The Nursing Process

Outline

Background & Hx. of nursing process Definitions Benefits of nursing process Purposes of using nursing process Characteristics Components of nursing process:

- Assessment

- Planning & nursing diagnosis

- Implementation

- Evaluation

Back Ground

The nursing process is based on a nursing theory developed by Ida Jean Orlando.

She developed this theory in the late 1950's as she observed nurses in action. She saw "good" nursing and "bad" nursing.

From her observations she learned that the patient must be the

central character. Nursing care needs to be directed at improving outcomes for the

patient. The nursing process is an essential part of the nursing care plan.

The Nursing Process

An organizational framework for the practice of nursing

Orderly, systematicCentral to all nursing careEncompasses all steps taken by the

nurse in caring for a patient

Definition of the Nursing Process

o A systematic problem-solving approach used to identify, prevent and treat actual or potential health problems and promote wellness.

o A systematic way to plan, implement and evaluate care for individuals, families, groups and communities.

Holistic

Physical- Emotional- Psychosocial- Developmental- Spiritual Being

Medical Diagnosis

Nursing Diagnosis

Rheumatoid Arthritis

Self-care deficit: bathing, related to joint stiffness

Benefits 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

Purposes of using nursing process

Continuity of care Prevention of duplication Individualized care Standards of care Increased client participation Collaboration of care

Characteristics: a. Planned, organized, &Systematic

• The nursing process has an ordered sequence of activities and each activity depends on the accuracy of the activity that precedes it and influences the activity following it.

b. Dynamic• The nursing process has great interaction and overlapping among the

activities and each activity is fluid and flows into the next activity c. Interpersonal

• The nursing process ensures that nurses are client-centered rather than task-centered and encourages them to work to enhance client’s strengths and meet human needs

d. Goal-directed• The nursing process is a means for nurses and clients to work

together to identify specific goals (wellness promotion, disease and illness prevention, health restoration, coping and altered functioning) that are most important to the client, and to match them with the appropriate nursing actions

e. Universally applicable• The nursing process allows nurses to practice nursing with well or ill

people, young or old, in any type of practice setting

5 components of the Nursing Process:

1. Assessment

2. Diagnosis

3. Planning

4. Implementing

5. Evaluating

1st Component of the Nursing Process- ASSESSMENT:

Two methods of Assessment

1. Subjective – client’s perspective

Examples: Report of fainting, complaint of

dizziness, nausea, headache

2. Objective – observable & measurable

Examples: Vomiting, unsteady gait, pale skin,rapid breathing Data Collection: By Observation, interview, & Examination

During Assessment, the care provider:

o Establishes A Data Base: comprehensive information you gather on initial contact with the person to assess all aspects of health status.

o Focus assessment – the data you gather to determine the status of a specific condition.

o Continuously Updates The Data Base.

o Validates Data: - Measurable data - Double check personal observations - Double check equipment - Check with experts and team members - Compare objective and subjective data & Clarify statements

o Communicates Data

Types of Data To Collect: Objective data-observable and measurable facts (Signs) Subjective data-information that only the client feels and

can describe (Symptoms)

Client

Other individuals Previous records Consultations Diagnostics studies

Relevant literature

Resources Primary source: Client Secondary source: Client’s family,

reports, test results, information in current and past medical records, & discussions with other health care workers

Sources of Data

A clinical judgment about individual, family, or community responses to actual or potential health problems.

A nursing diagnosis provides the basis for selection of nursing interventions to achieve outcomes for which the nurse is accountable.

2nd component of the Nursing

Process- Diagnosis:

Development of the Nursing Diagnosis

Two-part Statement1. Problem statement – describes the client’s response to an actual

or potential health problem (diagnostic label)

2. Etiology – cause of the problem

3. The diagnostic label & etiology are linked by the terminology Related to (R/T)

Example: Ineffective breathing pattern R/T neuromuscular impairment.

Cont. Development of the Nursing Diagnosis

Three-part-statement1. Problem statement – describes the client’s response to an

actual or potential health problem (diagnostic label)

2. Etiology – cause of the problem

3. The diagnostic label & etiology are linked by the terminology Related to (R/T)

4. Defining characteristics

Example:

Types of nursing diagnosis: Actual nursing diagnosis – a problem exists. Composed of the

problem statement, related factors and signs & symptoms

Risk nursing diagnosis – indicates the problem doesn’t exist but has special risk factors

Wellness nursing diagnosis – indicates the client’sdesire to attain a higher level of wellness in some area of function.

NANDA – North American Nursing Diagnosis Association

NANDA-International is recognized as the leader in development and classification of nursing diagnoses

Identifies nursing functions Creates classification system Establishes diagnostic labels

Example: Risk of infection related to compromised nutritional

state Potential complication of seizure disorder related to

medication compliance

3rd component of the Nursing Process- Planning:

The establishment of client goals/outcomes Working with the client, to prevent,

reduce, or resolve problems

To determine related nursing interventions (actions) that are most likely to assist client in achieving goals

This is about improving the quality of life for your patient.

This is about what your patient needs to do to improve his health status or better cope with his illness.

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

Note: In planning we establish the goals, interventions and outcomes

General Guidelines for Setting Priorities

1. Take care of immediate life-threatening issues.

2. Safety issues.

3. Patient-identified issues.

4. Hierarchy of needs models.

5. Nurse-identified priorities based on the overall picture, the patient as a whole person, and availability of time and resources.

Identification of Outcomes Provides guidelines for individualized nursing

interventions Establishes goals & evaluation criteria to

measure effectiveness of the nursing care plan

- Short-term goals – 1 week

- Long-term goals – weeks to months

Nursing Interventions An action performed by the nurse that helps the

client achieve the results specified by the goals and expected outcomes.

Evidence based nursing.

1. Monitor health status.

2. Minimize risks.

3. Resolve or control a problem.

4. Promote optimum health and independence.

o 3 types: independent, interdependent, dependent

Interventions

Direct interventions: actions performed through interaction with clients.

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

Documenting the Plan of Care To ensure continuity of care, the plan

must be written and shared with all health care personnel caring for the client.

Consists of:

1. Prioritized nursing diagnostic statements.

2. Outcomes.

3. Interventions.

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

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

5th 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.

During Evaluating, the care provider:

Measures The Clients Achievement Of Desired Goals/Outcomes

Identifies Factors That Contribute To The Client’s Success Or Failure

Modifies The Plan Of Care, If Indicated

Determining Outcome Achievement Must 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.

Short-Term GoalsOutcomes achievable in a few days or

1 week Developed form the problem portion of

the diagnostic statementClient-centeredMeasurableRealisticAccompanied by a target date

Long-Term GoalsDesirable outcomes that take weeks

or months to accomplish for client’s with chronic health problems