THE NURSING PROCESS

OVERVIEW OF THE NURSING PROCESSThe use of the nursing process in clinical practice gained additional legitimacy in 1973 when the phases were included in the American Nurses Association (ANA) Standards of Nursing Practice.The Standards of Practice within the most current Scope and Standards of Nursing Practice included the five phases of the Nursing Process: (a) Assessment(b) Diagnosis(c) Planning(d) Implementation(e) Evaluation

CHARACTERISTICS OF THE NURSING PROCESSThe nursing process has distinctive characteristics that enable the nurse to respond to the changing health status of the client.These characteristics include its cyclic and dynamic nature, client centeredness, focus on problem solving and decision making, interpersonal and collaborative style, universal applicability and use of critical thinking. A regularly repeated event or sequence of events (a cycle) that is continuously changing (dynamic) rather than staying the same (static). Client centered An adaptation of problem solving and systems theory Decision making is involved in every phase of the nursing process The nursing process is interpersonal and collaborative

Overview of the Nursing ProcessPHASE & DESCRIPTIONASSESSINGCollecting, organizing, validating and documenting client data

DIAGNOSING

Analyzing and synthesizing data

PLANNING

Determining how to prevent, reduce, or resolve the identified priority client problems; how to support client strengths; and how to implement nursing interventions in an organized, individualized, and goal-directed manner

IMPLEMENTING

Carrying out ( or delegating) and documenting the planned nursing interventions

EVALUATING

Measuring the degree to which the goals/outcomes had been achieved and identify the factors that positively or negatively influence goal achievementPURPOSE

To establish a database about the clients response to health concerns or illness and the ability to manage health care needs

To identify client strengths and health problems that can be prevented or resolved by a collaborative and independent nursing interventions

To develop a list of nursing and collaborative problems

To develop an individualized care plan that specifies client goals/desired outcomes, and related nursing interventions

To assist the client to meet desired goals/outcomes; promote wellness; prevent illness and disease; restore health; and facilitate coping with altered functioning

To determine whether to continue, modify, or terminate the plan of care

ACTIVITIES

Establish a database: Obtain a nursing health history Conduct a physical assessment Review client records Review nursing literature Consult support persons Consult health professionalsUpdate data is neededOraganize dataValidate dataCommunicate/Document data

Interpret and analyze data. Compare data against standards

Cluster or group data

Identify gaps and inconsistenciesDetermine clien ts strengths, risks, diagnoses and problems

Formulate nursing diagnoses and collaborative problem statements

Document nursing diagnoses on the care plan

Set priorities and goals/ outcomes in collaboration with clientWrite goals/desired outcomesSelect nursing strategies/interventionsCommunicate care plan to relevant health care providers

Reassess the client to update the database.

Determine the nurses need for assistancePerform planned nursing intervention.Communicate what nursing action were implemented. Document care and client response to care Give verbal reports as necessary

Collaborate with client and collect data related to desired outcomesJudge whether goals/outcomes have been achievedRelate nursing actions to client outcomesMake decisions about problem statusReview and modify the care plan as indicated or terminate nursing care

ASSESSMENTThe systematic and continuous collection, organization, validation and documentation of data.PURPOSE: to establish a database Elements of the Assessment Process: Data CollectionThe process of gathering information about a clients health status

Data VerificationThe information gathered during the assessment phase must be complete, factual, and accurate. Validation is the act of double-checking or verifying data that it is accurate and factual.

Data OrganizationUses a written format that organizes the assessment data systematically. This is often referred to as a Nursing Health history, nursing assessment, or nursing database form

Data DocumentationTo complete the assessment phase, the nurse records client data. Accurate documentation is essential and should include all data collected about the clients health status.

