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Fozia Ferozali 12/2/2011

Nursing Process 1

NURSING PROCESS

Competencies

Define the nursing process.

Describe the six steps of the nursing process.

Apply the nursing process in case study

11-2

The Nursing Process for Foundation of Nursing K3LN>>>@Hany2011

The Nursing Process

Systematic approach / Orderly

Dynamic

Interpersonal

Goal-oriented Patient-centered

Central to all nursing care

Encompasses all steps taken by the nurse in caring for a patient

The Nursing Process

Purposes of Nursing Process

Provides an orderly & systematic method for planning & providing care

Enhances nursing efficiency by standardizing nursing practice

Facilitates documentation of care

Provides a unity of language for the nursing profession

Is economical

Stresses the independent function of nurses

Increases care quality through the use of deliberate actions

Benefits of using the nursing process

Continuity of care

Prevention of duplication

Individualized care

Standards of care

Increased client participation

Collaboration of care


Nursing Process 2

MARTHA ROGERS, NURSE THEORIST

“When an apple is cut, others see seeds in the apple. We, as nurses, see apples in the seeds.”

We will only focus on 4 components of the

Nursing Process:

1. Assessment

2. Diagnosis

3. Planning

4. Implementing

5. Evaluating

ASESSMENT

Stage 1

11-9 The Nursing Process for Foundation of

Nursing K3LN>>>@Hany2008

Copyright 2002, Delmar, A division of Thomson

Learning

Assessment

First step in nursing process

Purpose

– Identifies the patient’s current health status

– Actual and potential health problems

– Areas for health promotion

Dynamic phase

Reasons for doing assessment:-

- To establish baseline information on the client

- To determine the client’s normal function

- To determine the client’s risk for dysfunction

- To determine the client’s strengths

- To provide data for the diagnosis phase


Nursing Process 3

Preparing for assessment

Type Aim Time frame

1- Initial assessment Initial identification of normal function,

functional status, and collection of data

concerning actual or potential

dysfunction.

Baseline for reference and future

comparison.

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.

Ongoing process, integrated with

nursing care, a few minutes to a few

hours between assessments.

3- Time – lapsed

reassessment

Comparison of client’s current status to

baseline obtained previously, detection

of changes in all functional health

patterns after an extended period of time

has passed

Several months (3,6,9 months or more)

between assessment

4- Emergency assessment Identification of life – threatening

situation

AT anytime

- Setting and environment

Assessment can take place in any setting

where nurses care for clients and their

family members: in the client’s home, at

a clinic, in a hospital room. – Ensure environment is conducive

– Arrange seating

– Allow adequate time

– Nurse introduces self

– Identifies purpose of interview

– Ensure confidentiality of information

– Provide for patient needs before starting

Assessment skills

1- Observation

Comprises more than the nurse’s ability to see the

client, nurses also use the senses of smell, hearing,

touch, and, rarely, the sense of taste. Observation

includes looking, watching, examining. Observation

begins the moment the nurse meets the client.

Observation done in the following order:

– Clinical signs of client distress.

– Threats to the client’s safety, real or anticipated.

– The presence and functioning of associated equipment.

– The immediate environment, including the people in it.

2- Interviewing

Is a planned communication or a conversation

with a purpose, for example to get or give

information, identify problems of mutual

concern, evaluate change, teach, provide

support. There are two approaches to

interviewing, directive and nondirective.

The directive interview is highly structured and elicits specific information. The nurse establishes the purpose of the interview and controls the interview. The client responds to questions but may have limited opportunities to ask questions or discuss concerns. The nondirective interview or rapport-building interview, by contrast the nurse allows the client to control the purpose, subject matter, and pacing.

3- Physical examination techniques

Is a systematic data collection method that uses

the senses of sight, hearing, smell, and touch to

detect health problems. Four techniques are

used: inspection, palpation, percussion, and

auscultation


Nursing Process 4

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.

Verifying Data

Essential in critical thinking!!!!!

Measurable data

Double check personal observations

Double check equipment

Check with experts and team members

Recheck out-liers

Compare objective and subjective data

Clarify statements

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.


Nursing Process 5

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. To increase

accuracy, the nurse records subjective data in

the client’s own words to avoid the chance of

changing the original meaning.

