NURSING PROCESS

Definition: It is a systematic, client-centered method for structuring the delivery of

nursing care.

Phases:1. Assessment2. Diagnosing3. Planning4. Implementing5. Evaluating

Characteristics:

1. It is cyclical and dynamic in nature.2. It is client-centered.3. It adapts problem solving.4. Decision-making is involved in every phase.5. It is interpersonal and collaborative.6. It is universally applicable.7. It uses variety of critical thinking skills.

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ASSESSMENT

Definition: It is a systematic and continuous collection, organization, validation and

documentation of data.

Characteristics: 1. It focuses on a client’s responses to a health problem.2. It should include the client’s perceived needs, health problems, related

experience, health practices, values and lifestyle.3. To be most useful, the data collected should be relevant to a particular

health problem.

Activities:1. Collecting Data 3. Validating Data2. Organizing data 4. Documenting Data

COLLECTING DATA/ DATA COLLECTION- process of gathering information about a client’s health status

Database/ baseline data- all the information about a client -which includes:

1. nursing health history 2. physical assessment3. physician’s history4. physical examination5. results of laboratory and diagnostic tests

THE NURSING HEALTH HISTORYPurpose:

1. To elicit information about all variables that may effect that client’s health status.

2. To obtain data that help the nurse understand and appreciate the client’s life experiences

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Judgmental

andConclusive

3. To initiate a non judgmental, trusting interpersonal relationship with the client.

Components:1. Biographic data2. Chief complaints or reason of visit3. History of present illness4. Past history5. Family history of illness6. Review of system (ROS)7. Life style8. Social data9. Psychological data10. Patterns of health care

TYPES OF DATA:1. Subjective Data

- information given verbally by the patient - information perceived only by the affected person - symptoms complained by the patient

example:Correct: “ I feel so nervous ”

“ Get out of my room ”“ Sakit akong samad “

Incorrect: Patient is anxiousPatient is hostilePatient has pain

2. Objective data - are detectable by an observe - consists of information that is perceptible to the senses - can be tested against an accepted standard - factual data observed by the Nurse

example:Correct: hair combed, make-up applied

drag right leg when walking tremors of both hands 250 cc dark amber urine

Incorrect: neatly- groomed Improve body image Patient very afraid Voided large amount

Sources of Data:1. Primary- client2. Secondary- significant others, other health personnel records and

reports- relevant literature

Data Collection Methods

A. Observation- occurs whenever the nurse is in contact with the client or support persons- gather data by using the 5 senses

B. Interviewing

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Concise

andDescriptive

- structured form of communication that the nurse uses to collect data or a conversation with a purpose

2 Approaches1. Directive2. Non- directive

Directive - structured and elicits specific information- used to gather and to give information in a limit amount of time

Non-directive - rapport building interview- uses open- ended questions, used for problem- solving counseling

and performance appraisal(Rapport- is an understanding between 2 or more people)

Kinds of Interview Questions:1. Closed question- used in directive interview, restrictive and generally

require only short answers- giving specific information2. Open-ended questions - non-directive interview

- lead clients to explore their thoughts and feelings disadvantages. The client may spend time conveying irrelevant information.

3. Neutral Questions – question that the client can answer without direction or

pressure from the nurse - is open-ended, and is used in non-directive interviews

4. Leading Questions – is usually closed, used in directive interview and thus directs

client’s answer

Some hints to make patient comfortable before beginning the nursing history:

a. Assess for painb. Offer the patient an opportunity to go to the bathroom or make a callc. Offer some beverages is medically permittedd. Sit-down- during interview- eye level

Planning the Interview and Setting:

1. Time2. Place- privacy3. Seating arrangement- 45 degree angle to the bed4. Distance-3 to 4 ft. apart5. Language

Stages of Interview

1. The opening /introductionsteps: a. establishing rapport

b. orienting the interviewee2. The body3. The closing

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Examination - major method used in the physical health assessment

- done systematically, according to examiners preference (head to toe or body systems)

a. Cephalo-caudal- head, neck, thorax, abdomen, and extremities and ends at the toes

b. Body System approach- respiratory, circulatory, etc.- data’s obtained are measured against norms or standards (ideal height/weight, temperature, Blood Pressure)

Techniques Used:1. inspection2. auscultation3. palpation4. percussion

INSPECTION- systematic- head to toe

PALPATION - the nurse uses the hands and sense of touch to gather data- used to detect tenderness, temp., texture, vibration, pulsations,

masess- rules out/confirms suspicious raised during interview and inspection

PERCUSSION- is the tapping of the body’s surface to produce vibration and sound

- sounds indicates the density of the underlying tissue

tympany-high-pitched-like sound over a hallow organdullness-low-pitched,thud-like soun over a dense organ

Technique: place the palmar surface of one hand against the client’s body while tapping with the other.