Types of AssessmentTYPE

Initial Assessment

Problem-Focused Assessment

Emergency Assessment

Time- lapsed AssessmentTIME PERFORMED

Performed within the specified time after admission to a health care facility

Ongoing process integrated within nursing care

During any physiologic or psychologic crisis of the client

Several months after initial assessmentPURPOSE

To establish a complete database for problem identification, reference, and future comparison

To determine the status of a specific problem indentified in an earlier assessment

To identify life-threatening problemsTo identify new or overlooked problems

To compare the clients current status to baseline data previously obtainedEXAMPLE

Nursing admission assessment

Hourly assessment of a clients fluid intake and urinary output

Rapid assessment of a persons airway, breathing status, and circulation during a cardiac arrest

Reassessment of a clients functional health patterns in a home care or outpatient setting or, in a hospital, at shift change

METHODS OF ASSESSMENT1. CEPHALOCAUDAL APPROACHHead-to-toe assessment

2. PROXIMODISTAL APPROACHRunning from the center of the body out towards the distal ends of appendages

3. SYSTEMIC APPROACH By System Assessment

COLLECTION OF DATATYPES OF DATA

SUBJECTIVE DATAApparent only to the person affected and can be described or verified only by that personex. Symptoms (Covert Data)

OBJECTIVE DATA Detectable by an observer or can be measured or tested against an accepted standardex. Signs (Overt Data)

EXAMPLES:Subjective

I feel weak all over when I exert myself

Client states he has a cramping pain in his abdomen. States, I feel sick to my stomach.

Im short of breath

Wife states: He doesnt seem so sad today. (subjective and secondary source data)

I would like to see the chaplain before surgery

Objective

Blood pressure 90/50Apical pulse 104Skin pale and diaphoretic

Vomited 100 ml green-tinged fluidAbdomen firm and slightly distendedActive bowel sounds auscultated in all four quadrant

Lung sounds cleat bilaterally; diminished in right lower lobe

Client cried during interview

Holding open bibleHas small silver cross on bedside table

Data Collection Method INTERVIEWA planned communication or a conversation with a purpose.Ex: get or give information, identify problems, evaluate change, teach, provide support2 Approaches Directive Interview highly structured and elicits specific information. The nurse establishes the purpose of the interview and controls the interview. Frequently used when time is limited

Nondirective Interview (Rapport-building interview) the nurse allows the client to control the purpose, subject matter and pacing

Types of Interview Questions

Open Ended Questions Invite the client to discover and explore, elaborate, clarify or illustrate their thoughts and feelings.It is useful at the beginning of an interview or to change topics and to elicit attitudes

Open-Ended questions may start with what or how

Closed Questions are restrictive and generally require only yes or no or short factual answers giving specific information

Closed questions often begin with when, where, who, what, do(did,does) or is(are,was)

The highly stressed person and the person who has difficulty communicating will find closed questions easier to answer.

OBSERVATION To gather data with the use of senses, use of units of measure, physical examination techniques, interpretation of lab results.

SOURCES OF DATA PRIMARY- patient/client; The best source of data SECONDARY family members, significant others, patients record/ chart

DIAGNOSINGNANDA NURSING DIAGNOSESTo use the concept of nursing diagnoses effectively in generating and completing a nursing care plan, the nurse must be familiar with the terms used, the types and the components of nursing diagnoses.DefinitionsThe term diagnosing refers to the reasoning process, whereas the term diagnosis is a statement or conclusion regarding the nature of the phenomenon. PURPOSE: to identify the clients health care needs and to prepare diagnostic statements

TYPES OF NURSING DIAGNOSES1. Actual Diagnosis a client problem that is present at the time of the nursing assessment.Examples: Ineffective Breathing pattern and Anxiety

An actual nursing diagnosis is bases on the presence of associated signs and symptoms.

2. Risk Nursing Diagnosis a clinical judgment that a problem does not exist, but the presence of risk factors indicates that a problem is likely to develop unless nurses intervene.

Examples: Risk for Infection

3. Wellness Diagnosis Describes the human responses to levels of wellness in an individual, family or community that have a readiness for enhancement

Examples: Readiness for enhanced Spiritual well-being or Readiness for enhanced family coping.

4. Possible Nursing Diagnosis- one in which evidence about a health problem is incomplete or unclear. A possible diagnosis requires more data either to support or to refute it.

