Nursing Process Nursing Fundamentals

Introduction Nursing process is a systematic method of providing care to clients Allows nurses to communicate plans and activities to Clients Other health care professionals Families Encourages orderly thought, analysis, planning

Overview of the Nursing Process Process: “A series of steps or acts that lead to accomplishment of some goal or purpose” Purpose is to provide client care that is: Individualized Holistic Effective Efficient

Overview of the Nursing Process Consists of 5 steps Assessment Diagnosis Planning Implementation Evaluation Build on each other Not linear

Nursing process is dynamic and requires creativity in its application Steps remain the same Application and results different Used throughout the life span in any care setting

Assessment Step # Collecting data to determine the needs and health problems of patient. Involves Collecting data (from variety of sources) Validating the data Organizing the data Interpreting the data Documenting the data

Assessment Purpose of assessment: Data collection Types of assessment: Comprehensive assessment Focused Ongoing

Assessment Comprehensive assessment Baseline Physical & psychosocial

Assessment Focused Assessment Limited in scope Screening for a specific problem Short stay Ongoing assessment Follow-up Monitoring and observation related to specific problems

Assessment Sources of Data Primary sources Client Interview Physical examination Secondary sources Family members Other health care providers Medical records

Types of data Subjective :(symptoms) Data from the client’s point of view Feelings, Perceptions, Concerns (feeling nervous, nauseated, chilly or experiencing pain) Main way to collect subjective data: Interview Objective Observable & measurable data Main way to collect objective data: Physical assessment &Lab and diagnostic testing Such as (increase temperature, lab. results, moist skin, refusal to look at or eat food)

12 Data Collection Methods 1. Observation. Is the conscious and deliberate use of the five senses to gather data (sighting, smelling, touching and hearing) 2. Interview. Is the planned communication, during the assessment step of the nursing process to obtain and establish a successful working partnership with the patient, then to obtain the necessary patient data.

13 Data Collection Methods (cont’d) 3. Techniques of Physical Assessment. Is the examination of the patient for objective data that may better define the patients condition and help the nurse in planning care, include: inspection, palpation, percussion, and auscultation.

14 Problems Related to Data Collection 1. Inappropriate organization of the database. 2. Omission of pertinent data. 3. Inclusion of irrelevant or duplicate data. 4. Misinterpreted data. 5. Failure to establish rapport and partnership.

Diagnosis Step 2 in the nursing process Formulating a nursing diagnosis Analysis and synthesis of data Health issue that can be prevented, reduced, resolved, or enhanced through independent nursing measures

Nursing diagnosis: “A clinical judgment about individual, family or community responses to actual or potential heal problems / life processes. A nursing diagnosis provides the basis for selection of nursing interventions to achieve outcomes for which the nurse is accountable.”

Medical vs. Nursing diagnosis Medical diagnosisNursing diagnosis Identifies conditions the MD is licensed & qualified to treat Identifies situations the nurse is licensed & qualified to treat

Medical vs. Nursing diagnosis Medical diagnosisNursing diagnosis Identifies conditions the MD is licensed & qualified to treat Identifies situations the nurse is licensed & qualified to treat Focuses on illness, injury or disease processes Focuses on the clients responses to actual or potential health / life problems

Medical vs. Nursing diagnosis Medical diagnosisNursing diagnosis Remains constant until a cure is effected Changes as the clients response and/or the health problem changes

Medical vs. Nursing diagnosis Medical diagnosisNursing diagnosis Remains constant until a cure is effected Changes as the clients response and/or the health problem changes i.e. Breast canceri.e. Knowledge deficit Powerlessness Grieving, anticipatory Body image disturbance Individual coping, ineffective

Diangosis Nursing diagnosisMedical diagnosis Breathing patterns, ineffective Chronic obstructive pulmonary disease Activity intoleranceCerebrovascular accident PainAppendectomy Body image disturbanceAmputation Body temperature, risk for altered Strep throat

22 Nursing Diagnosis Categories 1. Actual. 2. Risk. 3. Possible. 4. Syndrome. 5. Wellness.

23 Diagnostic Statements Name of the health-related issue or problem as identified in the NANDA (North American Nursing Diagnosis Association) 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”.

24 Purpose of Diagnosis To identify: 1. Actual and potential problems. 2. Factor that contribute the problems (etiologies) 3. Strengths the patients can drawn to prevent or resolve the problems.

25 Formulating and Validating Nursing Diagnosis Parts of Nursing Dxs. 1. Problem. The purpose of the problem statement is to describe the health state or health problem of the patient as possible. Identifies what is unhealthy about the patient, indicating the need for change 2. Etiology. Identifies the factors that are maintaining the unhealthy state or response (causative factor ) 3. Defining characteristics. The subjective and objective data that signal the existence of the problem identify.