AUSCULTATION – the process of listening to sounds produced by the body - Systems involved:

Cardiovascular SystemRespiratory SystemGastro-intestinal System

- Use: Stethoscope- an instrument that amplifies sounds produced by i

nternal organs

ORGANIZING DATA- nurse uses written format that organizes the assessment data

systematically

Nursing Conceptual Models/Framework which can be used to structure the nursing admission assessments:

1. Maslow’s Hierarchy of basic needs2. Henderson’s 14 components of nursing care3. Gordon;s 11 functional health pattern4. NANADA’s 9 response pattern

VALIDATING DATA

- information gathered during assessment phase must be complete, factual, and accurate because the nursing diagnoses and interventions are based on this information

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DOCUMENTING DATA

- to complete the assessment phase, the nurse records the data

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NURSING DIAGNOSIS

- is a clinical Judgment about individual, family or community responses to Actual or Potential health problems/ life process.

- It provides a basis for selection of nursing interventions to achieve outcomes for which the N is Accountable

Advantages:

1. Ng Dx facilitates communication among Nurses and other health team members.

2. Strengthen the Ng. Process and provide Direction for Planning independent Ng. Actions

3. Health the nurse focus on independent Nursing Actions.4. Help identify the focus of a Nursing Activity and thus facilitates peer

review and quality assurance program.5. Facilitate Nursing intervention when a client moves from one

hospital unit to another.6. They facilitate comprehensive health care by identifying, validating

and responding to specific health problems.

WRITING NURSING DIAGNOSIS

1. ACTUAL NURSING DIAGNOSIS

a. Ng. Dx = PATIENT PROBLEM AND ETIOLOGYEx. Impaired skin integrity r/t immobilityPrental role conflict r/t divorceImpaired verbal r/t culturalCommunication differences

b. Ng. Dx = P + E + S

Impaired skin integrity r/t immobilityManifested by disruption of skinSurface over the elbows and coccyx

Prental role conflict r/t divorce as manifested by statement or unsatisfactory child care during working hours

Impaired verbal r/t cultural differences as Communication manifested by inability to Speak English.

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2. POTENTIAL (High Risk) Ng. PROBLEMS:

HIGH RISK = PROBLEM + RISK FACTOR + NG DXHigh risk for skin r/t physical immobilizationBreakdown in totoal body cast

High risk for skin r/t diarrhea, age 3 years, low oralFluid vol. Intake, temperatureDeficit

High risk for injury r/t disorientation and division after cataractsurgery

3. POSSIBLE NG.DX

Possible sensory- perceptual alterationPossible nutritional deficitPossible fluid vol. Deficit

NURSING MEDICAL DX

Describe an individual’s response to a as Describe a specific do Process

Is oriented to the individual Is oriented to pathology

Changes as the client’s responses change Remains constant throughout

the duration of illness

Guides independent Ng. Guides medicalActivities: planning management, some ofIntervention and evaluation which may be carried out by

the nurse.

Is complementary to the MEDICAL Dx Is complementary to the Ng. Dx

Has no universally accepted classification Has well developed System classification system consistConsist of two-part of 2 or 3 wordsStatement of etiologyWhen known

STEPS OF DIAGNOSE PROCESSNG-DX= DATA PROCESSING + DETERMINING THE CLIENT’S HEALTH

PROBLEMS, HEALTH RISKS AND STRENGTHS + FORMULATION OF NURSING DIAGNOSE

1. Organized Data2. Compare data against standard -------- normal health patterns

-------- normal vital signs -------- lab values

3. Cluster data

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4. Identify gaps & inconsistencies in data

STANDARD/NORM- general accepted rule, model, pattern or measure used in comparing which must be relevant & reliable

CUE- a piece of information or data that influence decisions

BENEFITS:A. Client:

1. quality client care2. continuity of care3. participation by the client in their health care

B. Nurse:1. consistent and systematic nursing education 2. job satisfaction3. professional growth4. avoidance of legal action5. meeting professional nursing standards

Characteristics:

1. the NCP focuses on actions which are designed to solve or alleviate an existing problem.

