2 Outline Background & Hx. of nursing process Definitions Benefits of nursing processPurposes of using nursing processCharacteristicsComponents of nursing process:- Assessment- Planning & nursing diagnosis- Implementation- Evaluation
4 Back GroundThe 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.
5 The Nursing ProcessAn organizational framework for the practice of nursingOrderly, systematicCentral to all nursing careEncompasses all steps taken by the nurse in caring for a patient
6 Definition of the Nursing Process A systematic problem-solving approach used to identify, prevent and treat actual or potential health problems and promote wellness.A systematic way to plan, implement and evaluate care for individuals, families, groups and communities.
7 Holistic Physical- Emotional- Psychosocial- Developmental- Spiritual BeingMedical DiagnosisNursing DiagnosisRheumatoid ArthritisSelf-care deficit: bathing, related to joint stiffness
8 Benefits of Nursing Process Provides 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 nursesIncreases care quality through the use of deliberate actions
9 Purposes of using nursing process Continuity of carePrevention of duplicationIndividualized careStandards of careIncreased client participationCollaboration of care
10 Characteristics: a. Planned, organized, &Systematic b. Dynamic 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. DynamicThe nursing process has great interaction and overlapping among the activities and each activity is fluid and flows into the next activityc. InterpersonalThe 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 needsd. Goal-directedThe 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 actionse. Universally applicableThe nursing process allows nurses to practice nursing with well or ill people, young or old, in any type of practice setting
11 5 components of the Nursing Process: AssessmentDiagnosisPlanningImplementingEvaluating
12 1st Component of the Nursing Process- ASSESSMENT: Two methods of Assessment1. Subjective – client’s perspectiveExamples: Report of fainting, complaint ofdizziness, nausea, headache2. Objective – observable & measurableExamples: Vomiting, unsteady gait, pale skin,rapid breathingData Collection: By Observation, interview, & Examination
13 During Assessment, the care provider: Establishes A Data Base: comprehensive information you gather on initial contact with the person to assess all aspects of health status.Focus assessment – the data you gather to determine the status of a specific condition.Continuously Updates The Data Base.Validates Data: - Measurable data- Double check personal observations- Double check equipment- Check with experts and team members- Compare objective and subjective data & Clarify statementsCommunicates Data
14 Types of Data To Collect: Objective data-observable and measurable facts (Signs)Subjective data-information that only the client feels and can describe (Symptoms)ResourcesSources of DataClientOther individualsPrevious recordsConsultationsDiagnostics studiesRelevant literaturePrimary source: ClientSecondary source: Client’s family, reports, test results, information in current and past medical records, & discussions with other health care workers
15 2nd component of the Nursing Process- Diagnosis: 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.
17 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 problem3. The diagnostic label & etiology are linked by the terminology Related to (R/T)Example: Ineffective breathing pattern R/T neuromuscular impairment.
18 Cont. Development of the Nursing Diagnosis Three-part-statementProblem statement – describes the client’s response to an actual or potential health problem (diagnostic label)2. Etiology – cause of the problem3. The diagnostic label & etiology are linked by the terminology Related to (R/T)4. Defining characteristicsExample:
19 Types of nursing diagnosis: Actual nursing diagnosis – a problem exists. Composed of the problem statement, related factors and signs & symptomsRisk nursing diagnosis – indicates the problem doesn’t exist but has special risk factorsWellness nursing diagnosis – indicates the client’sdesire to attain a higher level of wellness in some area of function.
20 NANDA – North American Nursing Diagnosis Association NANDA-International is recognized as the leader in development and classification of nursing diagnosesIdentifies nursing functionsCreates classification systemEstablishes diagnostic labelsExample:Risk of infection related to compromised nutritional statePotential complication of seizure disorder related to medication compliance
21 3rd component of the Nursing Process- Planning: The establishment of client goals/outcomesWorking with the client, to prevent, reduce, or resolve problemsTo determine related nursing interventions (actions) that are most likely to assist client in achieving goalsThis 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.
22 During Planning, the provider: A. Establishes PrioritiesB. Writes Client Goals/Outcomes And Develops An Evaluative StrategyC. Selects Nursing InterventionsD. Communicates The PlanNote: In planning we establish the goals, interventions and outcomes
23 General Guidelines for Setting Priorities Take care of immediate life-threatening issues.Safety issues.Patient-identified issues.Hierarchy of needs models.Nurse-identified priorities based on the overall picture, the patient as a whole person, and availability of time and resources.
25 Identification of Outcomes Provides guidelines for individualized nursing interventionsEstablishes goals & evaluation criteria to measureeffectiveness of the nursing care plan- Short-term goals – 1 week- Long-term goals – weeks to months
26 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.Monitor health status.Minimize risks.Resolve or control a problem.Promote optimum health and independence.3 types: independent, interdependent, dependent
27 InterventionsDirect interventions: actions performed through interaction with clients.Indirect interventions: actions performed away from the client, on behalf of a client or group of clients.
28 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:Prioritized nursing diagnostic statements.Outcomes.Interventions.
29 Documentation Clear and concise Appropriate terminology Usually on a designated formPhysical assessmentUsually by Review of SystemsOverview of symptomsDietEach body system
30 4th Component of the Nursing Process- Implementing: The provider carries out the plan of care
31 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 NeededDocuments Care
32 5th Component of the Nursing Process- Evaluating: The measuring of the extent to which client goals have been metEvaluation 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.
33 During Evaluating, the care provider: Measures The Clients Achievement Of Desired Goals/OutcomesIdentifies Factors That Contribute To The Client’s Success Or FailureModifies The Plan Of Care, If Indicated
34 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.
35 Short-Term Goals Outcomes achievable in a few days or 1 week Developed form the problem portion of the diagnostic statementClient-centeredMeasurableRealisticAccompanied by a target date
36 Long-Term GoalsDesirable outcomes that take weeks or months to accomplish for client’s with chronic health problems