Nursing Process

Is an organized systematic method of giving individualized nursing care that focuses on identifying and treating unique responses  Provides organization of care in every clinical setting  Helps in resolving health problems  Provides a framework with which individualized needs of the patient/family/community can be met  Is an efficient method of organizing thought process for clinical decision making and problem solving 

Purposes of the Nursing Process

to identify a client's health status and actual or potential health care problems or needs to establish plans to meet the identified needs to deliver specific nursing interventions to meet those needs

LYDIA HALL was one of the first nurses to use term nursing process in the early 1955, since
then nursing process has been used to describe the accepted method of delivering nurse care. She introduced 3 steps:  Note observation  Ministration of care  Validation

In 1959, Dorothy Johnson introduced 3 steps of the nursing process:

   Assessment Decision Nursing action

In 1961, Ida Jean Orlando identified 3 steps in the nursing process:

   Client s behavior Nurse s reaction Nurse s action

March 2-April 27, 1967- a continuing education series was conducted by the Catholic University of America, 7 HelenYura and 8 Mary Walsh suggested the four components of the Nursing Process:
    Assessing Planning Implementing Evaluation

BENEFITS OF NURSING PROCESS FOR THE PATIENT

1. 2. 3. 4. 5. Quality Client Care it meets standards of care Continuity of Care Participation by the client s in their health care. This reflects respect for human dignity Individualize care Prevents omission and duplication

BENEFITS OF NURSING PROCESS FOR THE NURSES

1. Nurse gets to plan individualized care which helps her to develop a professional relationship 2. It involves the patient actively in all phases, so the nurse and patient derives satisfaction 3. It gives the nurse a framework to use in patient care 4. It makes the nurse to be aware of the skills and abilities used by her in patient s care 5. Consistent and systematic nursing education 6. Job satisfaction 7. Professional growth 8. Avoidance of legal action 9. Meeting professional nursing standards 10. Meeting standards of accredited hospital

Characteristics of the Nursing Process

1. Cyclic and dynamic nature - the nursing process is a regularly repeated event or sequence of events (a cycle) that are continuously changing (dynamic) rather than staying the same (static). 2. Client-centeredness - the nurse organizes the plan of care according to client problems 3. Focus on problem solving - is directed toward a client's responses to disease and illness. 4. Focus on decision-making - nurses can be highly creative in determining when and how to use data to make decisions 5. Interpersonal, collaborative style - the nurse communicates directly and consistently with clients and families to meet their needs. The nurse also collaborates with members of the health team in a joint effort to provide quality client care.

Characteristics of the Nursing Process

6. Universal applicability - is used as a framework for nursing care in all types of health care settings with clients of all age groups. 7. Use of critical thinking - nurse uses variety of critical-thinking skills to carry out the nursing process.

Critical Thinking defined:

Is an active, organized, cognitive process used to carefully examine one s thinking and the thinking of others. It involves use of the mind in forming conclusions, making decisions, drawing inferences and reflecting. It means taking nothing for granted. Is disciplined, purposeful, reflective reasoning focused on finding meaning and improving the current situation

Components of Critical thinking

Knowledge of information from nursing and related courses: book learning Experience giving patient care and making clinical decisions: hands-on learning Reasoning skills that give the framework for thinking: use of the nursing process Attitudes that motivate internally: curiosity, confidence that you can, courage to try to go against the status quo, perseverance, willingness to admit you were wrong. Standards of the nursing profession specifically and more general standards of clear thinking and fairness: doing the best job you can and measuring it against standards such completeness, accuracy and logic.