Example: an elderly widow who lives alone id admitted to the hospital. The nurse notices that she has no visitors and is pleased with attention and conversation from the nursing staff. Until more data are collected, the nurse may write a nursing diagnosis of Possible Social Isolation related to unknown etiology.

5. Syndrome Diagnosis a diagnosis that is associated with a cluster of diagnoses

Examples: Risk for Disuse Syndrome may be experienced by long-term bedridden clientsClusters of diagnoses associated with this syndrome include:Impaired Physical MobilityRisk for Impaired Tissue IntegrityRisk for Activity IntoleranceRisk for ConstipationRisk for InfectionRisk for InjuryRisk for PowerlessnessImpaired Gas Exchange, and so on

Components of a NANDA Nursing Diagnosis

A nursing diagnosis has three components:(1) The problem and its definition(2) The etiology(3) The defining characteristics

FORMAT: P E S P problemE- etiologyS- Signs and Symptoms

Basic Two-part Diagnostic statement

PROBLEMRELATED TOETIOLOGY

Ineffective Airway ClearanceRelated toTracheobronchial infection

Basic Three-part Diagnostic statement PROBLEMRELATED TOETIOLOGYAS EVIDENCED BYSIGNS/ SYMPTOMS

Ineffective Airway Clearance Related to Tracheobronchial infection As Evidenced by Adventitious breath sounds and copious green sputum production

STEPS IN DEVELOPING A NURSING DIAGNOSIS

1. Data cues are collected from the assessment phase2. Data cues are validated and examined3. Data cues are interpreted and assigned a meaning through the use of critical thinking4. Data are grouped into clusters5. The NANDA list is consulted6. The first part of the nursing diagnosis statement is written7. Related to (RT) factors are identified8. Phrases from steps 6 and 7 are combined to form a two-part nursing diagnosis

FORMULATING NURSING DIAGNOSESExample:

FUNCTIONAL HEALTH PATTERN

Nutritional/ MetabolicCLIENT CUE CLUSTERS

No Appetite since having cold has not eaten today; last fluids at noon todayNauseated x 2 daysINFERENCES

Imbalanced Nutrition: less than body Requirements

FORMULATING DIAGNOSTIC STATEMENTS

Imbalanced Nutrition: Less than Body Requirements related to decreased appetite and nausea and increased metabolism

Guidelines for Writing a Nursing Diagnostic StatementGUIDELINE

1. State in terms of a problem, not a need

2. Word the statement so that it is legally advisable

3. Use nonjudgmental statements

4. Make sure that both elements of the statement do not say the same thing

5. Be sure that cause and effect are correctly stated

6. Word the diagnosis specifically and precisely to provide direction for planning nursing intervention

7. Use nursing Terminology rather than medical terminology

8. Use nursing terminology rather than medical terminology to describe the probable cause of clients responseCORRECT STATEMENT

Deficient Fluid Volume (problem) related to fever

Impaired Skin Integrity related to immobility (legally acceptable)

Spiritual Distress related to inability to attend to church services secondary to immobility (nonjudgmental)

Risk for Impaired Skin Integrity related to immobility

Pain: Severe Headache related to fear of addiction to narcotics

Impaired Oral Mucous Membrane related to decreased salivation secondary to radiation of neck (specific)

Risk for Ineffective Airway Clearance related to accumulation of secretions in lungs

Risk for Ineffective Airway Clearance related to accumulation of secretions in lungs (nursing terminology)INCORRECT STATEMENT

Fluid Replacement (need) related to fever

Impaired Skin Integrity related to improper positioning (implies legal liability)

Spiritual Distress related to strict rules necessitating church attendance (judgmental)

Impaired Skin Integrity related to ulceration of sacral area (response and problem cause are the same)

Pain related to headache

Impaired Oral Mucous Membrane related noxious agent (vague)

Risk for Pneumonia (medical terminology)

Risk for Ineffective Airway Clearance related to emphysema (medical terminology)

