hkuspace higher diploma in nursing –year...

HKUSPACEHigher Diploma In Nursing – Year 1

1. Introduction to Nursing Process2. Comprehensive Health Assessment

of the Individual

Mr. W. Y. TANG

Learning ObjectivesAt the end of this lecture, students should be able to 1.Realize the history of nursing process.2.Conceptualize that nursing is art and science.3.List three dimensions of nursing activities.4. Outline 5 phases of nursing process.5. Compare subjective data with objective data.6.State nurses’ role in assessment phase of

nursing process.7.Differentiate between medical diagnosis with

nursing diagnosis.

Learning Objectives8. Differentiate among actual problems,

potential problems and collaborative

problems of a patient in the nursing process.

9. List 5 steps in planning phase of nursing

process.

10. List elements to be included when developing

goal and formulating nursing actions in

nursing process.

Learning Objectives11. State nurses’ responsibilities when executing

planned nursing actions.

12. State nurses’ responsibilities in evaluation

phase of nursing process.

13. State 7 benefits of the nursing process.

14. Explain the role of the nursing process in

systems theory.

History of Nursing ProcessIntroduction

The nursing process is based on a nursing theory

developed by Ida Jean Orlando in late 1950s.

1955 : Lydia E. Hall – first use the term nursing process

1967 : Yura and Walsh ‐ first book on nursing

process – 4 steps (assessment (include

nursing diagnosis, ND), planning, intervention and

evaluation)

History of Nursing ProcessIntroduction

1974: Gebbie, K. and Lavin, M.A. ‐ ND as a separate step

1994 : The Joint Commission on Accreditation of Health

Care Organization continues to require nursing

process as a mean for documenting all phases of

patient care.

Nursing ProcessNursing

Is an applied science integrating art and science.art i.e. dexterous and skilful way of delivering professional nursing care.science which rests on scientific knowledge of bio‐psycho‐social‐spiritual sciences

3 dimensions of nursing activities1. Dependence 2. Interdependence 3. Independence e.g. nursing process

Nursing Process

• is a dynamic, organized and systematic method of giving client‐centred nursing care that focuses on the unique human response of a patient or a group of patients to an actual or potential alteration in health.

• is a deliberative, goal‐directed

and problem‐solving approach

in organizing nursing care

Nursing Process• requires cognitive, technical and communication skills and is directed to meet the prioritized bio‐psycho‐social and spiritual needs of the patient.

• facilitates the growth of nursing profession. It shows nursing unique function through the use of art, science, humanity and skills.

• renders nurses to be more responsible and accountable for their work.

Nursing Process

Assessment

Planning

Diagnosis

Implementation

Evaluation

5 Phases

1. AssessmentThe first step of nursing process and of establishing

trusty relationship between patient and a nurse

Database ‐ Is deliberate, continual, on‐going and

systematic skilful way of collecting, categorizing and

interpreting subjective and objective data to

identify patient’s historical, actual, potential

problems.

Data reflect patient’s past and present health status,

strength, limitations and treatment response.

1. AssessmentMethods to obtain data :

a. Subjective data :

Client’s perception about their health

problems; difficult to measure

Complaints, comments and questions

. frequency, duration, location, intensity

. anxiety, discomfort, mental stress

Use interviews

1. Assessmentb. Objective data

– observation and measurements

i. Observed

‐ facial grimaces, colour, rash, posture, gait

‐ behaviour for :

i. Level of functioning – physical, developmental,

psychological, social aspects

ii. Consistency

iii. Congruency – matching of mood and

behaviour


ii. Measurement

Physical assessment

‐ head to toe assessment : inspection, auscultation,

palpation and percussion

‐ equipment e.g. thermometers, stethoscope,

calipers etc.

Medical records, nursing Kardex or notes of allied

health


Consultation reports – professionals, HC team and

significant others

Diagnostic and laboratory data

e.g. X‐ray reports;

‐ compared with norms – age and sex

Nursing literatures

Data are obtained within 24 – 48 hours after admission and documented in a standard form

Assessment DataRequirements

1. Database

. Primary or secondary sources

. Accuracy : reflect functional abilities

. Completeness : needs and responses

. Concise

. Facts

. Timely

Assessment DataRequirements

2. Validate, categorize, analyze, interpret data and identify patient’s needs ‐> formulate nursing diagnosis later

In analysis, recognize the pattern or trends,

compare with standards and reach conclusion.