STEPS OF NURSING PROCESS

     Assessment Nursing diagnosis Planning Implementation Evaluation

These five steps are performed by the nurse to achieve the ultimate goal of nursing. They are: 1. To promote, maintain/restore health, or to assist patient to achieve a peaceful death, when their condition is terminal 2. To enable patient/family/community to manage their own health care to the best of their ability

ASSESSMENT ( The Nurse collects patient s health data )

  Is both the initial step in the nursing process and ongoing component in every other step of the nursing process. Collecting , organizing, validating, and recording data about the client s health status. PURPOSE: to establish data base

The assessment process involves 4 closely related activities: 1. 2. 3. 4. Collecting data Organizing data Validating data Documenting data 3

The collection and organization should give the following:

1. Patient s current health status 2. Patient s strength and problem areas ( Actual or Potential )

Types of data
1. SUBJECTIVE ( symptoms or covert data ) Include the client's sensation, beliefs, values, feelings, attitudes and perception of health status and life situation. Consists of information given verbally by the patient Can be described and verified by the person affected are the facts presented by the patient in her or his perception
Ex. itching, pain, feelings of worry

2. OBJECTIVE data (signs or overt data)

are the facts which are observable and measurable by the nurse & could be noted by any other skilled worker are detectable by an observer or can be measured or tested against accepted standard. can be seen, heard, felt or smelled and can be obtained by observation or physical examination Ex. Discoloration of the skin or blood pressure reading

Sources of data:
PRIMARY : 1. Patient / Client best source of data; can provide subjective data that no one else can offer SECONDARY: 1. Support people - family members, friends and caregivers who know the client 2. Client records - medical records, record of therapies and laboratory records. 3. Health care professionals - nurses, physicians, therapist 4. Literature - professional journals and related text

Methods of Collecting Data

a. INTERVIEW is a planned purposeful communication or a conversation 2 Approaches in interviewing:
a. directive interview - highly structured and elicits specific information. b. nondirective - or rapport building interview - the nurse allows the client to control the purpose, subject matter, and pacing.

Rapport - is an understanding between two or more people. b. OBSERVATION use of five senses, use of units of measure, physical examination techniques, interpretation of laboratory reports is a conscious, deliberate skill that is developed through effort and with an organized approach. 4

c. ORGANIZING DATA clustering facts into groups of information The nurse uses a written format that organizes the assessment data systematically. often referred to as a nursing health history, nursing assessment, or nursing database. Ways of Clustering Data: 1. Clustering data according to body system 2. Clustering data according to human needs ( Maslows ) 3. Clustering data according to a nursing theory 4. Clustering data according to functional health pattern based on a theory d. VALIDATING Validation is the act of double-checking or verifying data to confirm that it is accurate or factual. 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 be overlooked. Differentiate between cues and inferences. Cues - are subjective or objective data that can be directly observed by the nurse, that is, what the client says and what the nurse can see, hear, feel, smell or measure. Inferences - are the nurse's interpretation or conclusions made based on the cues. Example: The nurse observes the cues that the incision is swollen; the nurse makes an inference that the incision is infected. * Avoid jumping to conclusions and focusing in the wrong direction to identify the problems. e. DOCUMENTATION To complete the assessment phase, the nurse records client data. Accurate documentation is essential and should include all data collected from the client's health status. Data are recorded in a factual manner and not interpreted by the nurse. Ex. The nurse records the client's breakfast intake as coffee 240ml, juice 120ml, 1 egg and a slice of bread (objective data ) rather than as "appetite good" ( a judgment) which may have different meanings for other people.

NURSING DIAGNOSIS
the second step in the nursing process is the phase during which the nurse analyzes the data gathered during assessment and identifies problem areas for the client. is the process of data analysis and problem identification. PURPOSE: to identify the client s health care needs to prepare diagnostic statements 5

