Nursing process

Nursing processsimple guide for student nurses

H. DeepaniRN, BN, Nursing TutorSchool of NursingColomboSri Lanka

Objectives DefinitionCharacteristicsBenefitsPhases

Definition The nursing process is a modified form of scientific method used in nursing profession toasses client needs and create a course of action to address and solve patients problems

The nursing process is a systematic, client centered, goal oriented method of caring that provides a framework for nursing practice

It is a systemic, rational method of planning and providing individualized nursing care for individuals, families, groups and communities

Benefits of Nursing ProcessProvides an orderly & systematic method for planning & providing careEnhances nursing efficiency by standardizing nursing practiceFacilitates documentation of careProvides a unity of language for the nursing professionIs economicalStresses the independent function of nursesProvide continuity of care and prevent duplication

Characteristics of the Nursing Process SystematicDynamic Client-centeredGoal-directed outcome focusedUniversally applicableSteps are interrelated and dependant on the accuracy of each step

Phases/Steps AssesmentNursing diagnosisPlanning and goal settingImplementationEvaluation

Steps of nursing process

Assesment 1st stepDefinition -Collecting, organizing, validating and documenting dataGathering information about psychological, physiological, social and spiritual statusData collected through observation, interview, physical examination, health records and family membersFocus on patient response to health problems

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Assesment types Initial after admission. Provide baseline data(vital signs)Problem focused- ongoing process to determine the state of previously identified problem(hourly UOP of ARF pt)Emergency at life threatening situations(ABC)Time lapsed- after several weeks/ months to determine the progress of disease and treatment(clinic follow up)

Types of dataSubjective (symptoms) information perceived only by affected person Eg: pain, worry, nauseaObjective (signs)information perceived by another person that can be verified by othersEg: vital signs, reddened skin

Sources of data ClientSupport peopleClient records and reportsHealth care professionalsHealth care literature

Methods of data collection

Observationconscious and deliberate use of the five sensesOrganized observation (a/c to disease eg. asthma)-clinical signs of patient(SOB)-threats to safety (no side rails)-associated equipment (IV drip not functioning)-immediate environment (slippery floor)-BHT (Drs order, Ix reports, charts, drugs)

2. Interviewplanned communication to obtain history3. Physical assessmentexamination of the client for objective dataFour methods of physical assessmentInspectionPalpationPercussionAuscultation4. Refer client records and reports5. consultation

Steps of assessment processData collectionValidation double checking for accuracyOrganizing- head to toe or system wiseDocumentation subjective (clients words)- Objective (medical terms, abbreviations)

Nursing diagnosisNursing diagnosis is a clinical judgment about individual, family or community response to actual and potential health problems/life processes1990 NANDA definitionNorth American Nursing Diagnosis Association

Nursing diagnosisAfter gathering information about the client, nurse analyze them and make a decision about the persons condition, strength, problems or needs

It is the judgment that the nurse makes, which forms the link between assessment and nursing care plan

Components of nursing diagnosis Problem statement (derived from NANDA nursing diagnosis)-self care deficitEtiology/related factor (contributing factor for the problem)-R/T paralysis of lower limbsDefining characteristics (data that signals the existence of the problems)-as evidenced by strong body and urine odor

Descriptive wordsAcuteChronicIntermittentAlteredImpairedIncreasedDecreasedDeficientExcessDisturbedIneffectivedepleted dysfunctional

Types of nursing diagnosis Actual- current/obvious problemEg : fluid volume deficit(decreased intake due to nausea and vomiting, dry skin, low UOP, Potential/risk problems which may occur in the future due to current health statusEg : risk for infection(surgical incision, discharge on dressing)

Wellness clinical judgment about the state of wellnessEg: potential for enhanced spiritual wellbeing(practice religious activities, family provides good support in practices )

Medical vs. nursing diagnosisMedical- identify disease (one)

Nursing - identify unhealthy responses associated with a disease (several for signs and symptoms)

NANDA - nursing diagnosesStandard and approved

Keep a copy with you always

Guidelines to write nursing diagnosesSelect problem statement/nursing diagnosis from NANDA list based on pts assessmentLink the etiology and problem statement with the phrase related toDo not write medical diagnosis, signs or symptoms as problem statement

Use legally advisable termsBe sure the problem statement indicates what is unhealthyActual diagnoses must have obvious relevant data in the assessment columnUse your knowledge, experience and medical literature to develop risk diagnoses Reread and confirm the diagnoses

Prioritizing nursing diagnosesRanking of nursing diagnoses in order of importanceHigh priority- if untreated could harm to clienteg. Ineffective breathing patternMedium non life threateningeg. Risk for impaired skin integrityLow not directly related to current illness or prognosisEg. Impaired social interaction

Guides for prioritizing nursing diagnosesMaslows hierarchyVirginia Hendersons guide for needsClient preferenceAnticipation of future problems

Planning In this phase Nurse and client work together to1. develop client goals if achieved which solve the client problem in nursing diagnosis2. identify the nursing interventions which are most likely assist the client in achieving those goals

Types 1- Initial planning: the nurse who performs the admission usually develops the initial comprehensive plan of care.