Data Documentation

Clear and concise

Appropriate terminology – Usually on a designated form

Physical assessment – Usually by Review of Systems

Overview of symptoms

Diet

Each body system

Documentation

Record in permanent record ASAP

Use patient’s own words in subjective data – enclose in “ ___” (quotation marks)

Avoid generalizations – be specific

Don’t make summative statements – describe - e.g. patient is being ornery should be patient resists instruction or patient states “Don’t talk to me, I don’t care about that”

Clustering

according to Orem Model

Air Requisite

Lungs clear

RR 18 labored

O2, Chest X-ray shows

pneumonia

nonproductive cough

Activity & Rest Requisite

Bed rest, full passive ROM

P.T.daily, Reddened skin

on ankle & elbow, 40 degree

contracture on left leg, atrophy

of muscles

Respiratory Problem

Possible Skin Problem

Ineffective Airway Risk for Impaired Tissue

Integrity

DIAGNOSIS

Stage 2


Nursing Process 6


Learning

Diagnosis

Second step in nursing process

Describes conditions treated by nurses

North American Nursing Diagnosis Association (NANDA)

Provides the basis for selection of nursing interventions to achieve outcomes for which the nurse is accountable

National American Nursing Diagnosis

Association-------NANDA

1973 --- First national conference of

nursing diagnosis .(theorists, educators,

administrators and practioners)

1985 named NANDA

1990 ANA endorsed it as official diagnosis taxonomy

….Is incorporated in ANA standards of practice

Meets every two years

Local chapters 148 diagnoses

+ 16 Carpenito

1953 term first used

E. NURSING DIAGNOSIS ( problem identification)

A Nursing Diagnosis is a clinical judgment about individual,

family or community responses to actual or potential health

problems/life processes. Nursing diagnosis provide the basis for

selection of nursing interventions to achieve outcomes for which

the nurse is accountable.

1. Benefits of a Nursing Diagnosis

a. Communication between Nurses

b. Identification of patient goals

2. Types of Diagnostic Statements

• actual

• risk

• wellness

• syndrome.

ACTUAL DIAGNOSIS An actual diagnosis represents a state that has been clinically

validated by identifiable major defining characteristics. Consists of a

label, related factors & defining characteristics.

Three Part Statement P E S

P = Problem

( Precise qualifier / modifiers )

Altered High Risk Ineffective Decreased

Deficit Excess Dysfunctional Disturbance

Chronic Less than More than Anticipatory

Diagnostic Label = Problem + modifier

= Chronic Pain

Actual dx.

E = Related Factors Related factors are etiological or other contributing factors

that have influenced the health status change.

Etiology sometimes = Causes or factors of risk Chronic pain r/t Altered Tissue perfusion

………. secondary to Diabetes

Pathophysiologic Alteration in skin Integrity r/t ( caused by)

Compromised immune system Inadequate circulation

Inadequate peripheral circulation

Treatment-related

Medications

Diagnostic studies Anxiety r/t (caused by) lack of knowledge

Surgery of how to dress his wound

Treatments

Etiological factors

Situational

Environmental

Home Risk for Injury r/t unsteady gait

Community

Institution

Personal

Life experiences

Roles

Maturational Nutrition Imbalance : Less than Body Requirements r/t

Age related to inadequate sucking


Nursing Process 7

Actual dx.

S = Defining characteristics

S= signs / symptoms

Clinical cues--subjective and objective signs or

symptoms that point to the nursing diagnosis

• Are separated into major and minor

designations.

• Major defined as critical indicators present 80-

100 of the time.

• Minor are supporting and present 50-79%

Major defining characteristics must be present

for a

diagnosis to be valid

Actual diagnosis

P E

Diagnostic Label Related factor

I impaired Skin Integrity related to prolonged immobility

S Defining characteristics

as evidenced by a 2 cm sacral lesion

A real problem exists !!!!!!!!

RISK DIAGNOSIS

Is a clinical judgment that an individual, family or

community is more vulnerable to develop the

problem than others in the same or similar situation.

.

Two part statement.---------P ( problem)

E ( related risk factors)

No defining characteristics

No signs or symptoms because

No problem yet

Risk dx

Risk nursing diagnoses

P E

Diagnostic label Etiological risk factors

Risk for Injury related to lack of awareness of

hazards

Factors present which present a risk situation for

a problem to occur

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.

Two cues must be present:

1. desire for a higher level of wellness

2. effective present status or function.

One part statement beginning with Readiness for Enhanced

Diagnostic Label

Readiness for Enhanced Parenting

SYNDROME

DIAGNOSIS

Comprise a cluster of actual or risk nursing diagnoses that

are predicted to be present because of a certain event or situation.