2. The NCP is a prodcut of a deliberate systematic process.3. The NCP relates to the future. It utilizes events in the past and what is

happening in the present to determine trends.4. The NCP revolves around identified healtgh and nursing problem5. The NCP is a means to an end, not end in itself.6. Nursing care planning is a continuous process.

DESIRABLE QUALITIE OF NCP

1. should be based on a clear definition of the problem2. is realistic3. consistent with the goals and philosophy of the health agency4. NCP is drawn with the family5. Is best kept in written form

NCP-Importance

1. they individualize care to clients2. Healps in setting priorities by providing information about the client as well as

the nature of his problems3. Promotes systematic communication among those involved in the health care

effort4. Continuity of care facilitated5. Facilitates the coordination of care

STEPS IN DEVELOPING FNCP:

1. the problem definition2. the goals and objectives of care3. the plan of intervention4. the plan for evaluating care

ESTABLISHING GOALS:

Goal - is a general statement of purpose- it is the end toward which all efforts are directed

S - specific

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M - measurableA - attainableR - realisticT - time bounded

DIAGNOSING- is the process of making a clinical judgement (nursing diagnosis) about a client’s potential or actual health problem that nurses are licensed and able to treat.

PLANNING- inv9olves setting priorities, writing goals, and establishing a written plan for nursing interventions designed to prevent, resolve or identify problems or potential problems.IMPLEMENTING- is carrying out or delegating the nursing interventions

EVALUATING- involves the nurse and the client in determining whether that client’s goals or predetermined outcomes of care have been met

- identifying factors that facilitated or inhibited goal achievement- and modifying or terminated the care plan accordingly

METHOD DISCHARGE PLANNING

F. MedicationThe client will know:

Drug name What dosage to take and when Purpose of drug Effect (s) the drug should have Symptoms of possible adverse effects, and which ones to report

(repeat for each drug prescribed)

A. ENVIRONMENTThe client will be assured of:

Adequate instruction in necessary homemaking skills Investigation and correction of any physical hazards in the home

environment Adequate emotional support Investigation of sources of economic support Investigation of transportation means to appointment and/ or

clients

T. TreatmentThe client and family will:

Know the purpose of any treatment to be continued at home Be able to demonstrate correct performance of treatment

H. Health TeachingThe client will:

Describe how his or her disease or condition affects body function Describe the means necessary to maintain present level of health,

or achive a higher level of health

O. Outpatient Referral/ Observable Signs and SymptomsThe client will:

Know when and where of his or her prescribed diet Know when and whom to call for medical help Take home written discharge instructions

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D. DietThe client will be able to:

Describe the purpose of his or her prescribed diet Plan several typical menus using prescribed diet

PLANNING

Definition- is the process of designing the Ng. Strategies or interventions required to prevent, reduced opr eliminate those client health problems identified and validated during the diagnostic phase.

- the process in which problem solving and decision- making are carried out.

Uses:1. data obtained during assessing2. the diagnostic statements that present client’s health problem

6 Compaonents of P:1. setting priorities2. establishing client goals and outcome criteia3. planning Ng Strategies4. writing Ng orders5. writing the NCP6. Consulting

I. Setting PrioritiesDetermined by the following factors:

1. client’s health values and belief2. client’s priorities3. resource available to the N. and C.4. time needed for the nursing strategies5. urgency of the health problems6. medical treatment plan

II. Establishing client’s goal and criteria

Client’s goal- is a desired outcome or change in client behavior in the direction of the health

Purposes:1. provide direction of planning nursing intervention2. provide direction for establishing evaluation

Types of Goals

a. long term- client living at home or having chronic health problems, in NG. Homes and rehab center.

b. short term- client’s requiring short term care- persons who are frustrated by long term goals

Establishing goals for Fr Ng Dx

Nursing Diagnosis- Impaired Physcial Mobility r/t painClient problems- Impaired physical mobilityClient goals- client will demonstrate increase in physical

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Ng. Dx - SELF CARE DEFICIT: inability to feed self r/t depression

Client problems - Self- care deficit: inability to feed self.

