The Nursing Process

Nursing Process
The Nursing Process is a framework that helps organize and deliver nursing care. It: Is orderly, systematic. Is central to all nursing care. Is used to identify, prevent and treat actual or potential health problems and promote wellness. Encompasses all steps taken by the nurse in caring for individuals, families, groups, and communities. Must be used by nurses

Definition of the Nursing Process

An

organized sequence of problemsolving steps used to identify and to manage the health problems of clients It is accepted for clinical practice established by the American Nurses Association

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

Characteristics of the Nursing Process

Within

the legal scope of nursing Based on knowledge-requiring critical thinking Planned-organized and systematic Client-centered Goal-directed Prioritized Dynamic

Being Accountable
Using critical thinking before taking actions Being responsible for your actions Entering the professional role Working at the level of your peers Using the nursing process

Something to think about:

Nurses are responsible for a unique dimension of healthcare the diagnosis and treatment of human responses to actual or potential health problems

The Nursing Process Is:

Cyclic and dynamic Goal directed and client centered Interpersonal and collaborative Universally applicable Systematic

NURSING PROCESS

Nursing Process

1. Assessment The nurse gathers subjective & objective

information from the client & other sources in order to understand the clients situation. 2. Nursing Diagnosis Organizes (in collaboration with the client), interprets the data and makes nursing diagnosis/diagnoses, which is nursings perspective on the appropriate focus for client nursing care. 3.Planning- Sets, in collaboration with client, mutually agreed upon goals of care, desired outcomes strategies to achieve goals of care & the identification & prioritization of appropriate nursing actions.

Nursing Process
4.Intervention- Perform the nursing actions identified in planning. 5.Evaluation- Determine if the goals are met and outcomes achieved.

Advantages of using the Nursing Process

Continuity of care Prevention of duplication Individualized care Promotes critical thinking & safety

Increased client participation Collaboration of care Application of Standards of care.

Critical Thinking
CRITICAL THINKING - is an active, organized cognitive process used to examine ones own thinking. It is a time for making decisions and reflecting, and taking nothing for granted. Nurses use critical thinking as they begin to question WHY? What else? Why not??? What?

A nurse who is a good critical thinker & uses the nursing process as intended, faces problems without forming a quick simple solution, but considers the value of all reasonable options.

Step #1 NURSING ASSESSMENT

Information Gathering & Processing

What Is the Nursing Assessment?

Assessment is the first step of the Nursing Process. It includes the collection & analysis of subjective & objective data pertinent to a client.

Nursing Assessment

Initially, the nurse must determine if the assessment should be a quick overview (consider the clients presenting priorities, specialty area of practice) or a detailed examination of the clients case.
In facilities, data is usually collected on standardized nursing assessment forms, designed to collect targeted relevant data. Forms may differ depending on hospital and setting.

Nursing Assessment

After the initial assessment the nurse focuses on the clients potential problems by conducting a more comprehensive assessment.

How Is Data Obtained?

Data

are obtained through:

Interviews- patient, nurses, support persons, HCPs Physical examinations Observations Review of records and diagnostic reports Collaboration with colleagues

Data Collection: Sources of Data

Client-usually the best source of information, pay attention to your client, act interested. Family and Significant Others- used as primary sources of information about infants, children, and critically ill, intellectually disabled, disoriented, or unconscious clients. Can be used as secondary sources of information. Health Care Team /nurse caring for patient -change of shift report Nurses Own Experience- Through experience the nurse learns to ask questions that yield important information Medical or Other Records- medical hx, lab tests, diagnostic study tests, educational, military records ect. Literature Review, Standards of Care, Procedures

Assessment Data Gathering Tools/Reports

Health History Health promotion & disease prevention behaviours, health problems & responses & risk factors (biological & environmental).

Other: Health practices, family and social support, goals, values, and expectations about the health care system.

