nursing process

Nursing ProcessNursing Process

“To you, O Lord, I lift up my soul. In you, I trust ,

Oh my God.”Psalm 25:1

NURSING PROCESS

• systematic, rational method of planning and providing individualized nursing care

• Is a problem-solving framework for planning and delivering nursing care to patients and their families

NURSING PROCESS

NURSING PROCESS• A way of thinking as a nurse.• A framework of interrelated activities

resulting in competent nursing care.• Dynamic and cyclical in nature.• A scientific, problem-oriented

approach to patient care.

Assessing – collecting, organizing and communicating /

recording client dataPurpose: to establish data base

about the client’s response to health concerns or illness and the ability to manage health care needs

Assessment

Activities:• Obtain health hx• Perform P.A.• Review records, e.g. lab records,

other health care records• Interview support persons• Review literature• Validate assessment data

Nursing Process

Assessment

Assessment (Data Collection)

= Observation + Interview + Examination

Observation

Interview

Examination

Data Collection – process of gathering information about the

client’s health statusTYPES OF DATA : • Subjective – symptoms or covert

datae.g. – itching pain, feelings of worry• includes client’s sensations, feelings,

values, beliefs, attitudes and perception of personal health status and life situations.

Problem : Fever subjective cue: “Mainit ang pakiramdam ko.”

Assessment“Let me look at that.”“Tell me about it.”

Types of Data

•Objective data –signs or overt data; detectable by an observer or can be tested against an accepted standard

•e.g. – discoloration of the skin • Problem: fever-objective

cue : skin is warm to touch; temp. is 38.9 C/ax

Objective dataCaput medusae BP reading

SOURCES OF DATA:

•Primary source - client (best source of data)

SOURCES OF DATA:• Secondary sources –

indirect sourcese.g. – family members, -support people,

-client records (medical records, records of therapies by other health professionals and laboratory records),

-health care professionals,- literature

METHODS OF DATA COLLECTION:

•Observing using the five senses; a conscious deliberate skill that is developed only through effort and with an organized approach

METHODS OF DATA COLLECTION

•Interview a planned communication or conversation with a purpose

2 approaches: • a. direct

interview highly structured and elicit specific information by asking closed questions that call for a specific amount of data.

Interview• b. nondirective

the nurse allows the client to control the purpose, subject matter and pacing

Requirement: RAPPORT - the

understanding between two or more people.

Interview

Kinds of interview questions:•Closed

questions restrictive and generally require only short answers giving specific information; often begin with when, where, who, what, do, does, did

•Open-ended questions lead or invite clients to explore their thoughts or feelings

PLANNING THE INTERVIEW AND SETTING:

• Time need to be scheduled when the client is comfortable and free of pain

• Place must have adequate privacy to promote communication• Seating arrangement • Distance most people feel comfortable 3 to 4 ft apart during an interview

STAGES OF AN INTERVIEW:• Opening sets the tone of the remainder of

the interview.a.1. Establish rapport process of creating

good will and trusta.2 Orientation explaining the purpose and

nature of the interview• Body client communicates what he or she

thinks, feels, knows and perceives in response to questions from the nurse

• Closing important in facilitating future interactions.

ASSESSMENT TOOLS:GORDON’S FUNCTIONAL HEALTH

PATTERN FRAMEWORK

• pattern -signifies a sequence of recurring behavior

• dysfunctional as well as functional behavior

• to discern emerging patterns.

TYPOLOGY OF 11 FUNCTIONAL HEALTH PATTERNS:

1.Health – perception – health – management – pattern:

• describes client’s perceived pattern of health and well-being and how health is managed

• How does the person describe her/• his current health? • What does the person do to improve or

maintain her/ his health?


• What does the person know about links between lifestyle choices and health?

• How big a problem is financing health care for this person?

• Can this person report the names of current medications she/he is taking and their purpose?

1.Health – perception – health – management –

pattern:• If this person has

allergies, what does s/he do to prevent problems?

• What does this person know about medical problems in the family?

• Have there been any important illnesses or injuries in this person's life?