One part statement

Diagnostic label

Disuse syndrome.

Nursing Diagnoses Associated with Disuse

Syndrome

Risk for Constipation

Risk for Altered Respiratory Function

Risk for Infection

Risk for Thrombosis

Risk for Activity Intolerance

Risk for Injury

Risk for Altered Thought Processes


Nursing Process 8

INEFFECTIVE BREATHING PATTERNS

DEFINITION

Ineffective Breathing Patterns: State in which a person

experiences an actual or potential loss of adequate

ventilation related to an altered breathing pattern

DEFINING CHARACTERISTICS

Major (Must Be Present, One or More)

Changes in respiratory rate or pattern (from baseline)

Changes in pulse (rate, rhythm, quality)

Minor (May Be Present)

Orthopnea Tachypnea, hyperpnea, hyperventilation

Dysrhythmic respirations. Splinted/guarded respirations

Diagnosis Ineffective Breathing Patterns

Related to

r/t

(E) Immobility and chest pain

Secondary to abdominal surgery

As evidenced by

(P)

(S) in respiratory rate from 12 to 22

pulse rate 88 to 104 and irregular

Common Errors In Diagnostic

Statements 1. Don’t use medical terms when writing a

diagnosis

I- Self-Care Deficit Hygiene r/t Stroke

C- Self-care Deficit: Hygiene r/t weakness

secondary to Stroke

2. Don’t write a diagnosis for an unchangeable

situation

I- Anxiety r/t impending death aeb stating” I am afraid

to die”

C- Anxiety r/t fear of dying

Common errors

3. Use of procedure / treatment instead of a human response

I- Catherization r/t urinary retention

C- Risk for Infection Transmission r/t device

with contaminated drainage:urinary

4. Don’t write diagnoses that are too general

I- Constipation r/t nutritional intake aeb small hard stools

C- Constipation r/t dietary roughage and fluid intake

Common errors

5. Don’t combine two problems at the same time

I- Pain and Fear r/t to upcoming abdominal surgery

C- Pain r/t tissue trauma secondary to abdominal

surgery aeb “ Pain ranked 4/5”

.

6. Don’t use judgmental/value laden language or make assumptions

I- Spiritual Distress r/t atheism aeb statement “ I don’t believe in God

anymore”

C- Spiritual Distress r/t to feelings of abandonment

aeb “ I don’t think God cares about me”

Common errors

7. Don’t make statements that are legally inadvisable

I- Tissue Integrity Impaired r/t to infrequent turning aeb 3

cm diameter ankle ulcer

C- Tissue Integrity Impaired r/t immobility

secondary to fracture

8. Both parts of a diagnostic statement are the same

I- Self care deficit : feeding r/t feeding problem aeb unable to bring food

to mouth

C- Self Care Deficit: feeding r/t neurological impairment

of rt. hand aeb unable to bring food to mouth

Don’t use due to or caused


Nursing Process 9

Risks of Diagnostic Errors

1. may aggravate problems

2. omit essential interventions

3. allow problems to exist

4. wasteful interventions

5. influence others

6. danger of legal liability

Pohon Masalah

Identifikasi daftar kebutuhan dan masalah klien dengan menggambarkan adanya suatu sebab akibat yg dpt digambarkan sebagai pohon masalah (Problem tree)

Langkah-Langkah dlm pohon masalah

1. Tentukan masalah utama (core problem) berdasarkan identifikasi data subyektif (keluhan utama) dan obyektif (data-data mayor)

2. Identifikasi penyebab (E) dari masalah utama

3. Identifikasi penyebab dari penyebab masalah utama (akar dari masalah)

4. Identifikasi penyebab dari penyebab masalah

Contoh Kasus:

Tn. A datang ke ruang Interna dengan keluhan diare 20X pada malam hari sebelum masuk rumah sakit. Keadaan klien sangat lemah, muka pucat, dan turgor jelek. Menurut pengakuan klien, sehari sebelum masuk rumah sakit klien makan rujak di kantornya. Selama di rumah sakit klien ditunggui istrinya. Klien adalah seorang dosen di perguruan tinggi negeri, usia 40 tahun.

Pohon Masalah Kasus

PLANNING

Stage 3

The Nursing Process for Foundation of Nursing K3LN>>>@Hany2008 11-54


Nursing Process 10

During Planning, the provider:

A. Establishes Priorities

B. Writes Client Goals/Outcomes And

Develops An Evaluative Strategy

C. Selects Nursing Interventions

D. Communicates The Plan

Nursing Planning

The third step of the nursing process includes

the formulation of guidelines that establish

the proposed course of nursing action in the

resolution of nursing diagnoses and the

development of the client’s plan of care.