2- Ongoing planning: - Is done by all nurses who work with the client.

3- Discharge planning: The process of anticipating and planning for needs after discharge. 30

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Planning Process: 1- Setting priorities. 2- Establishing client goals/desired out comes. 3- Selecting nursing strategies./interventions 4- Writing nursing orders. 31

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Planning Process:1-Setting priorities:As you learned above 32

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Planning Process:Formulating Goal/ objective/ expected outcome * Purpose of Goals: a- provide direction for planning nursing interventions b- Serve as criteria for evaluating client progress. c- Enable the client and the nurse to determine when the problem has been resolved. 33

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Formulating goals- derived from the problem statement of nursing diagnosis-for each diagnosis at least one goal-consider clients preference-find the descriptive term of the diagnosis-find the opposite term of descriptive term-write the goal as To +verb stem

Example problem statement-impaired skin integrityDescriptive term-ImpairedOpposite of impaired- improvedVerb stem- improveGoal- To improve skin integrity

SMART goalsS - SpecificM - MeasurableA - AchievableR - RealisticT - Time bound

SMART goal exampleNursing diagnosis- Fluid volume deficit r/t frequent passage of stools GoalS- Mr. Sirisena M- will drinkA- 60ml fluidR-while awakeT- every hour

Types of Goals:a- Short Term Goals: For a client who require health care for a short time.usually achieved in less than one weekb- Long Term Goals: Are often used for clients who have a chronic health problemusually takes more than one to two weeks to achieve 38

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Nursing strategies/ interventionsDerived from nursing diagnosisBased on causative factors for the problemIdentify several optionsSimple to complex

Selecting nursing interventionsTypes of Nursing Intervention: 1- Independent intervention: activities that nurses are licensed to initiate on the basis of their knowledge and skills. 2- Dependent intervention: are activities carried out under the physician orders. 3- Collaborative intervention: are actions the nurse carries out in collaboration with other health team member. 40

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Writing nursing ordersWrite as orders-provide back care 2hly-change the dressingClearbriefSimple to complexUse abbreviations

Implementation

Putting the planned care into actionPrerequisite nursing skillsIntellectualInterpersonaltechnical42

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Process of implementationDetermine the need for assistance(basic human needs)Promote self care, teaching and counseling(active participation of client and family)Assisting to meet health goals(carry out the planned actions)Ongoing data collectionCommunicating care(documentation only about carried out actionspast tense)

Evaluation Planned, ongoing, purposeful activity in which clients and health care professionals determine:- The clients progress toward goals an achievement.- The effectiveness of the nursing care plan. 44

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Evaluation Process of evaluating client responses: 1- Identify the desired out comes. 2- Collecting data related to desired out comes. 3- Relate nursing actions to client goals/desired outcomes. 4- Draw conclusions about problem status. 5- Continue to modify or terminate the clients care plan.45

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Documenting evaluationGoal metPartially metNot metwith brief relevant description

Writing care plansUse institutional formatDate/time/assessment/nursing diagnosis/planning/implementation/ evaluationAssessment- include significant data about basic human needs, signs and symptoms, feelings,Ix reports, special medical care, vital signs etc. Avoid too long descriptions

Nursing diagnoses- use NANDA problem statement +related factorPlanning-goals and plans to achieve goalwrite as ordersImplementation- about carried out actionswrite in past tenseEvaluation- mention about goals met or not with brief description.Use accepted abbreviations and symbols of your agencyKardex-mostly used care plan

Important !important!! Important!!!Every client is uniqueThey have unique problemsDevelop ability to identify unique problems of each clientUnique ,clear assessment helps to provide unique care for each clientNEVER COPY AND PASTE from web sources for study purposes

Questions?

Thank you!

Case study 52 years old Mr. Perera is a clerk. He was admitted to your ward with a history of difficulty in breathing, difficulty in swallowing, mild chest pain and hoarseness of voice. He has lost 5kg of weight within last two months. Today is the second day after admission. Still he has all the symptoms he had on admission.

He looks ill and complains generalized body weakness. he is on liquid diet , but he refuses his meals saying no appetite. His urinary and bowel elimination normal. He has not slept last night due to unfamiliar environment. Today he is waiting for his endoscopic biopsy report. He worries about the uncertain results of the report. He wants to know the reason for his physical changes. His last Hb report is 9.2g/dl. His vital signs are normal.

Underline clients problemsWrite those in a separate paperWrite possible problems which may occur in the futureSelect problem statement for each problem from NANDA diagnoses listSelect etiology from assessment and literatureWrite two part nursing diagnosis for each problem.Formulate goalsPlan actions to achieve goals