EVOLUTION OF THE NURSING DIAGNOSIS

Nursing has attempted to define itself professionally and functionally since the writings of Nightingale, who stated that the purpose of nursing care was to put patients in the best condition for nature to act upon them. However, in the mid-1950s and early 1960s, nursing leaders and educators started to revise the curricula around client-centered problems. Virginia Fry (1953) proposed that nursing could be more creative by formulating nursing diagnosis and an individual care plan. She stated that nursing diagnosis must be based on the client s needs for nursing, rather than medical care. Until that time nursing had been seen as a set of tasks nurses assisted physicians in treating diseases, they gather data to ensure doctors could make the right medical diagnosis. Initially, nursing diagnosis was not supported by professional nursing, as a result, nurses were hesitant to use nursing diagnostic labels in their practice. In 1973, the American Nurses Association (ANA) Standards of Nursing Practice included nursing diagnosis as an important nursing activity, making it a legitimate function of a professional nurse Kristine Gebbie and Mary Ann Lavin, faculty members of Saint Louis University perceived a need to identify nurse's role in an ambulatory setting. The First National Conference for the Classification of Nursing Diagnosis was held to identify nursing functions and establish a classification system. Subsequent national conferences occurred in 1975, and every 2 years thereafter In 1982, a professional association, The North American Nursing Diagnosis association(NANDA) was established.

NORTH AMERICAN NURSING DIAGNOSIS ASSOCIATION (NANDA)

    has developed and classified nursing diagnosis helps in identifying a communication pattern among the nurses also gives a clear distinction between nursing diagnosis and medical diagnosis PURPOSE OF NANDA: To develop, refine and promote a taxonomy of nursing diagnostic terminology of general use for professional nurses." Taxonomy classification system

In 1990, NANDA adopted a working definition of Nursing Diagnosis    is defined as a clinical judgment about the individual, family or community responses to actual and potential health problems/life processes. It is a cluster of signs and symptoms of an actual and potential health problems in which the nurse by virtue of his/her profession is licensed and able to treat. It provides a basis for the selection of nursing interventions to achieve outcome for which the nurse is accountable. 6

Types of Nursing Diagnosis 1. Actual diagnosis - is a client problem is present at the time of the nursing assessment ,based on the presence of actual signs and symptoms. ex. Ineffective breathing pattern 2. Potential (Risk) nursing diagnosis is a clinical judgment that a problem does not exist, but the presence of risk factors indicates that a problem is likely to develop unless the nurse intervenes. ex. A 78 y/o male client with diabetes was admitted, the nurse would appropriately use the label Risk for Infection. 3. Wellness diagnosis - describes human responses to levels of wellness in an individual, family or community where the nurse can intervene to promote growth and maintain health ex. Readiness for Enhanced Spiritual Well-being. Effective Therapeutic Regimen Management Readiness for Enhanced Nutrition 4. Possible nursing diagnosis - is one in which evidence about a health problem is incomplete or unclear; requires more data either to support or to refute it. ex. An elderly woman who lives alone is admitted to the hospital. The nurse notices she has no visitors and is pleased with the attention given to her by the nursing staff. Until more data are collected, the nurse may write: Possible social isolation related to unknown etiology 5. Syndrome diagnosis - a diagnosis that is associated with a cluster of other diagnoses. ex. Risk for disuse syndrome may be experienced by a long term bed-ridden client. Cluster of diagnosis may include: Impaired physical mobility, Risk for impaired tissue integrity, Risk for constipation, Risk for infection etc. NURSING DIAGNOSIS  A statement of client s potential or actual alteration of health status  Uses the critical thinking skills of analysis and synthesis  Uses PRS / PES format P problem ; diagnostic label R related or risk factors S signs and symptoms ; defining characteristics P problem E Etiology S signs and symptoms 7

COMPONENTS OF NURSING DIAGNOSIS

1. Problem or diagnostic label  Describes the client s health problem, the client s health status clearly and concisely in few words Purpose: to direct the formation of client s goals and desired outcomes and suggest nursing interventions Ex. Ineffective Airway clearance Fluid volume deficit Impaired physical activity

Qualifiers words added to some NANDA labels:

     Deficient inadequate in amount, quality or degree; not sufficient, incomplete Impaired made worse, weakened, damaged, reduced, deteriorated Decreased lesser in size, amount or degree Ineffective not producing the desired effect Compromised to make vulnerable to threat

2. Etiology (Related or risk factors)  Identifies one or more probable causes of the health problem, gives direction to the required nursing therapy and enables the nurse to individualize the client s care. Ex. Presence of thick mucus secretion Vomiting, insufficient fluid intake Pain right arm, immobility 3. Defining Characteristics  Clusters of signs and symptoms that indicate the presence of a health problem Ex. Fatigue Weakness Difficulty of breathing Abnormal BP 150/100mmHg Nasal congestion