The planning of nursing care occurs in three

phases: initial, ongoing, and discharge. Each

type of planning contributes to the

coordination of the client’s comprehensive

plan of care.

The four critical elements of planning include:

• Establishing priorities

• Setting goals and developing expected

outcomes (outcome identification)

• Planning nursing interventions (with

collaboration and consultation as needed)

• Documenting

1- Establishing Priorities

The establishment of priorities is the first

element of planning. In establishing priorities,

the nurse examines the client’s nursing

diagnoses.

Methods of selecting priorities is the

consideration of Maslow’s hierarchy of

needs, which requires that a life-threatening

diagnosis be given more urgency than a non

life threatening diagnosis.

2- Establishing Goals and Expected Outcomes

The purposes of setting goals and expected

outcomes are to provide guidelines for

individualized nursing interventions and to

establish evaluation criteria to measure the

effectiveness of the nursing care plan. A goal

is an aim, an intent, or an end.


Nursing Process 11

A goal is a broad or globally written statement

describing the intended or desired change in

the client’s behavior, response, or outcome.

An expected outcome is a detailed, specific

statement that describes the methods through

which the goal will be achieved.

A short-term goal is a statement written in

objective format demonstrating an expectation

to be achieved in resolution of the nursing

diagnosis in a short period of time, usually in a

few hours or days.

A long-term goal is a statement written in

objective format demonstrating an expectation

to be achieved in resolution of the nursing

diagnosis over a longer period of time, usually

over weeks or months.

Guidelines for Writing Outcomes

Written outcomes can be evaluated by seeing if

they conform to the following criteria:

• Each set of outcomes is derived from only one

nursing diagnosis.

• At least one of the outcomes shows a direct

resolution of the problem statement in the

nursing diagnosis.

• Both long-term and short-term outcomes are

identified as necessary.

• Cognitive, psychomotor, and affective

outcomes appropriately signal the type of

change needed by the patient.

• The patient and family value the outcomes.

• Each outcome is brief and specific (clearly

describes one observable, measurable patient

behavior/manifestation), is phrased positively,

and specifies a time line.

• The outcomes are supportive of the total

treatment plan

Example

NURSING DIAGNOSIS: Disturbed Sleep

Pattern

Goal: Client will sleep uninterrupted for 6 hours.

EXPECTED OUTCOMES

• Client will request back massage for relaxation.

• Client will set limits to family and significant

other visits.

NURSING DIAGNOSIS: Ineffective Tissue

Perfusion: Peripheral

Goal: Client will have palpable peripheral pulses

in 1 week.

EXPECTED OUTCOMES

• Client will identify three factors to improve

peripheral circulation.

• Client’s feet will be warm to touch.


Nursing Process 12

3- Planning Nursing Interventions

Once the goals have been mutually agreed on by

the nurse and client, the nurse should use a

decision-making process to select appropriate

nursing interventions.

Nursing interventions are treatment, based

upon clinical judgment and knowledge that a

nurse performs to enhance patient / client

outcomes.

Writing a client plan of care

Two important concepts guide a client plan of

care:

1- The plan of care is client centered.

2- The plan of care is a step – by step process.

Sufficient data are collected to substantiate

nursing diagnoses.

At least one goal must be stated for each

nursing diagnosis

Outcome criteria must be identified for each

goal

Nursing interventions must be specifically

designed to meet the identified goal.

Each intervention should be supported by a

scientific rationale.

Evaluation must address whether each goal

was completely met, partially met, or

completely unmet.

Nursing Outcome Criteria (NOC)

Began since Florence Nightingale

7 domain, 29 outcome classes, 260 outcomes

IMPLEMENTATION

Stage 4


Nursing Process 13

4th Component of the Nursing Process-

Implementing:

The provider carries out the plan of care

During Implementing, the care

provider:

Carries Out The Plan Of Nursing Care or

Setting your plans in motion and delegating

responsibilities for each step.

Continues Data Collection And Modifies The

Plan Of Care As Needed

Documents Care

4th Component of the Nursing Process-

Evaluating:

The measuring of the extent to which client goals have been met

Evaluation involves not only analyzing the success of the goals and interventions, but examining the need for adjustments and changes as well.

The evaluation incorporates all input from the entire health care team, including the patient.