PLANNINGPlanning is a deliberative, systematic phase of the nursing process that involves decision making and problem solving.Planning begins with the first client contact and continues until the nurse-client relationship ends.The Nurse refers to the clients assessment data and diagnostic statements for direction in formulating client goals and designing the nursing interventions required to prevent, reduce or eliminate the clients problem.TYPES OF PLANNING Initial Planning The nurse who performs the admission assessment usually develops the initial comprehensive plan of care Should be initiated as soon as possible after the initial assessment

Ongoing Planning Done by all nurses who work with the client Occurs at the beginning of a shift as the nurse plans the care to be given that dayThe nurse carries out daily planning for the following purposes:(1) To determine whether the clients health status has changed(2) To set priorities for the clients care during the shift(3) To decide which problems to focus on during the shift(4) To coordinate the nurses activities so that more than one problem can be addressed at each client contact

Discharge Planning The process of anticipating and planning for needs after discharge A crucial part of comprehensive health care and should be addressed in each clients care plan

DEVELOPING CARE PLANSThe end product of the planning phase of the nursing process is a formal or informal plan of care Informal Nursing Care Plan a strategy for action that exists in the nurses mind.Ex: Mrs. Phan is very tired. I will need to reinforce her health teaching after she has rested

Formal Nursing Care Plan a written or computerized guide that organizes information about the clients care. Provides for continuity of care

Standardized Care Plan formal plan that specifies the nursing care for groups of clients with common needs(e.g. all clients with Myocardial Infarction)

Individualized Care Plan tailored to meet the needs of a specific client needs that are not addressed by the standardized care plan.

GUIDELINES FOR WRITING NURSING CARE PLANSThe nurse should use the following guidelines when writing care plans:(1) Date and Sign the plan Essential for evaluation, review and future planning The nurses signature demonstrates accountability to the client and to the nursing profession

(2) Use category headings Nursing Diagnoses, Goals/Desired Outcomes, Nursing Interventions, and Evaluation

(3) Use standardized/approved medical or English symbols and key words rather than complete sentences to communicate your ideas Ex: Turn and reposition q2h rather than Turn and reposition the client every two hours.

(4) Be Specific Nurses are working shifts of different lengths, some working 12hour shifts some 8 hour shifts, it is more important to be specific about expected timing of an intervention. Writing down specific times during the 24 hour period will help clarify

(5) Refer to procedure books or other sources of information rather than including all the steps on a written plan Ex: See unit procedure book for tracheostomy care

(6) Tailor the plan to the unique characteristic of the client by ensuring that the clients choices are included Reinforces the clients individuality and sense of control. Ex: Nursing Intervention Provide prune juice at breakfast rather than other juice, indicates that the client was given a choice of beverages.(7) Ensure that the nursing plan incorporates preventive and health maintenance aspects as well as restorative ones Ex: Nursing Intervention Provide active assistance ROM exercise to affected limbs q2h prevents joint contractures and maintains muscle strength and mobility

(8) Ensure that the plan contains interventions for ongoing assessment of the client E.g. (Inspect incision q8h)

(9) Include collaborative and coordination activities in the plan- Ex: The nurse may write interventions to ask a nutritionist of physical therapist about specific aspects of the client care(10)Include plans for the clients discharge and home care needs- The nurse begins discharge planning as the client has been admitted- Add teaching and discharge plans as addenda if they are lengthy and complex

THE PLANNING PROCESSIn the process of developing client care plans, the nurse engages in the following activities: Setting Priorities Establishing client goals/desired outcomes Selecting nursing interventions Writing individualized nursing interventions on care plansSetting Priorities The process of establishing a preferential sequence for addressing nursing diagnoses and interventions Nurses frequently use Maslows Hierarchy of needs when setting priorities

Priorities change as the clients responses, problems, and therapies change. The nurse must consider a variety of factors:

Clients health values and beliefs Values concerning health may be more important to the nurse than to the client When ther is difference in opinion, the client and nurse should discuss it openly to resolve any conflict In life-threatening situation the nurse usually must take the initiative

Clients priorities The clients perception of what is important conflicts with the nurses perception of what is important The nurse aware of potential complications needs to inform the client and carry out necessary interventions

Resources available to the nurse and client If the necessary resources are not available, the solution to the problem might need to be postponed, or the client may need a referral

Urgency of the health problem Situations that affect the integrity of the client, those that could have a negative or destructive effect on the client, also have high priority

Medical treatment plan The priorities for treating health problems must be congruent with the treatment by other health professionals Ex: a high priority for the client might be to become ambulatory ; however if the primary care providers therapeutic regimen calls for extended bed rest, then ambulation must assume a lower priority.

