THE NURSING PROCESS

THE NURSING PROCESS

The NURSING Process

is the way one thinks like a nurse. This process is the foundation, the essential, enduring skill that has characterized nursing from the beginning of the profession.

 The

nursing process is a systematic, rational method of planning and providing individualized nursing care for individuals, families, groups and communities.

Nursing Process - provides the framework in which nurses use their knowledge and skills to express human caring and to help clients meet their health needs. - a systematic, rational method of planning and providing care using the process of ADPIE.

Through the years the nursing process has changed and evolved, growing in clarity and understanding

Its goal are: to identify a clients actual or potential health care needs, to establish plans to meet the identified needs, and to deliver and evaluate specific nursing interventions to meet those needs. (Kozier.2004)

Characteristics of the Nursing Process: 1. Systematic 2. Skills and Knowledge-based 3. Cyclical 4. Dynamic 5. Client-centered 6. Interpersonal and Collaborative 7. Universal 8. Goal-oriented 9. Priority-based

The NURSING Process is divided into five steps

Steps: 1. ASSESSMENT 2. DIANOSIS 3. PLANNING 4. IMPLEMENTATION 5. EVALUATION

1. ASSESSMENT
What brought you to the hospital? Let me have a look at that. Describe how you are feeling.

STANDARD I. The nurse collects client health data.

PHASE I: ASSESSMENT

- is Collecting, Organizing, Validating, and Recording data about a clients health status. Purpose: - To establish a data base.

4 Types of Assessment:

1. Initial Assessment - completed upon admission. - Ex. Nursing History, Assessment Worksheet 2. Problem-Focused/Ongoing Assessment - on-going assessment performed during nursing care. - Ex. Hourly Assessment of Intake and Output

3. Emergency Assessment - rapid assessment of the patients ABC during any physiologic and psychologic crisis. - Ex. Cardiac Arrest, Suicidal Ideation 4. Time-Lapse Reassessment - assessment performed in two periods of time. - Ex. Operation Timbang, Assessment for Hypertension

Different Methods of Assessment: 1. Observation - gathering data using the 5 senses. 2. Interview - a planned and purposive conversation between the nurse and the client. A. Directive interview: - highly structured - elicits specific information. B. Nondirective interview: - less structured - allows the client to verbalize his thoughts and feelings.

3 Types of Interview Questions: 1. Closed-ended 2. Open-ended 3. Leading questions

3. Physical Examination - systematic data collection method using the techniques of IPPA. - objective data are collected. 2 Types of Data: 1. Subjective - data that are apparent only to the person affected. 2. Objective - data that can be seen, heard, felt, smelled, or even tasted.

2. DIAGNOSIS
What

is the problem? What is the Cause? How do I know it? STANDARD II. The nurse analyzes the assessment

PHASE II: NURSING DIAGNOSIS

- is a clinical judgment about individual, family, or community responses to actual and potential health problems/life processes. C clustering A analysis N nursing diagnosis formulation

TYPES OF NURSING DIAGNOSIS: 1. ACTUAL DIAGNOSIS - judgment about a clients response to a health problem at the time of assessment and signified by the presence of associated signs of symptoms. Examples: Fluid volume deficit Ineffective airway clearance

2. RISK NURSING DIAGNOSIS - a clinical judgment that a client is more vulnerable to develop the problem than others in the same situation. Examples: Risk for injury Risk for infection

3. POSSIBLE NURSING DIAGNOSIS - evidence about a certain health problem is unclear or the causative factors are unknown; needs collection of more data either to support or refute it; not a real type or nursing diagnosis. Examples: Possible social isolation Possible ineffective coping

4. WELLNESS DIAGNOSIS - is a clinical judgment about an individual, family, or community in transition from a specific level of wellness to a higher level of wellness. Example: Readiness for enhanced spiritual well-being

COMPONENTS OF A NURSING DIAGNOSIS: 1. Problem - clients response to his/her illness. - ex. Elimination, Breathing pattern, airway clearance * Qualifiers words added to give meaning to the diagnostic statement. - ex. Decreased, Ineffective, Impaired

2. Etiology - related factor/probable cause. 3. Signs and symptoms - defining characteristics. - evidences or manifestations.

Guidelines for Writing Nursing Diagnosis

1. Word the statement so that it is legally advisable. Example: Impaired skin integrity related to improper positioning

2. Make sure that both elements of the statement do not say the same thing. Example: Impaired skin integrity related to skin ulceration.

3. Make sure to use universally accepted abbreviations. Example: Ineffective airway clearance related to accumulation of secretions

4. Use nursing terminology rather than medical term to describe the clients response. Example: Ineffective airway clearance related to pneumonia.

5. Use non-judgmental statements. Example: Ineffective sexuality pattern related to sexual role confusion.

6. Word the diagnosis specifically and precisely to provide direction for planning nursing intervention. Example: Impaired oral mucous membrane related to noxious agent.

NURSING DIAGNOSIS VERSUS MEDICAL DIAGNOSIS Nursing 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 the client responses change

Medical Diagnosis
Identifies diseases Describe problems for which the physician directs the primary treatment Remains the same for as long as the disease is present

3. PLANNING

What can I do about it? What is most important? What do I want to happen, by when?