1.Health – perception – health – management – pattern: Nsg. Dx

• Ineffective health maintenance • Ineffective therapeutic regimen

management• Ineffective family therapeutic

regimen management • Ineffective community

therapeutic regimen management


Nsg. Dx•Risk for infection •Risk for injury (trauma) •Risk for falls

TYPOLOGY OF 11 FUNCTIONAL HEALTH PATTERNS:

2.Nutritional – metabolic pattern:

• pattern of food and fluid consumption relative to metabolic need and pattern indicators of local nutrient supply

• Is the person well nourished?• How do the person's food choices

compare with recommended food intake?

2.Nutritional – metabolic pattern:Nsg. Dx

• Imbalanced nutrition: more than body requirements

• Risk for imbalanced nutrition: more than body requirements

• Imbalanced nutrition: less than body requirements

TYPOLOGY OF 11 FUNCTIONAL HEALTH

PATTERNS:3.Elimination – pattern:• describes pattern of excretory

function ( bowel, bladder and skin)• Are the person's excretory functions

within the normal range? • Does the person have any disease of

the digestive system, urinary system or skin?

3.Elimination – pattern:Nsg. Dx

• Constipation • Diarrhea• Risk for constipation • Bowel incontinence • Impaired urinary elimination • Functional urinary incontinence


PATTERNS:4. Activity – exercise pattern :• describes pattern of exercise, activity,

leisure and recreation• How does the person describe her/ his

weekly pattern of activity and leisure, exercise and recreation?

• Does the person have any disease that affects her/ his cardio-respiratory system or musculo-skeletal system

4. Activity – exercise pattern :Nsg. Dx

• Activity intolerance • Risk for activity intolerance • Fatigue • Deficient diversonal activity • Impaired physical mobility


PATTERNS:5.Cognitive – perceptual pattern :• describes sensory perceptual and

cognitive pattern-make a quick neurological assessment


PATTERNS:6.Sleep – rest pattern:• describes patterns of sleep, rest and

relaxation• Describes person's sleep-wake

cycle.• Does this person appear physically rested

and relaxed?

6.Sleep – rest pattern:Nsg. Dx

• Disturbed sleep pattern

7.Self – perception – self – concept – pattern:

• describes self-concept pattern and perceptions of self (body comfort, body image, feeling state)

• Is there anything unusual about this person's appearance?

• Does this person seem comfortable with her/ his appearance?

• Describe person's feeling state

7.Self – perception – self – concept – pattern:Nsg. Dx

• Fear • Anxiety • Risk for loneliness • Hopelessness • Powerlessness • Risk for

powerlessness

• Situational low self-esteem • Risk for situational low self-

esteem• Chronic low self-esteem • Body image disturbed • Disturbed personal identity • Risk for violence, self-

directed


PATTERNS:8.Role – relationship pattern :

• describes patterns of role engagements and relationships

• How does this person describe her/ his various roles in life?

• Has, or does this person now have positive role models for these roles?

8.Role – relationship pattern :

• Which relationships are most important to this person at present?

• Is this person currently going though any big changes in role or relationship? What are they?

8.Role – relationship pattern :Nsg. Dx•Anticipatory grieving

•Dysfunctional grieving •Risk for dysfunctional

grieving • Ineffective role performance •Social isolation • Impaired social interaction•Relocation stress syndrome


PATTERNS:9.Sexuality – reproductive pattern:

• describes client’s patterns of satisfaction and dissatisfaction with sexuality; describes reproductive pattern

• Do you have regular menstruation?• When was the last sexual intercourse?

• Sexual activities?

9.Sexuality – reproductive pattern:Nsg. Dx

• Sexual dysfunction • Rape-trauma syndrome


PATTERNS:10.Coping – stress – tolerance – pattern:

• describes general coping pattern and effectiveness of the pattern in terms of stress tolerance

• How does this person usually cope with problems?

• Do these actions help or make things worse? • Has this person had any treatment for

emotional distress?

10.Coping – stress – tolerance – pattern:Nsg. Dx.

• Ineffective coping• Disabled family coping • Ineffective community coping • Post-trauma syndrome • Risk for post-trauma syndrome • Risk for suicide


PATTERNS:11. Value – belief pattern:• describes patterns of values, beliefs

or goals that guide choices or decisions

• E.g reads bible everyday

REVIEW OF SYSTEMS

goal : to gather data from the client in each of the major body systems.

• General Health. Weight loss, weakness, feelings of fatigue, mood changes, night sweats, or bleeding tendencies?