Difference between a Nursing Diagnosis and Medical Diagnosis Nursing Diagnosis

   Statement of a nursing judgment and refers to a condition that nurses by virtue of their education, experience and expertise are licensed to treat Describes the human response, client s physical, socio cultural, psychologic and spiritual response to an illness or health problem Relate to the nurse s independent functions

Medical Diagnosis
 Used to define the disease process; focus on function and malfunction of a specific organ system 8

PLANNING
    Nurse develops plan of care that prescribes intervention to attain the expected outcome It includes setting priorities and establishing target dates, nursing actions and evaluations by setting standards is a deliberate, 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 strategies required to prevent, reduce or eliminate the client s health problem. The product of the planning phase is a client care plan.

 

Types of Planning
Planning begins with the first client contact and continues until the nurse-client relationship ends, usually when the client is discharged from the health care agency. 1. Initial Planning  the nurse who performs the admission assessment usually develops the initial comprehensive plan of care;  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;  use available information to develop preliminary plans and refine them as the missing data become available. 2. Ongoing Planning  is done by all nurses who work with the client. The nurse carries out daily planning for the following purposes: a. to determine whether the client s health status has changed b. to set the priorities for the client s care during the shift c. to decide which problems to focus on during the shift d. to coordinate the nurse s activities so that more than one problem can be addressed at each client contact 3. Discharge Planning the process of anticipating and planning the needs after discharge. Each client should be assessed for potential health needs, availability and ability of the client s support network to assist with the needs and hoe the home environment supports the client. Effective discharge planning begins with the first client contact

Steps of Planning:
1. Setting Priorities: The problems which need immediate attention are taken care first is the process of establishing a preferential sequence or order for addressing nursing diagnoses and interventions. The nurse decides which nursing diagnosis requires attention first. Group them as high, medium, or low priority: Life-threatening problems are designated as high priority such as loss of respiratory or cardiac functioning Health-threatening problems are usually assigned as medium priority such as acute illness and decreased coping ability that may result in delayed development or cause destructive physical or emotional changes 9

A low priority problem is one that arises from normal developmental needs or that requires only minimal nursing support. Priority setting is a decision making process that ranks the order of nursing diagnosis in terms of importance to the client a. LIFE threatening situations should be given HIGHEST PRIORITY b. Use of Principles of ABC s Airway, Breathing , Circulation c. Use Maslow s Hierarchy of Needs physiologic needs are given priority over psychosocial needs d. Consider something that is very important to the client e. Clients with unstable condition should be given priority over stable conditions f. Actual problems take precedence over potential problems g. Attend to client before equipment 2. Establishing goals: This is what the nurse and patient expect to accomplish in a particular time framework Goal/desired outcomes describe what the nurse hopes to achieve by implementing nursing interventions *The term goal and expected outcome are sometimes use interchangeably Goals as broad statements about the effects of nursing interventions Ex. To improved nutritional status Expected outcomes are more specific, measurable criteria used to evaluate whether the goal has been met. Ex. To gain 5 lbs by March 27 3. Determining nursing interventions: The activities the nurse and patient will do to achieve the desired goals 4. Recording care plan: Other nurses need to know the plan of care that you have prescribed and the goals you expect to achieve

Purpose of Goals/Desired Outcomes

1. Provide direction for planning nursing interventions that will achieve the desired changes in the client. 2. Provide a time span for planned activities. 3. Serve as criteria for evaluation of client progress. 4. Enable the client and nurse to determine when the problem has been resolved. 5. Help motivate the client and nurse by providing a sense of achievement.