Physical assessment: Head to toe assessment

During Assessment Use:

Critical thinking Broad knowledge base Effective communication skills Keen observation and physical assessment skills

ASSESSMENT ALSO INCLUDES CLIENTS:

current and past health and functional status present and past coping patterns (strengths and limitations) response to therapy (past/present, nursing/medical) risk for potential problems desire for a higher level of wellness health practices support system goals, values & expectations re health care system need for nursing

Importance of Client Expectations

Client/patient expectations influence the nurses success in developing a relationship with the client that leads to a directed, purposeful and comprehensive assessment.

Subjective vs. Objective Data

Subjective data- information reported by the client. Only the client can determine this data. Ex: I am scared, about surgery Objective data- observations or measurements made by nurse - i.e. vital signs, physical assessments, laboratory tests/values, changes in behavior (physical assessment) Based on assessment data gathering tools modeled on Orems Self-Care Model.

Nursing Health History

The Nursing Health History is the systematic collection of subjective and objective data used to determine a clients self care requisites, functional ability and ways of coping.

Purpose of the Subjective Component of the Nursing Health History

Provides subjective data on the clients health care experiences and current health and lifestyle habits.

i.e. patients level of wellness, present and past family history, changes in life patterns, review of systems etc

Nursing Health History

Nurses need to document all relevant information on time Pay attention to facts and be as descriptive as possible.

What Are Your Responsibilities?

Recognize health problems. Anticipate complications. Initiate actions to ensure appropriate and timely treatment.

Begin to think CRITICALLY !!!!!!

Critical Thinking

MENTAL OPERATIONS decision making & reasoning

KNOWLEDGE-having the facts & understanding the reason behind the knowledge

ATTITUDES- curious/open-minded/nonjudgmental.

TYPES OF INTERVIEWS

DIRECTED NON-DIRECTED

THINGS THAT IMPAIR COMMUNICATION: PRESENTING QUICK SOLUTIONS UNWARRANTED CHEERFULNESS FALSE REASSURANCE GIVING ADVICE CHANGING THE SUBJECT

COMMON Challenges: Defense Mechanisms

COMPENSATION DENIAL DISPLACEMENT RATIONALIZATION

PROJECTION REPRESSION SUPPRESSION REGRESSION

Continued
THE NURSING PROCESS HELPS NURSES UNDERSTAND THE STRATEGIES CLIENTS USE IN their attempt at coping: This knowledge will help you FURTHER INDIVIDUALIZE THEIR CARE

Planning
Establish

the goals, interventions and outcomes

General Guidelines for Setting Priorities

1.

2. 3. 4.

Take care of immediate life-threatening issues. Safety issues. Patient-identified issues. Nurse-identified priorities based on the overall picture, the patient as a whole person, and availability of time and resources.

Nurse Identified Priorities

Composite of all patients strengths and health concerns. Moral and ethical issues. Time, resources, and setting. Hierarchy of needs. Interdisciplinary planning.

Identifying Client-centered Outcomes

State what the patient will do or experience at the completion of care. Give direction to the patients overall care. Patient behaviors not nurse behaviors!!
The patient will

DIAGNOSIS
Sort, cluster, analyze information Identify potential problems and strengths Write statement of problem or strength Risk of infection related to compromised nutrition

Nursing Diagnosis (cont.)

Potential for effective breastfeeding related to knowledge level and support system Prioritize the problems Not a medical diagnosis

Steps for deriving outcomes from Nursing Diagnosis

Look at the first clause of the nursing dx and restate in a statement that describes improvement, control or absence of the problem. Risk for infection r/t surgical procedure. The client will demonstrate no signs or symptoms of infection.

Components of Outcomes

Subject: who is the person expected to achieve the outcome? Verb: what actions must the person take to achieve the outcome? Condition: under what circumstances is the person to perform the actions? Performance criteria: how well is the person to perform the actions? Target time: by when is the person expected to be able to perform the actions?

Nursing Interventions

1. 2. 3. 4. 5.