REVIEW OF SYSTEMSSkin. • Skin diseases such as eczema, psoriasis, • acne; change in pigmentation;• tendency toward bruising; • excessive dryness or moisture; jaundice;• itching, rashes, hives;• change in color or size of moles; • or open sores that are slow to heal?• Hair. Itchy scalp, loss of hair, excessive body hair?

Does the client wear a wig?

Nails. color changes, biting, clubbing, splitting?

REVIEW OF SYSTEMSHead • Frequent or severe headaches,• fainting, • dizziness,• accident resulting in unconsciousness

REVIEW OF SYSTEMSEyes. Difficulty seeing, eye infection, eye pain, excessive tearing,

double vision, blurring, sensitivity to light, cataracts, itching, spots in front of eyes?

• Does the client wear glasses (for near or far vision) or contact lenses?

• When was the client’s last eye examination?

REVIEW OF SYSTEMSEars • Any infection,• loss of hearing, pain, discharge, ringing in the

ears?• Does the client wear a hearing aid?

Nose. Frequent colds, nosebleeds, allergies, pain, tenderness, postnasal drip?

REVIEW OF SYSTEMS• Mouth and throat.• Sore gums; bleeding gums; sores, lumps

or white spots on the mouth, lips or tongue;

• toothaches, cavities, • difficulty swallowing; • voice change or hoarseness?• Does the client wear dentures (upper,

lower, partial)? • When was the client’s last dental

appointment?

REVIEW OF SYSTEMSNeck. Pain, swelling, stiffness, limited movements,

swollen glands?

Breasts. Nipple discharge, Scaling or cracks around

nipples, dimples, lumps, • pattern of self breast examination?• Last mammogram?

REVIEW OF SYSTEMS

Respiratory system. • Chest pain; cough; shortness of breath;

wheezing; coughing up blood;• lung disease such as tuberculosis, emphysema,

asthma, bronchitis? • Has the client ever had a chest x-ray? When?

Results?

REVIEW OF SYSTEMS

Cardiovascular system.• Heart disease,• palpitations, heart murmur,• high blood pressure, • anemia, • varicose veins,• leg swelling or ulcer?

REVIEW OF SYSTEMSGastrointestinal system.• Nausea, vomiting, loss of appetite,

indigestion, • heartburn,• bright blood in stools, • diarrhea, constipation,• abdominal pain; excessive gas, • hemorrhoids, rectal pain, • colostomy, ileostomy?

REVIEW OF SYSTEMSGenitourinary system. Frequency, dribbling, urgency, urination at night, difficulty starting stream, blood in urine, incontinence, pain or burning upon urination, urinary tract

infection, sexually transmitted disease such as

gonorrhea or syphilis?

REVIEW OF SYSTEMSFemales: • Age of menarche, last menstrual period

(LMP), • duration, amount of flow, regulatory of

cycle? • Any problems with painful menstruation,

bleeding within periods,• pain during intercourse, • vaginal discharge, vaginal itching, vaginal

infection?

REVIEW OF SYSTEMSMales:• Penile discharge,• swelling, masses or lesions,• difficulty in sexual functioning?

REVIEW OF SYSTEMS

Musculoskeletal system: • Muscular pain, • swelling or weakness;• joint swelling,• soreness, or stiffness; • leg cramps;• bone defects?

REVIEW OF SYSTEMSNeurologic system: • Difficulty of walking;• unconsciousness; • seizures;• tremors; • paralysis; numbness, tingling; or burning

sensations in any body part;• weakness on one side of body; speech

problems; unclear thinking; changes in emotional state?

REVIEW OF SYSTEMS• Endocrine system: • History of goiter;• heat or cold;• intolerance;• diabetes;• excessive thirst;• excessive eating?

NURSING DIAGNOSIS :• statement of the client’s health status• clinical judgment about individual, family or

community responses to actual and potential health problems / life processes.