Implementing Consists of doing and documenting the activities

that are the specific nursing actions needed to

carry out the interventions or nursing orders.

The first three nursing process phases-

assessing, diagnosing, and planning-provide

the basis for the nursing actions performed

during the implementing step. In turn, the

implementing phase, provide the actual

nursing activities and client responses that are

examined in the final phase, the evaluating

phase.

While implementing nursing orders, the nurse

continues to reassess the client at every

contact, gathering data about the client’s

responses to nursing activities and about any

new problems that may develop. To implement

the care plan successfully, nurses need

cognitive, interpersonal, and technical skills.

These skills are distinct from one another. The

cognitive skills (intellectual skills) include

problem solving, decision making, critical

thinking, and creativity.

Interpersonal skills are all of the activities, verbal

and nonverbal, people use when interacting

directly with one another, this depends on the

ability of the nurse to communicate effectively

with others. It is necessary for all nursing

activities, caring, comforting, advocating,

referring, counseling, and supporting others.

Technical skills are hands-on skills such as

manipulating equipments, giving injections and

bandaging, moving lifting, and repositioning

clients. These are called procedures, tasks, or

psychomotor skills.

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Nursing Process 14

Process of Implementing

Reassessing the client

Determining the nurse’s need for assistance

Implementing the nursing interventions

Supervising the delegated care

Documenting nursing activities

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. The nurse also

provides supportive communication to help

alleviate the client’s stress.

Determining the Nurse’s Need for Assistance,

for one of the following reasons:

The nurse is unable to implement the nursing

activities safely alone

Assistance would reduce stress on the client

The nurse lacks the knowledge or skills to

implement a particular nursing activities

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 outcome is. Ensure client privacy,

coordinate client care, and involve scheduling

client contacts with other departments.

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 order to be

implemented and question any that are not

understood.

Adapt activities to the individual client, a

client’s beliefs, values; age, health status, and

environment are factors that can affect the

success of a nursing action.

Implement safe care

Provide teaching, support and comfort to

enhance the effectiveness of nursing care plans.

Be holistic; view the client as a whole.

Respect the dignity of the client and enhance the

client’s self- esteem

Encourage client to participate actively in

implementing the nursing interventions.


Nursing Process 15

Supervising Delegating Care, if care has been

delegated to other health care personnel, the

nurse responsible for all the client’s care must

ensure that the activities have been

implemented according to the care plan.

Documenting Nursing Activities, the nurse complete

the implementing phase by recording the

interventions and client responses in the nursing

process notes. The nurse may record routine or

recurring activities such as mouth care in the client

record at the end of shift, while some actions

recorded in special worksheets according to agency

policy. Immediate recording helps safeguard the

client to prevent double actions.

EVALUATION

Stage 5

Evaluation

The last phase of the nursing process, follows

implementation of the plan of care, it’s the

judgment of the effectiveness of nursing care

to meet client goals based on the client’s

behavioral responses.

Process of Evaluating Client Responses

Collecting data related to the desired outcomes

Comparing the data with outcomes

Relating nursing activities to outcomes

Drawing conclusions about problem status

Continuing, modifying, or terminating the

nursing care plan.

When determining whether a goal has been

achieved, the nurse can draw one of the three

possible conclusions:

– The goal was met, that is the client response

is the same as the desired outcomes.

– The goal was partially met, that is either a

short term goal was achieved but the long

term was not, or the desired outcome was

only partially attained.

– The goal was not met.


Nursing Process 16

Relationship of Evaluation to Nursing Process

“When goals have been partially met or when

goals have not been met, two conclusions may

be drawn:

The care plan may need to be revised,

since the problem is only partially resolved

OR

The care plan does not need revision,

because the client merely needs more time

to achieve the previously established goals.

So the nurse must reassess why the goals

are not being partially achieved.

DOCUMENTATION


Learning

Documenting the Nursing Process

Methods – SOAPIER

Subjective

Objective

Assessment

Plan

Implementation

Evaluation

Revision

(continues)


Learning


– PIO

Problem

Intervention

Outcome

(continues) Copyright 2002, Delmar, A division of Thomson

Learning


– DAR

Data

Action

Response

– PIE

Problem

Intervention

Evaluation

(continues)


Nursing Process 17


Learning


– CBE

Charting by exception

– Focus

Specific to client’s primary diagnosis

ANY QUESTIONS?

11-99

The Nursing Process for Foundation of Nursing K3LN>>>@Hany2008

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