:
-Base nursing interventions on scientific
knowledge, nursing research, and professional
standards of care whenever possible.
-Clearly understand the orders to be implemented
and question any that are not understood.
-Adapt activities to the individual client.
-Implement safe care.
-Provide teaching, support, and comfort.
MENU
-Be holistic.
-Respect dignity of the client and enhance the
client’s self-esteem.
-Encourage clients to participate actively in
implementing the nursing interventions.
MENU
ASSESSING
Collect data
Organize data
Validate data
O
Document data
DIAGNOSING
V Analyze data
Identify health problems, risk, and strengths
Formulate diagnostic statements
E
PLANNING
R Prioritize problems/diagnoses
Formulate goals/desired outcome
Select nursing interventions
V Write nursing orders
I IMPLEMENTATION
Reassess the client
Determine the nurse’s need for assistance
W EVALUATION
Collect data related to outcomes
Compare data with outcomes
Relate nursing actions to client goals/outcomes
Draw conclusions about problem status
HOME END Continue, modify, or terminate the client’s care plan
EVALUATION PHASE
To evaluate is to judge or to appraise.
Evaluating is a planned, ongoing, purposely
activity in which clients and health care
professionals determine (a) the clients progress
toward achievement of goals/outcomes and (b)
the effectiveness of the nursing care plan. The
purpose of this stage is to evaluate progress
toward the goals identified in the previous stages.
If progress towards the goal is slow, or if
regression has occurred, the nurse must change
the plan of care accordingly. Conversely, if the
goal has been achieved then the care can cease.
New problems may be identified at this stage,
and thus the process will start all over again. It is
due to this stage that measurable goals must be
set - failure to set measurable goals will result in
poor evaluations. The entire process is recorded
or documented in an agreed format in the
patient's care plan in order to allow all members
of the nursing team to perform the agreed care
and make additions or changes where
appropriate.
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Process of Evaluating Client
Responses
Before evaluation, the nurse identifies the
desired outcomes (indicators) that will be
used to measure client goal
achievement. Desired outcomes serve
two purposes: they establish the kind of
evaluative data that needed to be
collected and provide a standard against
which the data are judged. The
evaluation process has five components:
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Evaluating the Quality of Nursing Care
In addition to evaluating goal achievement for
individual clients, nurses are also involved in
evaluating and modifying the overall quality of
care given to groups of clients. This is an
essential part of professional accountability.
Quality Assurance
A quality-assurance (QA) program is an ongoing,
systematic process designed to evaluate and
promote excellence in the health care provided to
clients. Quality assurance frequently refers to
evaluation of the level of care provided in a health
care agency, but it may be limited to the
evaluation of the performance of one nurse or
more broadly involve the evaluation of the quality
of the care in an agency, or even in a country. It
consists of three components of care: the
structure evaluation (focuses on the setting in
which care is given. It answers this question:
what effect does the setting have on the quality of
care?), the process evaluation (focuses on how
the care was given.
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It answers question such as these: Is the care
relevant to the client’s needs? Is the care
appropriate, complete and timely?), and
outcome evaluation (focuses on demonstrable
changes in the client’s health status as a result of
nursing care. Outcome criteria are written in
terms of client responses or health status.
Quality Improvement
Quality improvement (QI) is also known as
continuous quality improvement (CQI), total
quality management (TQM), performance
improvement (PI), or persistent quality
improvement (PQI)
Nursing Audit
An audit means the examination or review of
records. A retrospective audit is the evaluation of
a client’s record after discharge from an agency.
Retrospective means “relating to past events”.
These evaluations use interviewing, direct
observation of nursing care, and review of clinical
records to determine whether specific evaluative
criteria have been met.
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