Purpose: Provides the basis for selections of nursing interventions to achieve outcomes for w/c the nurse is accountable

NURSING DIAGNOSIS :

Eg.• Problem : Fever

nursing diagnosis : Alteration in thermoregulatory function: or

hyperthermia related to inflammatory process

TYPES OF NURSING DIAGNOSES:

• Actual Nursing Diagnosis a judgment about the client’s response to a health problem w/c is present at the time of nursing assessment

• Potential Nursing Diagnosis a judgment that a client is more vulnerable to develop the problem in the same / similar situation

• Problem Statement describes the client’s health problem or response for which nursing therapy is given

• Qualifiers added words to give additional meaning to the diagnostic statement

• Altered change from baseline• Impaired made worse, weakened,

damaged• Decreased smaller in size, amount or

degree• Ineffective not producing the desired

effect• Acute severe or of short duration• Chronic lasting a long time

COMMON ERRORS IN FORMULATING NURSING DIAGNOSES

1.Using medical diagnosis–INCORRECT: Self-care deficit related

to stroke–CORRECT: Self-care deficit related to

neuromuscular impairment2.Relating the problem to an

unchangeable situation


3. Confusing the etiology or signs/symptoms for the problem– INCORRECT: Post-operative

lung congestion related to bed rest

– CORRECT: Ineffective airway clearance related to general weakness and immobility


4. Use of a procedure instead of a human response– INCORRECT:

Catheterization related to urinary retention

– CORRECT: Urinary retention related to perineal swelling


5. Lack of specificity• INCORRECT: Constipation

related to nutritional intake• CORRECT: Constipation related

to inadequate dietary bulk and fluid intake


6. Combining two nursing diagnosis• INCORRECT: Anxiety and fear

related to separation from parents

• CORRECT: Anxiety related to change in environment and unmet needs


7. Relating one nursing diagnosis to another

• INCORRECT: Coping, individual ineffective related to anxiety

• CORRECT: Anxiety, severe related to change in role functioning and socio-economic status


• Use of judgmental/value-laden language

• Ineffective airway clearance related to bad habit


9. Making assumptions • INCORRECT: Risk for altered

parenting related to inexperience• CORRECT: Deficient knowledge

regarding child care issues related to lack of previous experience, unfamiliarity with resources

10.Writing a Legally Inadvisable Statement

• INCORRECT: Skin integrity related to not being turned every 2 hours

• CORRECT: Impaired skin integrity related to pressure and altered circulation

A Nursing Diagnosis

• Is– A statement of a

patient problem– Actual or potential– Within the scope of

nursing practice– Directive of

nursing intervention

• Is Not– A medical diagnosis– A nursing action– A physician order– A therapeutic

treatment

Medical Dx vs.Nursing Diagnosis

• Myocardial infarction

• Chronic ulcerative colitis

• Chronic ulcerative colitis

• Cancer of the breast

• Cerebral vascular accident

• Fear r/t possible recurrence of uncertain outcome

• Diarrhea r/t dis. process• Alteration in nutrition: less

than body requirements r/t altered GI absorptions

• Risk for(Potential) body image disturbance if mastectomy is required

• Self-care deficit: dressing & grooming r/t right sided flaccidity

Etiology (Related/ Risk Factors) the probable cause of the health problem; may include client’s behavior, environmental factors or the interaction of the two;

NANDA-“ related to” to describe the etiology or likely cause

Example:• Activity intolerance related to decreased

cardiac output.• Ineffective breast-feeding related to first-

time experience • Altered bowel elimination; constipation

related to insufficient fluid intake.

• Medical Diagnosis made by a physician refers to a pathophysiologic responses that are fairly uniform from one client to another.

• Nursing Diagnosis describes the clients’ physical, sociocultural, psychologic and spiritual responses to an illness or potential health problems; vary among individuals.

Nursing diagnosisActual nursing diagnoses

PES approach= Problem + Etiology + S/S• Impaired verbal communication r/t

cultural differences as manifested by inability to speak English

Nursing diagnosis

Potential nursing diagnosisPRF approach (risk factor)

• Potential skin breakdown r/t physical immobilization in total body cast

• Potential fluid volume deficit r/t diarrhea, age 3 yrs., low oral intake, elevated temperature

PLANNING• involves decision making and problem solvingPlanning process includes:A.Setting priorities establishing a preferential order

for nursing strategies ; the nurse must consider a variety of factors :

1.Client’s health values and beliefs a client may believe that being home with children is more urgent than a health problem.