Client goals - client will perform self feeding

OUTCOME CRITERIA:4 purposes:

1. provide direction for nursing intervention2. provide a time spab for planned activities3. serve as criteria for evaluation of progress toward goal achievement

COMPONENTS OF OUTCOME CRITERIA:

1. subject2. verb3. condition or modifier4. criterion

SUBJECT VERB CONDITION DESIRED PERFORMANCE

StandardClient Drinks 100 ml of fluid Q 4 hoursClient List Three hazards of

Smoking(three)

Client Identifies Advance of Immunization

On the next visit

Client States The purpose of his medication

Before discharge

Cleint Identifies Importance of eating right kind of food

On the next visit

GUIDELINES:

1. Write goals and outcome criteria in term of client behavior- focus on the client not nursing action.

2. Avoid statement that short and enable, facilitate, allow, let, permit followed by the word client

3. Make sure the goal statement is appropriate for the NG. Dx and those outcome criteria are appropriate for goal

4. Make sure the client considers the goals important and values them.5. Ensure that the (goals) (client) goals and outcome criteria are compatible

with the word and therapies of other professionals6. Make sure that each goals is derived from only on NG Dz7. When writing outcome criteia, use observable, measurable terms (smart)

III. PLANNING NG STRATEGIES:1. generating alternative nursing strategies

a. brainstormingb. Hypothesizing c. Extrapolating

2. considering the consequences of each strategies3. choosing nursing strategies

IV. WRITING NURSING ORDERS:

5 components:1. date2. action verb

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3. time element4. signature

Relationship of OC Vs CG

1. OC- outcome criteria are derived from and relate to the client goals CG from 1st clause of the Ng Dx

Ng Dx- POTENTIAL IMPIARED SKIN INTERITY r/t imposed bed rest.Client goal- maintain intact ski, particular over bony prominenceOutcome Criteria- demonstrate correct techniques for positioning and turning

Note: 3-6 outcome criteia are neede to each goalCharacteristics of a well stated outcome criteria:

1. each outcome criteria related to the established goals2. the outcome stated in the criteria is possible to achieve3. each criteria is a specific and concrete as possible, to facilitate

measurement4. each criteria is appraisable or measurable

V. WRITING NCP

NCP- is a guide that organizes information about a Client’s health into a meaningful whole

Format: 4 columns or categories

1. Ng. Dx or problem list2. Goals3. Ng. Strategies/ interventions/ orders4. Outcome or evaluation criteria

Ng. Dx Goals Ng. Orders Outcome criteriaFears r/t cardiac catherterization, possible heart surgery and its outcome

Experience increased emotional comfort and feelings of control

Establish a trusting relationship with the client and family to express feelings and concern discuss the cardiac cath procedure and what is expected of him before and after the procedure

Verbalizes specified concerns communicate thoughts clearly and logically facial expressions, voice tone, and body posture correcpond to verbal expressions and increased emotional comfort after instruction, describe cath procedure and what is expected of him.

CONSULTING- is deliberating between 2 people

7 steps:

1. identify the problem2. collect pertinent data about the client3. select the consultant4. communicate the problem

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5. discuss the recommendation with the consultant6. include the recommendations in the client’s NCP

Discharge Planning- the process of anticipating and planning for needs after discharge form a Hospital or other facility.

IMPLEMENTING- Intervening- putting the nursing strategies listed in the hrsing care plan into action

by: Belucheck and Mc CloskeyNursing Intervention- an autonomous action based on scientific rationale that is executed to benefit the client in a predicted way related to the Nursing diagnosis and stated goals.

TYPES OF NURSING ACTIONS:

1. Independent Nursing Action- an activity that the nurse initiates as a result of the nurses own knowledge and skill autonomous nursing practice.Taxonomy- is a set of classification that are ordered and arranged on the basis of a single principle or consistent set of principle.

2. Dependent Nursing Action- are those activities carried out in the order of the physician, under the physicians supervision or according to specified routines.