3. Document data

2. Nursing DiagnosisThe second step of nursing process

A statement that describes health state or actual or potential health problem of a patient that nurses, by virtue of their education and experience, are capable to treat independently.

The collected data are firstly critically analyzed and interpreted. The nursing diagnosis is then drawn regarding the patient’s abilities, needs, health problems, concerns and human responses.

2. Nursing DiagnosisTypes of problems

a. Actual problem – intervene stat, written in problem, etiology and signs and symptoms (PES) format

e.g. Fluid volume deficit related to excessive urinary

output as evidenced by dry lips, gum and sunken

eyeballs.

b. Potential problems – covert problems that have high chance of occurring if no preventive measures are taken

e.g. Risk for aspiration related depressed cough/gag

reflexes

2. Nursing DiagnosisTypes of problems

C. Collaborative problem

– to be solved in collaboration with other

members of health care team

e.g. Risk for complications of pneumonia

Formulate it using NANDA (North American

Nursing Diagnosis Association)

2. Nursing DiagnosisCommon errors & Suggestions

Errors Suggestion1. Use medical diagnosis(imply medical interventions)

State the client’s responsee.g. Pain related to physical exertion.

2. Use sign or symptom(one sign or symptom is insufficient for problem identification)

2. Use NANDA diagnostic statemente.g. Ineffective breathing patterns related to increased airway secretions.

3.Not identify a clinical sign, a diagnostic test, chronic dysfunction or problem

3. Identify a treatable etiologye.g. Ineffective tissue perfusion related to inadequate oxygen intake.

2. Nursing DiagnosisCommon errors

Errors Suggestion4. Identify a problem or a

study 4. Identify the problem caused by the treatment or diagnostic studye.g. Anxiety related to lack of knowledge about cardiac catheterization.

5.Identify the equipment 5. Identify the client response to the equipment e.g. knowledge deficit regarding the need and use of cardiac monitoring.

6.Identify the nurse’s problem

6. Identify the client’s problem e.g. Risk for infection related to presence of invasive lines.


Errors Suggestion7. Identify the nursing

interventions7. Identify the client’s probleme.g. Diarrhoea related to food intolerance .

8.Identify the goal 8. Identify the client’s probleme.g. Imbalanced nutrition : less than body requirements related to inadequate nutritional intake.

9.Make prejudicial judgment 9.Make professional judgmente.g. Readiness for enhanced knowledge regarding perineal care.


Errors Suggestion10. Write legally

statement10. Avoid legally inadvisable statemente.g. Pain related to improper use of medication

11. Identify a circular statement

11. Identify problem and etiologye.g. Ineffective breathing patterns related to incisional pain.

12. Include more than one problem

12. Identify only one problem in a diagnostic statement e.g. Impaired physical mobility related to pain in knee joint and anxiety related to difficulty in ambulating.

Nursing DiagnosisRequirements

1. Accurate nursing diagnosis

2. Priority of problem statements

3. Actual, potential and collaborative problems

4. PES format (Problem – etiology – signs and symptoms)

5. Avoid diagnostic errors:

a. Error of omission – fail to identify a HC problem

b. Errors of commission : diagnose non‐exist

health care problem

Medical DiagnosisMedical DiagnosisVs Nursing DiagnosisVs Nursing Diagnosis

Medical DiagnosisMedical Diagnosis Nursing DiagnosisNursing DiagnosisBy doctors By nurses

Identify a disease (treated by a doctor)

Clinical judgment about the client (treat by a nurse)

Prescribe treatment Goal : identify actual and potential problems

e.g. Rheumatoid Arthritise.g. Rheumatoid Arthritis e.g. Selfe.g. Self‐‐care deficit: care deficit: bathing, related to joint bathing, related to joint stiffnessstiffness

3. PlanningThe third step of nursing process

Setting goal and plan nursing actions

. Goal : expected outcome within a time frame

: use “SMART” – specific, measurable,

attainable, realistic and time‐frame

. Aims : prevent, reduce or resolve an

individual’s problems identified in the

nursing diagnosis

: focus for evaluation

3. PlanningMethods :a.Work with the patient ‐ set priorities :

‐ high : physical, psychology (Basic human needs)‐ Intermediate : non‐emergency, non‐life threatening