DERIVING DESIRED OUTCOMES FOR NURSING DIAGNOSESNursing Diagnosis

Impaired Physical Mobility: inability to bear weight on left leg, related to inflammation of knee joint

Ineffective Airway Clearance related to poor cough effort, secondary to incision pain and fear of damaging suturesOpposite Healthy Responses (Goals)

Improved mobilityAbility to bear weight on left leg

Effective Airway Clearance

Desired OutcomesThe Client will:

Ambulate with crutches by the end of the week

Have lungs clear to auscultation during entire postoperative periodHave no skin pallor or cyanosis by 12 hours postoperationWithin 24 hours after surgery, demonstrate god cough effort.

TYPES OF NURSING INTERVENTIONSNursing Interventions are identified and written during the planning step of the nursing process. Independent Intervention Activities that nurses are licensed to initiate on the basis of their knowledge and skills. They include: physical care, ongoing assessment, emotional support and comfort, teaching, counseling, environmental management.

Dependent Interventions Activities carried out under the physicians orders or supervision, or according to specified routines

Collaborative Interventions Actions the nurse carries out in collaboration with other health team members, such as physical therapists, social workers, dieticians and physicians

NURSING CARE PLANNURSING DIAGNOSIS: Ineffective Airway Clearance Related to Viscous secretions and Shallow Chest Expansion secondary to Deficient Fluid Volume, Pain, and FatigueDESIRED OUTCOMESNURSING INTERVENTIONSRATIONALE

Respiratory Status: Gas Exchange as evidenced by Absence of pallor and cyanosis (skin and mucous membrane) Use of correct breathing/coughing technique after instruction Productive cough Symmetric chest excursion of at least 4cm

Within 48-72 hours Lungs clear to auscultation Respirations 12-22/min; pulse 100beats/min Inhales normal volume of air on incentive spirometerMonitor respiratory status q4h: rate, depth, effort, skin color, mucous membranes, amount and color of sputumMonitor result of blood gases, chest x-ray studies and incentive spirometer volume as availableMonitor level of consciousness.Auscultate lungs q4h.Vital signs q4h (TPR, BP, pulse oximetry)

Instruct in breathing and coughing techniques. Remind to perform, and assist q3h.

Administer prescribed Expectorant; schedule for maximum effectiveness. Maintain Fowlers or semi-fowlers position.Administer Prescribed analgesics.Notify physician if pain not relieved.

Administer oxygen by nasal cannula s prescribed. Provide portable oxygen if client goes off unit (e.g. for x0ray examination)

Administer prescribed antibiotic to maintain constant blood level.Observe for rash and GI or other side effectsTo Identify progress toward or deviations from goal. Ineffective Airway Clearance leads to poor oxygenation, as evidenced by pallor, cyanosis, lethargy and drowsiness.

Inadequate oxygenation causes increased pulse rate. Respiratory rate may be decreased by narcotic analgesics. Shallow breathing further compromises oxygenation

Enable the client to cough up secretions. May need encouragement and support because f fatigue and pain

Helps loosen secretions so they can be coughed up and expelled.Gravity allows for fuller lung expansion by decreasing pressure on abdomen on diaphragm.Controls pleuritic pain by blocking pain pathways and altering perception of pain, enabling client to increase thoracic expansion. Unrelieved pain may signal impending complication.

