Nursing Process

Maj Nusrat Bashir RN,RM,BScN,MScN

Nursing Process

Definition It is an organized, systematic method of giving individualized care that focuses on identifying and treating unique responses of individuals to actual and potential health problems.

Cont

Nursing Definition Nursing is the diagnosis and treatment of human responses to actual and potential health problems

Purposes

To provide a frame work within which

the individualized needs of the client, family and community can be met

It guides the planning of care for a

patient It is an efficient method of organizing thought process for clinical decision making and problem solving

Cont..
It is beneficial for both nurse and client because it helps to ensure that care is planned, individualized and reviewed over a period of time It requires the involvement of patient throughout all the phases.

Characteristics
The system is open and flexible to meet the unique needs of client, family, group and community It is cyclical and dynamic, no absolute beginning and ending It is client centered It individualizes the approach to each client particular needs It is interpersonal and collaborative

Cont..
It is planned and goal directed It permits creativity for the nurse and client in devising ways to solve that stated health problems It emphasis feed back It is universally applicable It is used as framework for nursing care for all types of health care settings

Role in planning care

Why do we need to plan care? The patient has right to expect that the nursing care received will be complete and of high quality care Care planning and its documentation provides professional communication It provides legal protection for the nurse Finally for accreditation and approval of agencies

Type
1- Initial assessment

Aim
Initial identification of normal function, functional status, and collection of data concerning actual or potential dysfunction. Baseline for reference and future comparison.

Time frame
Within the specified time frame after admission to a hospital, nursing home, ambulatory healthcare center.

2- Focus assessment

Status determination of a specific problem identified during previous assessment. Comparison of clients current status to baseline obtained previously, detection of changes in all functional health patterns after an extended period of time has passed Identification of life threatening situation

Ongoing process, integrated with nursing care, a few minutes to a few hours between assessments. Several months (3,6,9 months or more) between assessment

3- Time lapsed reassessment

4- Emergency assessment

AT anytime

- Collection of data - Organization of data allows to: - Determine the patient current health status. - Determine the patient strengths and problems area (actual and potential) - Prepare the second step of process

Data sources and Types

Primary source Secondary source Subjective data Objective data Historical data Current data

Types of data: -Subjective data also known as symptoms or covert cues include the client's feeling and statement about his or her health problems and are best recorded as direct quotations from the client, such as '' Every time I move, I feel nauseated.''

- Objective data also known as signs or overt cues, are observable and measurable (quantitative) data that are obtained through observation, standard assessment techniques performed during the physical examination, and laboratory and diagnostic testing.

Sources of data It can be primary or secondary. The client is the primary source of data. Family members or other support persons, other health professionals, records and reports, laboratory and diagnostic analyses, and relevant literatures are secondary or indirect sources.

2- Validate data Validation, commonly referred to as double checking the information at hand, is the process of confirming the accuracy of assessment data collected. Validation assists in verifying and clarifying cues and inference.

Examples of cues and inferences Example 1 Group of cues client has - Blurry vision or visual defect - Headache - Tingling and numbness in extremities - Dizziness Possible inferences - Client has a brain tumor - Client is having warning signals of a stroke - Client may be diabetic - Client is anxious

3- Organize data After data collection is completed and information is validated, the nurse organizes, or clusters, the information together in order to identify areas of strengths and weaknesses. This process is known as data clustering. How data are organized depends on the assessment model used. One of these model is Head to Toe model.

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 clients health status. To increase accuracy, the nurse records subjective data in the clients own words to avoid the chance of changing the original meaning.

Essentials skills

Interviewing Physical assessment Head to toe approach Body system approach Functional health pattern approach

Data grouping
Organizing the information into said categories. Organizing framework are; - Maslows hierarchy - NANDAS human responses pattern - Gordons Functional health patterns

Definition:

Nursing diagnosis is a clinical judgment about individual, family, or community response to actual and potential health problems/life processes. Nursing diagnosis provides the basis for selection of nursing interventions to achieve outcomes for which the nurse is accountable. (NANDA, 1990)

The second step in the nursing process involves further analysis (breaking the whole down into parts that can be examined) and synthesis (putting data together in a new way) of the data that have been collected.

Nursing Diagnosis

According to the North American Nursing Diagnosis Association (NANDA) a nursing diagnosis is a clinical judgment about individual, family, or community responses to actual or potential health problems/life processes. Nursing diagnoses provide the basis for selection of nursing interventions to achieve outcomes for which the nurse is accountable. (Carroll-Johnson, 1990, p. 50).

