The Nursing Process

Resources

Andrea Ackermann, Mount St. Mary College, Critical-thinking-the-nursing-process 2001.

http://www.umanitoba.ca/nursing/courses/128,(2005)

Sara-jo Wiscombe, Nursing Process ,Wallace Community College ,May 22,2001.

Tucker C, MODULE A INTRODUCTION TO NURSING Process, August 21, 2002 .

The Nursing Process

An organizational framework for the practice of nursing

Orderly, systematicCentral to all nursing careEncompasses all steps taken by the

nurse in caring for a patient

Definition of the Nursing ProcessAn organized sequence of problem-

solving 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

The Nursing Process Utilizes The Following

AssessmentNursing DiagnosisPlanningImplementationEvaluation

Characteristics of the Nursing ProcessWithin the legal scope of nursingBased on knowledge-requiring critical

thinkingPlanned-organized and systematicClient-centeredGoal-directedPrioritizedDynamic

Benefits of using the nursing process Continuity of care Prevention of

duplication Individualized

care Standards of care

Increased client participation

Collaboration of care

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”

MARTHA ROGERS, NURSE THEORIST

“When an apple is cut, others see seeds in the apple. We, as nurses, see apples in the seeds.”

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/non-judgmental….

Critical Thinking Critical thinking in nursing is an essential component of professional

accountability and quality nursing care.

Critical thinking is careful, deliberate, and goal directed.

Assessment of Well-Being

According to the World Health Organization is well-being in these domains:EmotionalPhysicalSocialSpiritual

Lets Get Started :

Nurse collects background info from previous charts

Ensure environment is conducive Arrange seating Allow adequate time Nurse introduces self Identifies purpose of interview Ensure confidentiality of information Provide for patient needs before starting

TYPES OF INTERVIEWS

DIRECTED NON-DIRECTED

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

ASSESSMENT

Observation Interview

Types of questionsEnvironment (physical and

emotional) Spiritual conciderations

Examination

Types of Data To Collect:Objective data-observable and

measurable facts (Signs)Subjective data-information that only

the client feels and can describe (Symptoms)

CULTURAL DIVERSITY

MUST PROVIDE CARE CONGRUENT WITH A CLIENT’S EXPECTATIONS

“This is not about you” ? Respect INDIVIDUAL’S DIFFERENCES,

What is the significance of the problem or illness to the client?

What does it mean in the family/community?

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

Resources

Client Other individuals Previous records Consultations Diagnostics studies Relevant literature

Assessment

Data base assessment – 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.

Sources of DataPrimary source: ClientSecondary source: Client’s family,

reports, test results, information in current and past medical records, and discussions with other health care workers

Disease Prevention

Primary prevention – protection from a disease while still in a healthy state.

Secondary prevention – early detection and treatment of disease.

Tertiary prevention – prevent complications and to maintain health once the disease process has occurred.

Verifying Data

Essential in critical thinking!!!!! Measurable data Double check personal observations Double check equipment Check with experts and team members Recheck out-liers Compare objective and subjective data Clarify statements

Planning

Establish the goals, interventions and outcomes

General Guidelines for Setting Priorities

1. Take care of immediate life-threatening issues.

2. Safety issues.3. Patient-identified issues.4. 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 patient’s 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 patient’s 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

Road maps directing the best ways to provide nursing care.

Evidence based nursing.

1. Monitor health status.

2. Minimize risks.

3. Resolve or control a problem.

4. Assist with ADLs.

5. 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 DiagnosisHealth issue that can be prevented,

reduced, resolved, or enhanced through independent nursing measures

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:

1. Prioritized nursing diagnostic statements.

2. Outcomes.

3. Interventions.

Documentation

Clear and concise Appropriate terminology

Usually on a designated form Physical assessment

Usually by Review of Systems• Overview of symptoms• Diet• Each body system

Documentation

Use patient’s own words in subjective data – enclose in “ ___” (quotation marks)

Avoid generalizations – be specific Don’t make summative statements –

describe - e.g. patient is being ornery should be patient resists instruction or patient states “Don’t talk to me, I don’t care about that”

Evaluation

1. Determining outcome achievement

2. Identifying the variables affecting outcome achievement

3. 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 StatementsName of the health-related issue or

problem as identified in the NANDA listEtiology (its cause)Signs and SymptomsThe 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 Problems-Nurse’s 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 DiagnosisJudgment or conclusion about the risk for—

or actual—need/problem of the patientNANDA format

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

PlanningThe 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 PrioritiesDetermine problems that require

immediate actionMaslow’s Hierarchy of Human Needs

Short-Term GoalsOutcomes achievable in a few days or

1 week Developed form the problem portion of

the diagnostic statementClient-centeredMeasurableRealisticAccompanied by a target date

Long-Term GoalsDesirable outcomes that take weeks

or months to accomplish for client’s with chronic health problems

The Nursing Process

PlanningIdentification of goals and outcome criteriaPrioritizationTime frame

Selecting Nursing InterventionsPlanning 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 PlanThe nurse shares the plan of care with

nursing team members, the client, and client’s family.

The plan is a permanent part of the record.

EvaluationThe way nurses determine whether a

client has reached a goal. It is the analysis of the client’s

response, evaluation helps to determine the effectiveness of nursing care.

The Nursing Process

EvaluationOngoing part of the nursing processDetermining the status of the goals

and outcomes of care

Monitoring the patient’s response to drug therapy

Documentation

Clear and concise Appropriate terminology

Usually on a designated form Physical assessment

Usually by Review of Systems• Overview of symptoms• Diet• Each body system