STANDARD III. The nurse identifies expected outcomes individualized to the client. STANDARD IV. The nurse develops a plan of care that prescribes intervention to attain expected outcomes.

PHASE III: PLANNING

- a deliberative, systematic phase of the nursing process that involves decision making and problem solving. - the nurse refers to the assessment data and the diagnostic statement. - the end product is the creation of NCP. - begins upon the admission and ends when nurse-patient relationships ends.

PLANNING involves the following activities: Establishing priorities. Writing goals/outcomes and developing an evaluate strategy. Selecting nursing strategies/interventions. Developing nursing care plans Communicate the plan of nursing care.

Types of Planning:

1. INITIAL PLANNING - the nurse who performs the initial admission assessment develops the initial comprehensive plan of care; needs refinements when missing data becomes available.

2. ONGOING PLANNING - using ingoing assessment data, the nurse carries out daily planning for the following purposes: a. to determine whether the clients health status has changed b. to set the priorities for the clients care during the shift c. to decide which problems to focus on during the shift d. to coordinate the nurses activities so that more than one problem can be addressed at each client contact

3. DISCHARGE PLANNING - the process of anticipating and planning for needs after discharge; is becoming a crucial part of comprehensive healthcare.

Effective discharge planning begins at the time of admission where each client is assessed for: a. potential health needs b. availability and ability of the clients support network to assist with these needs c. how the home environment supports the client, and d. client, family, and community resources

Types of Discharge Planning: A. Simple/Basic - patient has been discharged from the agency and proceeded directly into his/her home. B. Complex - patient is discharged from the agency and returned to another health care institution.

Setting Priorities - the process of establishing the preferential sequence or rank of interventions in accordance to the clients most immediate needs.

Nursing Goal/Expected Outcome - declaration of purpose/ intention which directs interventions. Types of Goals: 1. Short Term - can be achieved in a short period of time. 2. Long Term - requires longer period of time to be accomplished.

PURPOSE of GOALS/EXPECTED OUTCOMES: 1. Provide direction for planning nursing interventions. 2. Provide a time span for planned activities. 3. Serve as a criteria for evaluation of client progress 4. Enable client and nurse to determine when the problem has been resolved. 5. Help motivate client and nurse by providing a sense of achievement.

Guidelines in Writing Goals and Outcomes:

1. The goals must pertain to the client. 2. It should be realistic. 3. It should be compatible with the therapies of other health professionals. 4. It must be specific. 5. It must be written in behavioral terms. 6. It should be measurable. 7. It should be time-bounded.

Intervention Selection 1. Independent - nurse-initiated. Example: Health Teaching, Taking Vital Signs, Making NCP

2. Dependent - physician-initiated. - performed under the doctors order and supervision. Example: Medications, Blood Transfusion, Catheterization

3. Collaborative/Interdependent - overlapping functions among health care team. Example: Diet, Laboratory Exams

4. IMPLEMENTATION
Move

into action. Carry out the plan. STANDARD V. The nurse implements the interventions identified in the plan of care.

PHASE IV: IMPLEMENTATION

- is putting the nursing care plan in action. Activities: 1. Reassessing 2. Set priorities 3. Perform nursing intervention 4. Record actions

Composed of 3 Ds: 1. Doing 2. Delegating 3. Documenting

Doing * Cognitive Skills intellectual skills * Technical Skills psychomotor skills * Interpersonal Skills communication skills Activities: 1. Reassessing the client. 2. Prepare the client physically and psychologically. 3. Prepare the equipment and supplies. 4. Implement the interventions. 5. Communicate the nursing actions.

Delegation - the transfer of responsibility or task to a subordinate with commensurate authority while retaining accountability for the outcome. 5 Rights to Delegation 1. Right Task 2. Right Circumstance 3. Right Person 4. Right Direction/Communication 5. Right Supervision

Activities that cannot be delegated: 1. Initial and ongoing assessment. 2. Planning, nursing diagnosis formulation and evaluation. 3. Education and supervision of the nursing personnel. 4. Special activities like Sterile procedures. 5. Speech and signing of names.

Activities that can be delegated: 1. Routine activities. - Vital signs taking - Bed bath 2. Clean procedure. - Enema - Ear irrigation

5. EVALUATION
Did it work? Why or why not? Is the problem solved, or do I need to try again?

STANDARD VI. The nurse evaluates the clients progress towards attainment of outcomes.

PHASE V: EVALUATION

- is assessing the clients response to nursing interventions 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.

3 Types of Evaluation: 1. Ongoing 2. Intermittent 3. Terminal

3 Possible Judgments during Evaluation: 1. Goal met 2. Goal partially met 3. Goal not met

4 Types of Outcome Evaluated: 1. Cognitive 2. Psychomotor 3. Affective 4. Physiologic

Quality Assurance

1. Structure Evaluation - physical settings, condition through which care is given. 2. Process Evaluation - pertains to the manner on how the care was given. 3. Outcome Evaluation - pertains to any changes in the clients health status as a result of the nursing intervention.

Nursing Care Plan blueprint of the nursing process