‐ low : needs that may not related to a specific illness or prognosis but may affect his future well‐being

3. PlanningMethods :b. Establish short (< 1week) or long‐term goals (weeks or months) to prevent, minimize or correct the health problem and improve coping of illness

c. analyze resources available

d. Write nursing actions

e. Record nursing diagnosis, goals and nursing actions in an organized fashion in the nursing care plan

Nursing Care PlanIs a tailor‐made plan with ND, goals, expected

outcomes & nursing actions (consider

+/‐ resources e.g. relatives, equipment and

supplies)

Written complete, safe and accurate guidelines

with inputs from patient and other health care workers.

Gives guidance and direction to nurses for carrying out activities.

Nursing Care PlanShould be safe and therapeutic in nature.

Is a communication tool among nursing staff

so that continual, consistent and coordinated

care can be given to a patient.

Provides guidance for evaluation of nursing care given to a patient.

Standardization and computerization

3. Planning Requirements

1. Goal

. Patient participate

. Set priorities

. Identify outcome criteria

. ‘SMART’ and observable

. Short‐term or long‐term

. “The patient will….” format (one behaviour only)

3. Planning Requirements

2. Nursing interventions / actions

‐ Discuss and communicate

‐ Nursing actions :

. Independent – no consultation (seek specialist’s

help to solve not take the problem) or collaboration

. Interdependent ‐ collaboration

. Dependent – drug prescription

‐ Action verbs

‐ Assess – actions ‐ evaluate

4. Implementation

The 4th step of nursing process

Is the execution and completion of the plan of actions necessary to achieve the formulated goals; collect data continuously and modify the plan of care as needed and document care

multi‐disciplinary care ‐ the planned actions are carried out by members of the health care team, the patient, or the patient’s family.

4. ImplementationFollow the nursing care plan, protocols (written procedures) and/or standing orders (standardized prescription)

The collected information is recorded in the proper document.

This document verifies that the plan of care has been carried out within or beyond the time frame and can be used as a tool to evaluate the plan’s effectiveness.

4. ImplementationThe achieved goals are dated.

The records should be made objectively, without any bias or value judgment. Only approved abbreviations are used.

All records should be accurate, complete, concise, specific, comprehensible, permanent and legible.

All entries are arranged chronologically.

4. ImplementationRequirements

1.Meet basic human needs

2.Resolve health problems

3.Implement:

. Competently – cognition (knowledge),

interpersonal skills, technical skills

. Confidently

. Caringly – total / assistive / supportive care

. Use protocols, standing order and NC plan

. Delegation – supervision and evaluation

4. ImplementationRequirements

4. Task : Assist to perform / Provide care

Prevent adverse reactions

Compensating for adverse reactions

Teach, educate, instruct

Refer to others

Monitor, observe and assess

5. Documentation , review, modify actions

5. EvaluationThe last step of nursing process

Is an on‐going process that a. measure the extent to which the goals of care

have been achieved (completely, partial or not met) and

b. evaluate the patient’s progress ‐ stabilized, improved, deteriorated, died or discharged

Document and decide whether to continue, modify or terminate nursing actions and update it

5. EvaluationEvaluation can bea. Positive ‐ desired outcome are metb. Negative

‐ problems were not solved and potential problems were not avoided ‐ identify barriers , establish corrective measures

‐ revise the nursing care plan accordingly c. Intuition – aware of subtle changes of patients‐> change nursing action earlier

5. EvaluationExampleGoal Outcome Criteria Client Response Evaluation

Peter’s lungs will be free of secretions by 27 July 2010.

1. Lungs will be clear to auscultation by 27 July 2010.

2. Non‐productive cough will be demonstrated by 26 July 2010.

3. Respirations will be 14‐18/ min. by 27 July 2010.

1. Lungs were clear toauscultation on 27 July 2010.

2. Client coughed sometimes but non‐productively

on 26 July 2010.3.Respirsationwere 17/min. on 26 July 2010.

Outcome criteria and client response agree.

The goal was met.

