Process Nursing

8/8/2019 Process Nursing

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It is a systematic, rational

method of planning and

providing individualizednursing care.


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The Nursing Process Is the underlying scheme that provides order anddirection to nursing care.

It is the essence of professional nursing practice.

It has been conceptualized as a systematic series of

independent nursing actions directed toward

promoting an optimum level of wellness for the

client. It is cyclical; the components follow a logical

sequence, but more than one component may be

involved at any one time.


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Purpose of Nursing Process To identify a clients health status, actual or potentialhealth care problems or needs, to establish plans to meetthe identified needs, and to deliver specific nursing

interventions to meet those needs.

It helps nurses in arriving at decisions and in predictingand evaluating consequences.

It was developed as a specific method for applying ascientific approach or a problem solving approach tonursing practice.


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PHASES OF THE NURSING

PROCESS

Assessment

Diagnosis

Outcome Identification

Planning

Implementation

Evaluation


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ASSESSMENT To establish baseline information on the

client.

To determine the clients normal function.

To determine the clients risk for diagnosis

function.

To determine presence or absence of

diagnosis function.

To determine clients strengths.

To rovide data for the dia nostic hase.


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Activities of Assessment

COLLECT DATA

VALIDATE DATA

ORGANIZE DATA RECORDING DATA

Assessment involves reorganizing andcollecting CUES:

Objective (overt) Subjective (covert)


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Clinical Skills used in Assessment

Observation act of noticing client cues.*looking, watching, examining, scrutinizing,surveying, scanning, appraising.

*uses different senses: vision, smell, hearing, touch.

Interviewing interaction and communication.

Physical Examination INSPECTION

PERCUSSION AUSCULTATION

INTUITION

- defined as insights, instincts or clinical experiences tomake judgment about client care.


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4PHASES OF INTERVIEW: Preparatory Phase

(Pre-interaction)

Introductory Phase(Orientation)

Maintenance Phase

(Working)

Concluding Phase

(Termination)


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COMMUNICATIONCOMMUNICATION

A process in which people affect oneA process in which people affect oneanother through exchange ofanother through exchange ofinformation, ideas, and feelings.information, ideas, and feelings.

Documentation/Recording is a vitalDocumentation/Recording is a vitalaspect of nursing practice.aspect of nursing practice.

Include both oral and writtenInclude both oral and writtenexchange of information betweenexchange of information betweencaregivers.caregivers.


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Modes of CommunicationModes of Communication

Verbal CommunicationVerbal Communication

-- Uses spoken or written words.Uses spoken or written words.

NonNon--verbal Communicationverbal Communication

-- Uses gestures, facial expression,Uses gestures, facial expression,

posture/gait, body movements, physicalposture/gait, body movements, physicalappearance (also body language), eyeappearance (also body language), eyecontact, tone of voice.contact, tone of voice.


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Characteristics of CommunicationCharacteristics of Communication

SIMPLICITYSIMPLICITY-- commonly understood words, brevity,commonly understood words, brevity,and completenessand completeness

CLARITYCLARITY

-- exactly what is meantexactly what is meant TIMING and RELEVANCETIMING and RELEVANCE

-- appropriate time and consideration ofappropriate time and consideration ofclients interest and concernsclients interest and concerns

ADAPTABILITYADAPTABILITY

-- adjustmentadjustment depending on moods anddepending on moods andbehaviorbehavior

CREDIBILITYCREDIBILITY

-- worthiness of beliefworthiness of belief


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Components of CommunicationComponents of Communication


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Documenting & ReportingDocumenting & Reporting

DOCUMENTATIONDOCUMENTATION-- Serves as a permanent record of clientServes as a permanent record of clientinformation and care.information and care.

REPORTINGREPORTING-- takes place when two or more peopletakes place when two or more peopleshare information about client careshare information about client care

NURSINGDOCUMENTATIONNURSINGDOCUMENTATION: the charting: the chartingof documents, the professional surveillanceof documents, the professional surveillanceof the patient, the nursing action taken inof the patient, the nursing action taken inthe patients behalf, and the patientsthe patients behalf, and the patientsprograms with regards to illness.programs with regards to illness.


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Purposes of Clients Record /ChartPurposes of Clients Record /Chart

1.1. CommunicationCommunication

2.2. Legal DocumentationLegal Documentation

3.