Long-term and Short-term Goals

A short term goal is an objective that is expected to be achieved in a short time, usually less than a week. Ex. Client will show improvement in bowel movement this afternoon. A long-term goal is an objective that is expected to be achieved over a longer period of time. Ex. Client will be able to resume ADL in 4 days. 10

Components of Goal/Expected Outcome Statements

1. Subject a noun, is the client; often omitted in goals; assumed that the subject is the client unless indicated otherwise. 2. Verb denotes an action the client is to perform; denotes directly observable behaviors such as administer, demonstrate, show, walk etc. 3. Conditions or modifiers may be added to a verb to explain the circumstances under which the behavior is to be performed. They explain what, where ,when or how.
Ex. Walks with the help of a walker (how) After attending two diabetes classes, lists signs and symptoms of diabetes(when) When at home, maintains weight at existing level (where)

4.Criterion of desired performance indicates the standard by which a performance is evaluated or the level at which the client will perform the specified behavior. The criteria may specify time or speed, accuracy, distance and quality. Ex. Weighs 5lbs by March 25 (time) Lists five out of six signs of diabetes (accuracy) Walks one block per day ( time and distance) Administers insulin using aseptic technique (quality)

Guidelines for Writing Goals/Expected Outcomes

1. Write goals and outcomes in terms of client responses not nurse activities. Ex. Client will drink 100ml of water per hour 2. Make sure the goal statement is derived from one nursing diagnosis. Ex. Deficient fluid volume 3. Be sure that the outcomes are realistic for the client s capabilities, limitations and designated time span. 4. Ensure that the goals/outcomes important are compatible with the therapies of other professionals. 5. Use observable, measurable terms for outcomes. Avoid words that are vague and require interpretation or judgment by the observer. Ex. Within 24 hours, bathes with assistance in bed; within 48 hours, bathes with assistance in sink; within 72 hours, bathes in shower without dyspnea 6. Make sure the client considers the goals/desired outcomes important and values them

Criteria for Choosing Nursing Interventions

The Planned action must be:  safe and appropriate for the individual's age, health, and so on.  achievable with the resources available.  congruent with the client's values and beliefs.  congruent with other therapies.  based on nursing knowledge and experience or knowledge from related sciences.  within established standards of care and policies of the institution Example:
Nursing Diagnosis Nursing Interventions

Impaired skin integrity related to immobility - Assess skin integrity over bony prominences q2hrs - Turn and change position q30mins - Pad pressure points

Types of Nursing Interventions

Independent nursing interventions
   referred to as nurse-initiated treatments are activities that nurses are licensed to initiate on the basis of their knowledge and skills. include physical care, on-going assessment, emotional support and comfort, teaching, counseling, environmental management and making referrals to other health professionals. may be termed as autonomous nursing actions - knowing why, when and how to position clients and doing it skillfully makes the function an autonomous therapy. The nurse determines that the client requires certain nursing interventions , either carries it out or delegates it to other nursing personnel and is accountable for the decision and actions. To be accountable is to be answerable.

Dependent interventions
   also called the physician-initiated treatments are activities carried out under the physician's orders or supervision include orders for medications, intravenous therapy, diagnostic tests, treatments diet and activity. the nurse is responsible for explaining, assessing the need for and administering the medical order are actions the nurse carries out in collaboration with other health team members, such as physical therapists, social workers, dietitians, and physicians. reflect overlapping responsibilities between health personnel. ex. The physician orders physical therapy to teach the patient crutch-walking. The nurse is responsible for informing physical therapy dept. and coordinating the client's care to include physical therapy sessions.

Collaborative interventions
 

Requirements of Implementation:
1. Knowledge 2. Technical skills 3. Communication skills 4. Therapeutic use of self

Nursing interventions are also called NURSING ORDERS. Nursing interventions are INDEPENDENT, DEPENDENT & INTERDEPENDENT/COLLABORATIVE activities that nurses carry out to provide client care. NURSING CARE PLAN is a written summary of the care that a client is to receive ; it is the Blueprint of the nursing process

EVALUATION
 Is assessing the client s response to nursing intervention and then comparing the response to predetermined standards or outcome criteria. PURPOSE: to appraise the extent to which goals and outcome criteria of nursing care have been achieved