Cont..
Wellness Diagnosis Definition: A wellness diagnosis is clinical judgment about an individual, family, or community in transition from a specific level of wellness to a higher level of wellness. (NANDA, 1990)

Nursing Diagnosis
- focus on unhealthy responses to health and illness.

Medical Diagnosis
- identify diseases

- describe problems treated by - describe problems for which the nurses within the scope of physician directs the primary Differentiating Nursing Diagnosis independent nursing practice. treatment .

versus Medical Diagnosis

- may change from day to day as - remains the same for as long as the patients responses change the disease is present

Nursing Diagnosis
- focus on unhealthy responses to health and illness.

Medical Diagnosis
- identify diseases

- describe problems treated by - describe problems for which the nurses within the scope of physician directs the primary Differentiating Nursing Diagnosis independent nursing practice. treatment .

versus Medical Diagnosis

- may change from day to day as - remains the same for as long as the patients responses change the disease is present

Cont
Definition It is carefully choosing a direction in the light of personal tacit and explicit knowing (Parse, 1996) It is the art of thinking about thinking. (Paul, 1988)

Critical Thing Cont The critical thinking allows the

nurse to make better decisions Creativity in thinking, problem solving, and decision making can enhance the effectiveness of the solutions or decision made

Critical Thing Cont

Critical thinking makes reliable observation, draws sound conclusion, creates new information and ideas, evaluates lines of reasoning, and improves their self knowledge

Characteristics of Critical Thinking

Rationality and reflection Healthy, constructive skepticism Autonomy Creative thinking Fair thinking Focus on what to believe and do

Skills in Critical Thinking Critical Analysis Socratic questioning Inductive & Deductive reasoning Making valid inferences Differentiating fact from opinion Evaluating the creditability of information source Clarifying concepts Recognizing assumptions

Attitudes That Fosters Critical Thinking

Independence of thought

Fair-Mindedness Insight into egocentricity and sociocentricity Intellectual Humility and suspension of judgment

Attitudes Cont Intellectual Courage Integrity Perseverance Confidence in reason Interest in Exploring Both thought Curiosity

 Types of Nursing Diagnosis An actual diagnosis A high risk diagnosis (more than normallyvulnerable to the problem A possible nursing diagnosis A wellness diagnosis

Components of Nursing Diagnosis Problem statement The etiology The defining characteristics (Gordon,1987)

Attitudes Cont
Problem statement: Describe the clients health status/problem clearly, concisely and specifically Qualifiers give additional meaning to the diagnostic statement e.g. Altered, Impaired, Ineffective.

2. The Etiology: Include clients behavior, environmental factors, or interaction of two Identifies one or more causes of the health problems Gives direction to the requires nursing therapy Individualize the clients care 3. The defining characteristics:

Cluster of signs and symptoms that indicate the presence of a particular diagnostic label For actual nursing diagnosis the defining characteristics are signs and symptoms For high risk nursing diagnosis the defining characteristics are same as the etiology

Cont..

 Suggests criteria or clients outcome and required nursing interventions 1. Major defining characteristics are those that must be present for the diagnosis to be valid e.g. for activity intolerance client exhibit altered response to activity which might manifest as dyspnea, shortness of breath

Cont..
Minor defining characteristics may or may not be present Errors In Diagnostic Reasoning Data Collection Errors Data Collection Errors Data Interpretation Errors Data Clustering Errors

 Avoiding Errors Verify Build a good knowledge base,and acquired clinical experience Have a working knowledge of what is normal

Cont
Consult resources Base diagnosis on patterns Improve critical-thinking skills

Planning It involves three subsets : Setting priorities Written expected outcomes Established target dates

Implementation
Two importing steps are involved: Determining specific nursing actions that will assist the patient to progress towards the expected outcomes (Independent and collaborative activities) Documenting the care administer

Documentation
It is an essential link between the provision the nursing care and quality of care provided The Problem Oriented Record POR Provide a system for documenting a record

Documentation Cont
It consists of for components The data base The problem list The plan of care The progress notes

Data base: Interview Observation Physical examination Diagnostic tests Problem List: Inventory of numbered Prioritized patients problems

Plan of Care: Incorporates the expected outcomes and interventions. The Progress Notes: Outcomes of patient care The full format for documentation the progress is based on SOPIER

Cont..

Evaluation: It is the feed back phase and control part of nursing process Assessing what progress has been towards meeting the expected outcomes

Thanks