Road maps directing the best ways to provide nursing care. Evidence based nursing. Monitor health status. Minimize risks. Resolve or control a problem. Assist with ADLs. Promote optimum health and independence.

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.

Nursing Diagnosis
Health

issue that can be prevented, reduced, resolved, or enhanced through independent nursing measures

Documenting the Plan of Care

1.

2.

3.

To ensure continuity of care, the plan must be written and shared with all health care personnel caring for the client. Consists of: Prioritized nursing diagnostic statements. Outcomes. Interventions.

Documentation
Clear and concise Appropriate terminology

Usually on a designated form Usually by Review of Systems Overview of symptoms Diet Each body system

Physical assessment

Documentation
Use patients own words in subjective data enclose in ___ (quotation marks) Avoid generalizations be specific Dont make summative statements describe - e.g. patient is being ornery should be patient resists instruction or patient states Dont talk to me, I dont care about that

Evaluation
1. 2.

3.

Determining outcome achievement Identifying the variables affecting outcome achievement Deciding whether to continue, modify, or terminate the plan

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.

Identifying Variable Affecting Outcome Achievement

Maintain individuality of care plan: 1. Is the plan realistic for the client? 2. Is the plan appropriate at the time for this particular client? 3. Were changes made in the plan when needed? 4. How does the client feel about the plan?

Predict, Prevent, and Manage

Focus on early intervention Based on research Predict and anticipate problems Look for risk factors

Diagnostic Statements
Name

of the health-related issue or problem as identified in the NANDA list Etiology (its cause) Signs and Symptoms The name of the nursing diagnosis is linked to the etiology with the phrase related to, and the signs and symptoms are identified with the phrase as manifested (or evidenced) by

Collaborative ProblemsNurses Responsibility

Correlating

medical diagnoses or medical treatment measures with the risk for unique complications Documenting the complications for which clients are at risk Making pertinent assessments to detect complications

Continued
Reporting trends that suggest development of complications Managing the emerging problem with nurse- and physician-prescribed measures Evaluating the outcomes

The Nursing Process

Nursing Diagnosis
or conclusion about the risk for or actualneed/problem of the patient NANDA format
Judgment

NANDA North American Nursing Diagnosis Association

Identifies nursing functions Creates classification system Establishes diagnostic labels

Risk of infection related to compromised nutritional state Potential complication of seizure disorder related to medication compliance

Planning
The

process of prioritizing nursing diagnoses and collaborative problems, identifying measurable goals or outcomes, selecting appropriate interventions, and documenting the plan of care. The nurse consults with the client while developing and revising the plan.

Setting Priorities
Determine

problems that require immediate action Maslows Hierarchy of Human Needs

Short-Term Goals
Outcomes

achievable in a few days or

1 week Developed form the problem portion of the diagnostic statement Client-centered Measurable Realistic Accompanied by a target date

Long-Term Goals
Desirable

outcomes that take weeks or months to accomplish for clients with chronic health problems

The Nursing Process

Planning
Identification Prioritization

of goals and outcome criteria

Time

frame

Selecting Nursing Interventions

Planning

the measures that the client and nurse will use to accomplish identified goals involves critical thinking. Nursing interventions are directed at eliminating the etiologies.

Selecting an intervention
The nurse selects strategies based on the knowledge that certain nursing actions produce desired effects. Nursing interventions must be safe, within the legal scope of nursing practice, and compatible with medical orders.

Communicating The Plan

The

nurse shares the plan of care with nursing team members, the client, and clients family. The plan is a permanent part of the record.

Evaluation
The

way nurses determine whether a client has reached a goal. It is the analysis of the clients response, evaluation helps to determine the effectiveness of nursing care.

The Nursing Process

Evaluation
Ongoing

part of the nursing process Determining the status of the goals and outcomes of care Monitoring the patients response to drug therapy

Documentation
Clear and concise Appropriate terminology

Usually on a designated form Usually by Review of Systems Overview of symptoms Diet Each body system

Physical assessment