26 Diagnosis Examples Example 1 : Hygiene self-care deficit ( problem ) related to fear of falling in the obesity (etiology ) as manifested by strong body and urine odder (characteristics )

27 Diagnosis Examples (Cont’d) Example 2 : Chest pain ( problem ) related to decrease coronary blood flow (etiology) as manifested by facial expression (characteristics )

28 Diagnosis Examples (Cont’d) Example 3 : Ineffective individual coping (problem) related to loss of job ( etiology ) as manifested by increase daily use of alcohol (characteristics )

29 Planning Step 3 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 works in partnership with the patient and family.

Planning & Outcome identification Types of planning Initial planning Ongoing planning Discharge planning

31 Elements of Planning Establishing priorities. Writing goals / outcomes that determine the evaluative strategy. Selecting appropriate nursing interventions. Communicating the plan of nursing care.

32 Priorities of Planning Determine problems that require immediate action. Maslow’s Hierarchy of Human Needs 1. Physiologic needs. 2. Safety. 3. Love and belonging needs. 4. Self-esteem needs. 5. Self- actualization needs.

Planning & Outcome identification Identifying outcomes Goals An aim, intent or end. Short term goals Hours to days (less than a week) Long term goals Weeks to months

34 Guidelines For Goal/Outcome Writing One of the most important consideration in goal/outcome writing is to encourage the patient and family to be as involved in goal development as their abilities and interest permit. Each patient goal/outcome must have 1- a subject : which is the patient. 2- a verb : which indicates the action. The patient will perform, and criteria which describe in observable such as ( define, identify, list, select, apply, explain, prepare …… etc

35 Problems Related to Planning 1. Insufficient data collection. 2. Nursing Dxs developed from inaccurate data. 3. Goals /outcomes that are stated too broadly. 4. Goals/outcomes that are derived from poorly developed nursing Dxs.

36 Implementation (Intervention) 4 th step: Execute the plan of care (action phase) The nurse implements medical orders and nursing orders. Implementation involves the client and one or more health care team. The information in the chart shows a correlation between the plan and the care that has been provided. Nurses are accountable for carrying out nursing orders and physician orders.

Planning & Outcome identification Developing specific nursing interventions Independent nursing interventions No order needed Elevate edematous legs Interdependent nursing interventions In conjunction with an interdisciplinary team member Assist client with physical therapy exercises Dependent nursing interventions Require an order Administering of medications

38 Carrying Out The Plan of Care  When carrying out the plan of care, nurses use specialized abilities to 1. Determine the patients continuing need for nursing assistance. 2. Promote self-care. 3. Assist the patient to achieve health goals.

Evaluation 5 th step Determining whether the clients goals have been met, partially met or not met.

40 Evaluation Evaluate the effectiveness of the plan of care in terms of patient goal achievements. The nurse and patient together measure how well the patient has achieved the goals/outcomes specified in the plan of care, and the purpose of evaluation is to allow the patients achievement of expected outcomes to direct future nurse patient interactions, based on the patients responses to the plan of care.

41 Measuring Patient Goal/Outcomes Achievement 1. Collecting evaluative data. The data collected to determine whither the identified health problems have been resolved through goal achievement. 2. Documenting evaluation. After the data have been collected the nurse writes an evaluative statement to summarize the findings. And the nurse has three decision options for how goals have been (met ….. Partially met ….. not met...)

42 Factors That Influence Goal/Outcome Achievement 1. Numerous patient:( cognitive, cooperate.etc ) 2. Nurse: excellent, frustrate, bored. 3. Health care system : inadequate staffing. relationships…. etc

43 Documenting, Reporting and Conferring Documenting care. Is the written, legal record of all pertinent interaction with the patient assessing, diagnosing, planning, implementing and evaluation to facilitate patient care. Patient record. Is a compilation of patients health information

44 Purposes of Patient Records 1. Communication : between health care professionals 2. Care planning : patient responding to treatment from day to day. 3. Education : for the manifestations and treatment 4. Decision analysis. 5. Research. 6. Legal documentation.

45 Methods of Documentation 1. Source – oriented records : one in which each health care group keeps data on its own separate form. 2. Problem- oriented medical records: POMR is organized around a patients problems rather than a round sources of information. 3. Charting by exception: Is a shorthand documentation method that makes use of well-defined standards of practice 4. Computerized records.

46 Common Methods of Communication Among Health Care Professionals  Face to face meeting.  Telephone conversation.  Written message.  Computer message.

47 Nursing Care Rounds Its procedures in which a group of nurses visit selected patients individually at each patient’s bed side to: 1. Evaluate the nursing care for the patient has received. 2. Gather information to help plan nursing care.