3. R

esearchR

esearch4.4. StatisticsStatistics

5.5. EducationEducation

6.6. Audit and Quality AssuranceAudit and Quality Assurance7.7. Planning Client CarePlanning Client Care

8.8. ReimbursementReimbursement


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TYPES OF RECORDSTYPES OF RECORDS

A.A. Source Oriented Medical RecordSource Oriented Medical Record

traditional client recordtraditional client record

FIVE BASIC COMPONENTS:FIVE BASIC COMPONENTS:

1.1. Admission sheetAdmission sheet

2.2. Physicians order sheetPhysicians order sheet

3.3. Medical historyMedical history

4.4. Nurses notesNurses notes

5.5.Special records and reports

Special records and reports


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B. ProblemB. Problem--oriented medical recordoriented medical record(POMR)(POMR)

-- arranged according to the sourcearranged according to the sourceof information.of information.

FOUR

BASI

C CO

MPON

ENTS:FO

UR

BASI

C CO

MPON

ENTS:

1.1. DatabaseDatabase

2.2. Problem listProblem list

3.3.

Initial list f orders or care plansInitial list f orders or care plans4.4. Progress notes:Progress notes:

Nurses notesNurses notes

(SOAPIE)(SOAPIE)

Flow sheetsFlow sheets

Discharge notes or referral summariesDischarge notes or referral summaries


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KARDEXKARDEX

Concise method of organizing andConcise method of organizing andrecording data.recording data.

Readily accessible to health careReadily accessible to health careteam.team.

Series of Flip cardsSeries of Flip cards

Ensure continuity of careEnsure continuity of care Tool for change of shift reportTool for change of shift report

For planning & communicationFor planning & communication

purposes.purposes.


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Characteristics Of Good RecordingCharacteristics Of Good Recording

1.1.

BR

EVITY.

BR

EVITY.

2.2. USE OFINK / PERMANENCE.USE OFINK / PERMANENCE.3.3. ACCURACY.ACCURACY.4.4. APPROPRIATENESS.APPROPRIATENESS.5.5. COMPLETENESS & CHRONOLOGY /COMPLETENESS & CHRONOLOGY /

ORGANIZATION / SEQUENCE / TIMING.ORGANIZATION / SEQUENCE / TIMING.6.6. USE OFSTANDARDTERMINOLOGY.USE OFSTANDARDTERMINOLOGY.7.7. SIGNED.SIGNED.8.8. In case of ERROR.In case of ERROR.9.9. CONFIDENTIALITY.CONFIDENTIALITY.10.10. LEGALAWARENESS.LEGALAWARENESS.11.11. LEGIBLE.LEGIBLE.12.12. DONOT use the word PATIENT or PT inDONOT use the word PATIENT or PT in

the chart.the chart.13.13. A HORIZONTALLINE drawn to fill up aA HORIZONTALLINE drawn to fill up a

partial line.partial line.


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REPORTINGREPORTING1.1. CHANGECHANGE--OFOF--SHIFTREPORTSORSHIFTREPORTSOR

ENDORSEMENT.ENDORSEMENT.

--for continuity of care / health care needs.for continuity of care / health care needs.

2.2. TELEPHONE REPORTS.TELEPHONE REPORTS.

--provide clear, accurate, & conciseprovide clear, accurate, & conciseinformationinformation

--includes: when, who made/was, whom,includes: when, who made/was, whom,what info given/received.what info given/received.

3.3. TELEPHONE ORDERS.TELEPHONE ORDERS.

-- RNs duty, must be signed w/in 24 hours.RNs duty, must be signed w/in 24 hours.

4.4. TRANSFERREPORTSTRANSFERREPORTS

-- from one unit to another.from one unit to another.


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Some Legal Significance ofSome Legal Significance of

CHARTINGCHARTING

1.1. Chart AccuratelyChart Accurately

2.2. Chart ObjectivelyChart Objectively

3.3. Chart PromptlyChart Promptly

4.4. Make No Mention of an IncidentMake No Mention of an IncidentReport in the ChartReport in the Chart

5.5. Write Legibly and Use OnlyWrite Legibly and Use OnlyStandard AbbreviationsStandard Abbreviations


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THIRTEEN CHARTING RULESTHIRTEEN CHARTING RULES

1.1. Write Neat andWrite Neat andLegiblyLegibly

2.2. Use Proper SpellingUse Proper Spellingand Grammarand Grammar

3.3. Write with Blue orWrite with Blue orBlack Ink and

Use

Black Ink and

UseMilitary timeMilitary time

4.4. Use AuthorizedUse AuthorizedAbbreviationsAbbreviations

5.5. Transcribe OrdersTranscribe OrdersCarefully

Carefully

6.6. DocumentDocumentCompleteCompleteInformation AboutInformation AboutMedicationMedication

7.7. Chart Promptly

Chart Promptly

8.8. Never Chart NursingNever Chart NursingCare or ObservationCare or ObservationAhead of Time.Ahead of Time.

9.9. Clearly Identify CareClearly Identify CareGiven by AnotherGiven by Another

Member of the HealthMember of the HealthCare Team.Care Team.10.10. Dont Leave Any BlankDont Leave Any Blank

Spaces on ChartSpaces on ChartForms.Forms.