5. EvaluationRequirements

1. Ongoing process

2. Goal statement – desired outcome

3. Based on documented facts :

‐ Assess the presence of the desired behaviour

‐ Compare patient progress with identified outcomes

‐ Identify barriers and factors of success

3. Revision care plan and decide nursing action :

‐ continue, modify, update or terminate

4. Health team communication

5. Executive new actions

Benefits of Nursing Process1. For patient

Applicable for all ages ; patient participates

Continuity and consistent of individualized

care to solve actual and

collaborative health problems in a safe

therapeutic environment and prevent

potential problems

A legal document for protection of patient

and staff

Client participation

Benefits of Nursing Process2. For nurses

Dynamic, holistic, systematic and

interpersonal planning and giving nursing care

. Client‐oriented / individualized care

. Outcome‐oriented care

. Sequential and ordered/interactive of 5

steps

. Complete and accurate database

. Application of knowledge and skills

Benefits of Nursing Process2. For nursesProvide for better communication via nursing documentation (accurate, concise, relevant and timely)Gain job satisfaction. Scientific problem‐solvinga. Data collectionb. Hypothesis formulationc. Plan of actiond. Hypothesis testinge. Interpretation of resultsf. Evaluation . Intuitive, logical and reasoning, creative thinkingGood nurse‐patient relationship ‐ responsibility

Benefits of Nursing Process3. For profession

Economical

. Based on client’s needs

. Efficient : time and cost

. For nursing research

Growth : autonomy, legal and professional

accountability

Unity of language

Increase caring quality – plan and deliberate

action, interdisciplinary care

Systems TheoryFacts :

A system has components : interrelated

Open system

. mutual influence with the environment

. e.g. nursing process

Systems TheoryAs a system, nursing process has 4 components :

‐ Input, output, feedback and contents

. Input : how a person interacts with the

environment and physiological function

. Output : health improves or remain stable

. Feedback : how system works

. Content : information about the nursing care

needed for clients with specific health care

problems

e.g. immobility ‐> turning needs ‐> no bed sore

Nursing Process As A SystemInput

(client interacts with the environment)

(Bio‐psycho‐socio‐spiritual, environmental, cultural, developmental)

Nursing Process

Output

(Client’s health)

Successful / unsuccessfulfunctioning

in the environmen

t

MARTHA ROGERS, NURSE THEORIST

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

Summary

Summary Nursing Process

The nursing process is presented as a working

tool in nursing practice.

It ensures individualized quality patient care

i.e. total patient care.

ReferencesCarpenito‐Moyet, L.J. Nursing Diagnosis – Application to Clinical

Practice. (2010). U.S.A. : Lippincott Williams & Wilkins.

Christensen, B.L. (1991). Foundations of Nursing. (1st ed., P.46‐55 ).

St. Louis : Mosby.

Estes, M. E. Z. (2010). Health Assessment & Physical Examination.

(4th ed., P. 7‐13). U.S.A. : Delmar.

Potter, P.A. & P.A. & Perry, A.G. (2007). Fundamentals of Nursing.

(7th ed., P.47). Canada : Mosby.

Potter, P.A. & Perry, A.G. (1995).Basic Nursing ‐Theory & Practice.

(3rd ed., P114‐178). U.S.A.: Mosby.

Tayor, C. et al (2008). Fundamentals of Nursing ‐ The Art & Science

of Nursing Care. (6th ed., P. 207‐216). U.S.A. : Lippincott Williams &

Wilkins.

Referenceshttp://www.nursingworld.org/EspeciallyForYou/StudentNurses/The

nursingprocess.aspx (The Nursing Process : A Common Thread

Amongst All Nurses)

http://www.thenursingsite.com/Articles/the%20nursing%20process.

Htm (The Nursing Process, 2007)

www. Portervillecollege.edu/ferozali/…/Nursing_Process_online.ppt

(The Nursing Process)

http://www.uri.edu/nursing/schmieding/orlando/ (Ida Jean

Orlando)

http://www.sabacare.com/Framework/NursingProcess.html (The

Nursing Process)

faculty.ksu.edu.sa/alrousan/Documents/…/Nursing%20Process.ppt‐

??? (The Nursing Process)

Referenceswww.elcamino.edu/.../N1510%20Nursing%20Process%20Outline.pdf‐

???? (Nursing Process Outline Kim Baily)