3. Interdependent Interventions- is completed with our without a physicians order or is written at a nurse suggestion

COLLABORATION- a ture partnership, in which power on both sides in valued by both, with recognition and acceptance of separate and combined spheres of activity and responsibility, mutual safe guarding of legitimate interests of each party and a commonality of goals that is recognized by both parties.

PROTOCOLS- is a written plan specifying the procedure to be followed in a particular situation.

STANDING ORDER- is a written document about policies, rules, regulations or orders regarding client care.

6 COMPONENTS OF IMPLEMENTING

1. Reassessing the client- focuses on more specific needs- N- determine whether planned nursing strategies are appropriate for the client.

2. Validating the NCPN reviews the NCP in 4 areas:a. safetyb. appropriatenessc. effectivenessd. individualize nursing careto validate the plan- to request another appropriate professional and patient iif possible to give plan approved or implementation

3. Determining the Needs for Assistance2 Reasons:

a. the N unable to implement the nursing strategies safety aloneb. the N lack the knowledge or skills to implement a particular nursing

activity

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4. Implementing Nursing Strategies- to help the client meet his/her health goals

4 Areas of Nursing Practicea. health promotionb. health maintenancec. health restorationd. care of the dying

6 Important Consideration for Implementing

1. The client’s individuality 2. The client’s need for involvement3. Prevention of Complication4. Preservation of body’s defenses5. Provision of comfort and support to the client6. Accurate and careful implementation of all nursing activities

5. Communicating Nursing Actions:Written and Verbal

IMPLEMENTING ACTIVITIES:3 important skills:

a. cognitive (intellectual skills)b. interpersonal skillsc. technical skills

IMPLEMENTING ACTIVITIES1. Caring2. Communicating3. Helping4. Teaching5. Counseling6. Client advocate

GUIDELINES FOR IMPLEMENTING NURSING STRATEGIES1. Nursing action are based on scientific knowledge2. Nursing actions resulting from a physicians order must be understood by the

N3. Nursing actions are adapted to the individual4. Nursing actions should always be safe5. Nursing actions often require teaching, supportive and comfort components6. Nursing actions should be holistic7. Nursing action should respect the dignity of the client and enhance client’s

self-esteem8. The client’s active participation in implementing nursing actions should be

encouraged as health permits.

EVALUATING

To evaluate- to identify whether or to what degree to client’s goals have been met

6 Components

1. Identifying Outcome Criteria2 purposesa. establish the kind of evaluation data that need to bo collectedb. provide a standard against which data are judged

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2. Collecting Data- observation- direct communication- purposeful listening/ reports

3. Judging Goal Achievement4. relating Nursing Action to Client Outcomes5. Reexamining the client’s care plan

- database- diagnostic statement- goal statements- nursing strategies

6. Modifying the care plan

3 alternative on how well a goal was meta. Goal met- if the patient was able to demonstrate the behavior by the

specific time on dateb. Goal Partially Met- if the patient was able to demonstrate the behavior but

not as well as the N had specified in the goal statementc. Goal Not Met- if the patient was unable or willing to perform the behavior

at all

Example:

Nursing Diagnosis- Activity intolerance related to prolonged bed restGoal Statement- Patient will walk length of hall and abck by 7/29\Goal Evaluation- (done on 7/29 or earlier)Goal Achieved- Patient walked length of hall but not too tired to walk backGoal partially achieved- Patient walked length of hall but too tired to walk backGoal not Achieved- Patient refused to walkGoal Not Achieved- Patient unable to bear his own weight

EVALUATING QUALITY OF NURSING CARE

- is essential part of professional accountability- other terms: QUALITY ASSESSMENT- examination of services

QUALITY ASSURANCE- implies that efforts are made to evaluate and ensure quality health care

APPROACHES TO QUALITY EVALAUTION

1. the structure to which client care takes place2. The process of care- activity of the nurse

How:- talking with the client- auditing client’s record- observing the nursing activities

3. Outcomes of care- clients change in behavior toward goal achievement prior to discharge (concurrent audit)- client record- reviewed (retrospective audit)

TOOLS AND METHODS USED:

Steps:1. Defining and clarifying the nature of nursing2. Deciding what approach to take3. Developing standards and criteria4. Testing criteria

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