11.

11.Correctly Identify Late

Correctly Identify LateEntries.Entries.

12.12. Correct MistakenCorrect MistakenEntries Properly.Entries Properly.

13.13. Dont Sound TentativeDont Sound Tentative

Say What You Mean.

Say What You Mean.


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SIX More Charting RulesSIX More Charting Rules

1.1. Dont Tamper with Medical Records.Dont Tamper with Medical Records.2.2. Dont criticize other Health CareDont criticize other Health Care

Professionals in the chart.Professionals in the chart.3.3. Dont Document any Comments that aDont Document any Comments that a

patient or family member makes about apatient or family member makes about apotential lawsuit against a health carepotential lawsuit against a health careprofessional or the hospital.professional or the hospital.

4.4. Eliminate bias from written descriptions ofEliminate bias from written descriptions of

the patient.the patient.5.5. Precisely document any information youPrecisely document any information you

report to the doctor.report to the doctor.6.6. Document any potentially contributingDocument any potentially contributing

patient acts.patient acts.


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How to DocumentHow to Document

NonNon--ComplianceCompliance1.1. Refusing to comply with dietaryRefusing to comply with dietary

restrictions.restrictions.

2.2. Getting out of bed without askingGetting out of bed without asking

help.help.

3.3. Ignoring followIgnoring follow--up appointments atup appointments atthe clinic, emergency department,the clinic, emergency department,

outout--patient or doctors office.patient or doctors office.4.4. Leaving against medical advice (AMA)Leaving against medical advice (AMA)

5.5. Abusing or refusing to takeAbusing or refusing to take

medications.medications.


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Personal Items at thePersonal Items at the

BedsideBedsideYour notes should contain aYour notes should contain a

description of what was found anddescription of what was found and

how you disposed of it.how you disposed of it.

TAMPERING w/ MED. EQUIPMENTTAMPERING w/ MED. EQUIPMENT

Document wh t you w the tient doingDocument wh t you w the tient doing

orwh t you believe hes doing.orwh t you believe hes doing.


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Approaches to Collecting Data for Assessing

Clients Health:

ABDELLAHS 21 Nursing Problems

DOROTHEA OREMS Components of

Universal Self-Care

GORDONS Functional Health Patterns

Correlating a Body Systems PhysicalExamination with Data Gathered by

Functional Health Area.


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ABDELLAHs

21 Nursing Problems:1. To promote good hygiene and physical comfort.2. To promote optimal activity, exercise, rest and

sleep.

3. To promote safety through the prevention ofaccident, injury, or other trauma and through theprevention of the spread of infection.

4. To maintain good body mechanics and prevent andcorrect deformities.

5. To facilitate the maintenance of a supply of oxygento all body cells.6. To facilitate the maintenance of nutrition of all

body cells.

7. To facilitate the maintenance of eliminations.


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8. To facilitate the maintenance offood and electrolyte balance.

9. To recognize the physiological responses of thebody to disease conditionspathological,physiological, and compensatory.

10. To facilitate the maintenance of regulatory

mechanisms and functions.11. To facilitate the maintenance of sensoryfunctions.

12. To identify and accept the positive and

negative expressions, feelings, and reactions.13. To identify and accept the inter-relatednessof emotions and organic illness.

14. To facilitate the maintenance of effective

verbal and non-verbal communication.


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15. To promote the development of productiveinterpersonal relationships.

16. To facilitate progress toward achievement ofpersonal spiritual goals.17. To create/or maintain a therapeutic

environment.

18. To facilitate awareness of self as anindividual with varying physical, emotional, anddeveloping needs.

19. To accept the optimum goals in the light of

physical and emotional limitations.20. To use community resources as an aide inresolving problems arising from illness.

21. To understand the role of social problems

as influencing factors in the cause of illness.


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Dorothea Orems Components

of Universal Self-Care Maintenance of sufficient intake of air, water

and food. Provision of care associated with elimination

process and excrements. Maintenance of a balance between solitude

and social interaction. Prevention of hazards to life, functioning and

well-being. Promotion of human functioning anddevelopment within social groups in accord

with potential known limitations and thedesire to be normal.