2.Client’s priorities involving the client enhances cooperation between nurse and client

3.Urgency of health problems ABC’s of life (airway, breathing, circulation)

4.Medical treatment plan must be congruent with treatment of other health care professionals

PLANNINGshould be S-M-A-R-T (specific, measurable,

attainable, realistic and time-bound)

• Example:• Problem : Fever subjective cues : “Mainit ang

pakiramdam ko.”• objective cues : skin is warm to

touch; temp. is 38.9 C• nursing diagnosis : Alteration in

thermoregulatory function: hyperthermia related to inflammatory process

• plan : After 4 hours of continuous nursing intervention, patient’s temperature will decrease from 38.9 C to 37.5C/ ax.

PLANNING

Planning = setting priorities + establishing

goals + planning interventions

PLANNING

B. Establish GoalsComponents of a goal statement

Goal statement = pt behavior + criteria of performance +

Time + conditions (if needed)

Components of a goal statement

• PATIENT BEHAVIOR- an observable activity that the patient will demonstrate– (the patient) will void– Decrease in ( the patient’s) BP– (the patient) will ambulate– (the patient) will report– (the patient) will drink

Components of a goal statement

• TIME FRAME- a designated time or date when the patient should be able to achieve the behavior– Within the next hour– By discharge– At the end of this shift– By Dec. 25– In 2 months

Components of a goal statement• CONDITIONS

- specific aides which will facilitate the patient performing a behavior at the level in the criteria and within the specified time frame– With the help of a walker– With the use of a wheelchair– With the help of the family– With the use of medication– Using oral analgesics q3-4 hrs– Using IM Demerol q3-4 hrs

Planning Process

C. Planning Interventions• render continuous tepid sponge bath• loosen tight and thick clothing• increase fluid intake• keep room well ventilated• administer antipyretics as

indicated/ordered

IMPLEMENTATION / INTERVENTION implement the

interventions identified in the plan of care.

• Cognitive/Intellectual Skills include problem solving, decision making, critical thinking and creative thinking

IMPLEMENTATION / INTERVENTION• Interpersonal skills

activities use when communicating directly with one another; include verbal and nonverbal activities; necessary for caring, comforting, referring, counseling and supporting clients;

IMPLEMENTATION / INTERVENTION• Technical

/psychomotor skills ‘hands-on’ skills

such as manipulating equipment, giving injections and bandaging, moving, lifting, and repositioning clients; require knowledge and frequently manual dexterity.

The process of implementing:1.Reassessing the client

reassess whether the intervention is still needed

Note:even though an order is written on the

care plan, the situation or the client’s condition may have changed.

The process of implementing:2.Determining the need for

nursing assistance the nurse maybe unable to implement the nursing strategies safely alone

The process of implementing:3.Implementing nursing

strategies nursing activities include caring, communicating, helping, teaching, counseling, acting as a client advocate and change agent, leading and managing.

The process of implementing

4.Communicating nursing actions recording the interventions along with the client responses in the nursing progress notes.

TYPES OF NURSING ACTIONS:• Independent Nursing Actions an activity

that the nurse initiates as a result of the nurse’s own knowledge and skills

• Dependent nursing actions activities carried out on the order of the physician, under the physician’s supervision or according to specified routines

• Collaborative nursing actions activities performed either jointly with another member of the health care team or as a result of a joint decision by the nurse and another health care team member

• Problem : Fever subjective cues : “Mainit ang pakiramdam ko.”

• objective cues : skin is warm to touch; temp. is 38.9 C

nursing diagnosis : Alteration in thermoregulatory function: hyperthermia related to inflammatory process

plan : After 4 hours of continuous nursing intervention, patient’s temperature will decrease from 38.9 C to 37.5C.

Intervention

• continuous tepid sponge bath rendered

• tight and thick clothing loosened• fluid intake increased• room kept well ventilated• antipyretics as indicated/ordered

administered

EVALUATION• The evaluation process has 6 components:• Identifying the expected outcomes that the nurse

will use to measure client goal achievement• Collecting data related to the expected outcomes• Comparing the data with the expected outcomes

and judging whether the goals have been achieved

• Relating nursing actions to client outcomes• Drawing conclusions about problem status• Reviewing and modifying the client’s care plan• determine client’s progress toward goal

achievement and the effectiveness of NCP

• EVALUATION STATEMENT consist of 2 parts : a conclusion and a supporting data

• Example : Goal met : After 4 hours of continuous nursing intervention, temperature decreased from 38.9 to 37.4 C/ax

nursing process

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