Supplemental oxygen makes more oxygen available to the cells, even though less air is being moved by the client, therefore reducing the work of breathingResolves infection by bacteriostatic or bactericidal effect

Allergies to antibiotics are common

IMPLEMENTINGImplementing is the action phase in which the nurse performs the nursing interventions.Implementing consists of doing and documenting the activities that are the specific nursing actions needed to carry out the interventionsThe degree of participation depends on the client health statusIMPLEMENTING SKILLTo implement the nursing care plan successfully, nurses need skills1. Cognitive Skills (intellectual skills) include problem solving, decision making, critical thinking and creativity, they are crucial to safe, intelligent nursing care.

2. Interpersonal Skills all of the activities, verbal and nonverbal, people use when interacting with one another. The nurse uses Therapeutic Communication to understand the client and in turn be understood

3. Technical Skills purposeful hands-on skills such as manipulating equipment, giving injections, bandaging, moving, lifting and repositioning client Technical skills require knowledge and frequently manual dexterity

PROCESS OF IMPLEMENTINGThe process of implementing normally includes the following: Reassessing the patient To make sure the intervention is still needed

Determining the nurses need for assistance The nurse may require assistance for one or more of the following reasons: The nurse is unable to implement the nursing activity safely or efficiently (e.g. ambulating and unsteady or obese client) Assistance would reduce stress on the client (e.g. turning a patient who experiences acute pain when moved) The nurse lacks the knowledge or skills to implement a nursing activity (e.g. a nurse who is not familiar with a particular model of traction equipment needs assistance the first time it is applied)

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 expected outcome is

Supervising the delegated care If care has been delegated to other health care personnel, the nurse responsible for the clients overall care must ensure that the activities have been implemented according to the care plan.

Documenting nursing activities The nurse completes the implementing phase by recording the interventions and client responses in the nursing progress notes The nurse may record routine or recurring activities (e.g mouth care) in the client record at the end of the shift

EVALUATING The fifth and last phase of the nursing process. Evaluating is a planned, ongoing, purposeful activity in which clients and health care professionals determine

(a) The clients progress toward achievement of goals/outcomes and(b) The effectiveness of the nursing care plan

Conclusion drawn from the evaluation whether nursing interventions should be continued, terminated or changed Evaluation is continuous. Evaluation continues until the client achieves the health goal or is discharged from nursing care.PROCESS OF EVALUATING CLIENT RESPONSES Collecting data

Comparing data with outcomesWhen determining whether a goal has been achieved, the nurse can draw one of three possible conclusions:1. The goal was met, the client response is the same as the desired outcome2. The goal was partially met, either a short term goal was achieved but the long-term goal was not, or the desired outcome was only partially attained3. The goal was not met

Relating nursing activities to outcome

Drawing conclusions about problem statusWhen goals have been met, the nurse can draw one from the following conclusions: The actual problem stated in the nursing diagnosis has been resolved, or the potential problem is being prevented and the risk factors no longer exists

The potential problem stated in the nursing diagnosis is being prevented, but the risk factors are still present

The actual problem still exists even though some goals are being met

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 goal(s)

Continuing, Modifying, and Terminating the Nursing Care Plan Before making modifications, the nurse must determine if the plan as a whole was not completely effective

EVALUATING THE QUALITY OF NURSING CAREIn each of the processes described below, nurses and all health care providers work together as an interdisciplinary team focused on improving client care. Quality Assurance An ongoing systematic process designed to evaluate and promote excellence in the health care provided to clients. Refers to evaluation of the level of care provided in a health care agency.

Requires 3 components: Structure Evaluation focuses on the setting in which care is given. It answers this question:what effect does the setting have on the quality of care? Process Evaluation focuses on how the care was given. It answers the questions such as these: Is the care relevant to the clients needs?, Is the care appropriate, complete, and timely? Outcome Evaluation focuses on demonstrable changes in the clients health status as a result of nursing care.

Quality Improvement

Nursing Audit the examination and review of records Retrospective Audit the evaluation of a client record after discharge from an agency

Concurrent Audit the evaluation of clients health care while the client is still receiving care from the agency.

NURSING CARE PLANS