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GORDONS FUNCTIONALHEALTH PATTERNS

1. Health Perception Health ManagementPattern- describes clients perceived pattern of

health and well being and how health ismanaged.2. Nutritional Metabolic Pattern

- describes pattern of food and fluid

consumption relative to metabolic need andpattern indicators of local nutrient supply.3. Elimination Pattern

- describes pattern of excretory function(bowel, bladder, and skin)


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4. Activity Exercise Pattern

- describes pattern of exercise, activity,

leisure, and recreation.5. Cognitive Perceptual Pattern

- describes sensory, perceptual, and cognitivepattern

6. Sleep Rest Pattern

- describes patterns of sleep, rest, andrelaxation.

7. Self-perception Self-concept Pattern-describes self-concept andperceptions of self (body comfory,image, feeling state)


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8. Role Relationship Pattern- describes pattern of role engagementsand relationships.

9. Sexuality Reproductive Pattern- describes clients pattern of satisfaction anddissatisfaction with sexuality pattern,describes reproductive patterns.

10.Coping Stress Tolerance Pattern- describes general coping patterns andeffectiveness of the pattern in terms ofstress tolerance.

11.Value Belief Pattern- describes pattern of values andbeliefs, including spiritual and /or goalsthat guide choices or decisions.


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DIAGNOSING

Clinical act of identifying problems. Identify health care needs.

Prepare diagnostic statements.

Uses critical thinking skills of analysis and synthesis.

(PRS PES) ACTIVITIES:

- organize cluster or group data.

- compare data against standards.

- analyze data after comparing with standards.- identify gaps / inconsistencies in data.

- determine health problems, risks, and strengths.

- formulateNursing Diagnosis.


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Outcome Identification refers to formulating and documenting

measurable, realistic, client-focused goals.

PURPOSES: To provide individualized care

To promote client participation

To plan care that is realistic and measurable

To allow involvement of support people

ESTABLISH PRIORITIES!!!


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Classification of

NURSING DIAGNOSIS:T HIGH - PRIORITY

- life threatening and requires immediate

attention.

T MEDIUM - PRIORITY

- resulting to unhealthy consequences.

T LOW - PRIORITY

- can be resolve with minimal interventions.


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Characteristics of

Outcome Criteria: S - SPECIFIC

M - MEASURABLE A - ATTAINABLE

R- REALISTIC

T - TIME FRAMED

CAN BE SHORT TERM OR LONG TERM GOAL.


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PLANNING Involves determining beforehand the

strategies or course of actions to be taken

before implementation of nursing care.

To be effective, involve the client and hisfamily in planning!


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IMPLEMENTATION Putting nursing care plan into ACTION!

To help client attain goals and achieve optimal

level of health.

Requires: Knowledge, Technical skills,

Communication skills, TherapeuticUse of Self.

..SOMETHING THAT ISNOT

WRITTEN IS CONSIDERED ASNOTDONE!!!


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EVALUATION IS ASSESSING THE CLIENTS RESPONSE

TO NURSING INTERVENTIONS.

COMPARING THE RESPONSE TOPREDETERMINED STANDARDS OR

OUTCOMECRITERIA.

FOUR POSSIBLE JUDGMENTS:

The goal was completely met.

The goal was partially met.

The goal was completely unmet.

New problems or nursing diagnoses have developed.


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Characteristics of

NURSING PROCESS Problem-oriented.

Goal oriented.

Orderly, planned, step by step.

(systematic)

Open to new information.

Interpersonal. Permits creativity.

Cyclical.

Universal.


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Benefits of the NURSING

PROCESS: for the Client

QUALITY CLIENT CARE

CONTINUITY OF CARE PARTICIPATION BY

CLIENTS IN THEIRHEALTH CARE


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Benefits of the NURSING

PROCESS: for the Nurse CONSISTENTAND SYSTEMATICNURSING EDUCATION.

JOB SATISFACTION. PROFESSIONAL GROWTH.

AVOIDANCE OF LEGAL ACTION.

MEETING PROFESSIONAL NURSINGSTANDARDS.

MEETING STANDARDS OFACCREDITED HOSPITALS.


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HEART OF THE NURSING

PROCESS

KNOWLEDGE

SKILLS- manual, intellectual, interpersonal.

CARING- willingness and ability to care.


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Willingness to CARE

Keep the focus on what is best for

the patient. Respect the beliefs / values of

others.

Stay involved.

Maintain a healthy lifestyle.


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CARING BEHAVIORS

Inspiring someone / instilling hope and faith.

Demonstrating patience, compassion, and willingnessto persevere.

Offering companionship. Helping someone stay in touch with positive aspect of

his life.

Demonstrating thoughtfulness.

Bending the rules when it really counts. Doing the little things

Keeping someone informed.

Showing your human side by sharing stories

Documents

Process Nursing