Nursing Process Nursing Fundamentals

Didik S. S.Kep, Ns

IntroductionNursing process is a systematic method of providing care to clientsAllows nurses to communicate plans and activities to ClientsOther health care professionalsFamiliesEncourages orderly thought, analysis, planning

Overview of the Nursing ProcessProcess:A series of steps or acts that lead to accomplishment of some goal or purposePurpose is to provide client care that is:IndividualizedHolisticEffectiveEfficient

Purpose of the nursing process:To Achieve Scientifically- Based, Holistic, Individualized Care For The Client

To Achieve The Opportunity To Work Collaboratively With Clients, Others

To Achieve Continuity Of Care

Overview of the Nursing ProcessConsists of 5 stepsAssessmentDiagnosisPlanningImplementationEvaluationBuild on each otherNot linear

Nursing process is dynamic and requires creativity in its applicationSteps remain the sameApplication and results differentUsed throughout the life span in any care setting

Small group questions:How many steps are in the nursing process?What are the names of each of the steps?What is the purpose of the nursing process?In what clinical setting is the nursing process used?

AssessmentStep #1InvolvesCollecting data (from variety of sources)Validating the dataOrganizing the dataInterpreting the dataDocumenting the data

ResourcesClient Other individualsPrevious recordsConsultationsDiagnostics studiesRelevant literature

AssessmentPurpose of assessment:Data collectionTypes of assessment:Comprehensive assessmentFocusedOngoing

AssessmentComprehensive assessmentBaselinePhysical & psychosocial

AssessmentFocused AssessmentLimited in scopeScreening for a specific problemShort stay Ongoing assessmentFollow-upMonitoring and observation related to specific problems

AssessmentSources of DataPrimary sourcesClientInterviewPhysical examinationSecondary sourcesFamily membersOther health care providersMedical records

AssessmentTypes of dataSubjectiveData from the clients point of viewFeelings, Perceptions, ConcernsMain way to collect subjective data:InterviewObjectiveObservable & measurable dataMain way to collect objective data:Physical assessmentLab and diagnostic testing

AssessmentValidating the DataOrganizing the DataInterpreting the DataRelevant vs. irrelevantGaps?Identify patternsDocument the Data

Verifying DataEssential in critical thinking!!!!!Measurable dataDouble check personal observationsDouble check equipmentCheck with experts and team membersRecheck out-liersCompare objective and subjective dataClarify statements

Small group questions:Baby Jane a 2 month infant goes into the doctor for her initial immunization and well baby check-up. What type of assessment should the nurse perform?A. ComprehensiveB. Focused C. Ongoing

Small Group Questions2. Which of the following are objective data and which are subjective data.A. NauseaB. VomitingC. Unsteady gaitD. AnxietyE. Bruises on the right arms and faceF. Temperature 101 F

DiagnosisStep 2 in the nursing processFormulating a nursing diagnosisAnalysis and synthesis of data

Nursing diagnosis:A clinical judgment about individual, family or community responses to actual or potential heal problems / life processes.A nursing diagnosis provides the basis for selection of nursing interventions to achieve outcomes for which the nurse is accountable.

Medical vs. Nursing diagnosis

Medical diagnosisNursing diagnosisIdentifies conditions the MD is licensed & qualified to treatIdentifies situations the nurse is licensed & qualified to treat

Medical vs. Nursing diagnosis

Medical diagnosisNursing diagnosisIdentifies conditions the MD is licensed & qualified to treatIdentifies situations the nurse is licensed & qualified to treatFocuses on illness, injury or disease processesFocuses on the clients responses to actual or potential health / life problems

Medical vs. Nursing diagnosis

Medical diagnosisNursing diagnosisRemains constant until a cure is effectedChanges as the clients response and/or the health problem changes

Medical vs. Nursing diagnosis

Medical diagnosisNursing diagnosisRemains constant until a cure is effectedChanges as the clients response and/or the health problem changesi.e. Breast canceri.e. Knowledge deficitPowerlessnessGrieving, anticipatoryBody image disturbanceIndividual coping, ineffective

Diagnosis

Nursing diagnosisMedical diagnosisBreathing patterns, ineffectiveChronic obstructive pulmonary diseaseActivity intoleranceCerebrovascular accidentPainAppendectomyBody image disturbanceAmputationBody temperature, risk for alteredStrep throat

Planning & Outcome identificationStep 3Types of planningInitial planningOngoing planningDischarge planning

Planning & Outcome identificationIdentifying outcomesGoalsAn aim, intent or end. Short term goalsHours to days (less than a week)Long term goalsWeeks to months

Planning & Outcome identificationDeveloping specific nursing interventionsIndependent nursing interventionsNo order neededElevate edematous legs Interdependent nursing interventionsIn conjunction with an interdisciplinary team memberAssist client with physical therapy exercisesDependent nursing interventionsRequire an orderAdministering of medications

Prioritizing the nursing diagnosisMaslows hierarchy of needs

Maslows Hierarchy of Needs

General Guidelines for Setting PrioritiesTake care of immediate life-threatening issues.Safety issues.Patient-identified issues.Nurse-identified priorities based on the overall picture, the patient as a whole person, and availability of time and resources.

Nurse Identified PrioritiesComposite of all patients strengths and health concerns.Moral and ethical issues.Time, resources, and setting.Hierarchy of needs.Interdisciplinary planning.

Identifying Client-centered OutcomesState what the patient will do or experience at the completion of care.Give direction to the patients overall care.Patient behaviors not nurse behaviors!!

The patient will

Nursing InterventionsRoad maps directing the best ways to provide nursing care.Evidence based nursing.

Monitor health status.Minimize risks.Resolve or control a problem.Assist with ADLs.Promote optimum health and independence.

InterventionsDirect interventions: actions performed through interaction with clients.

Indirect interventions: actions performed away from the client, on behalf of a client or group of clients.

Implementation4th step:Execution of the nursing care planDelegationDO ITDO IT RIGHTDO IT RIGHT NOW!

Evaluation5th stepDetermining whether the clients goals have been met, partially met or not met.

EvaluationDetermining outcome achievementIdentifying the variables affecting outcome achievementDeciding whether to continue, modify, or terminate the plan

Determining Outcome AchievementMust be aware of outcomes set for the client.Must be sure patient is ready for evaluation.Is patient able to meet outcome criteria?Is it:

Completely met? Partially met? Not met at all?Record in progress in notes.Update care plan.

Predict, Prevent, and ManageFocus on early interventionBased on researchPredict and anticipate problemsLook for risk factors

Documenting the Plan of CareTo ensure continuity of care, the plan must be written and shared with all health care personnel caring for the client.Consists of:

Prioritized nursing diagnostic statements.Outcomes.Interventions.

DocumentationClear and conciseAppropriate terminologyUsually on a designated formPhysical assessmentUsually by Review of SystemsOverview of symptomsDietEach body system

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