Nursing Process - a systematic, problem solving method for providing individualized care for clients in all states of health

- unifying concept of nursing - first introduced by Lydia hall in 1955 - During the late 1950s and early 1960s Dorothy Johnson, Ida Orlando and Ernestine Weidenbach introduced a 3- step model - In 1969 Dolores Little and Doris Carnevali used a 4-step method - By 1973 the American Nurses Association (ANA) describes the 5 step method that is now being used up to the present time. - In 1982 the NCLEX examination were revised to include the nursing process as one of the organizational concepts - The Joint Commission on Accreditation of Healthcare Organizations (1994) requires the nursing process method as a means for documenting all phrases of client care

5 STEPS OF THE NURSING PROCESS 1. Assessment 2. Diagnosis (Nursing Diagnosis) 3. Planning 4. Implementation/ Intervention 5. Evaluation Assessment - First step of the nursing diagnosis - Nurse systematically gathers, verifies and communicates data about the client to establish a data base - Collecting, validation, sorting and organizing and finally documenting the data in an organized format a. data Collection - subjective and objective data b. Data Validation c. Data Clusterng d. Data Documentation Nursing Diagnosis - a statement that describes the clients actual or potential response toa health problem that the nurse is licensed and competent to treat. a. Analysis and interpretation of data b. Identification of Problems c. Formulation of Nursing Diagnosis NANDA PES

Planning - client-centered goals are established and strategies are designed to achieve goals - after formulating specific nursing diagnoses, the nurse establishes the priorities of the diagnoses by ranking them in order of importance Types of Goals: a. Short-term less than a week b. Long-term over weeks or months S M A R T criteria Implementation/ Intervention - actions by the nurse that implements the nursing care plan or any specific objective of plan Types of Interventions: a. Independent b. Dependent

Evaluation - clients response to nursing interventions and the clients toward achieving goals Steps in evaluation: 1. Examine the goal statement 2. Assess the client for presence of response 3. Compare goal to the response 4. Judge the degree of achievement between the goal and the response If clients response matches or exceeds the goal = goal is met If it shows changes but does not fully met the goal criteria = goal is partially met If ther is no progress = goal is not met ** Positive evaluation ** Negative evaluation Assessment Purpose: To gather, verify and communicate data so that database is established Steps: 1. Collecting nursing history

2. Performing physical examination 3. Collecting laboratory data 4. validating data 5. Clustering Data 6. Documenting data Nursing Diagnosis Purpose: To identify client health carer needs and responses to health problems so as to direct nursing care Steps: 1. Identify client problems 2. Formulating nursing diagnosis 3. Documenting nursing diagnosis Planning Purpose: To identify client goals: to determine priorities of care, to determine expected outcomes, to design nursing strategies to achieve goals of care Steps: 1. Identify client goals 2. Establishing expected outcomes 3. Selecting nursing actions 4. Consulting 5. Delegation of actions 6. Writing a nursing care plan

Implementation/ Intervention Purpose: To complete nursing actions necessary for accomplishing plan Steps: 1. Performing nursing actions 2. Reassessing client 3. Reviewing and modifying existing care plan

Evaluation Purpose: To determine extent to which goals of care have been achieved Steps: 1. Comparing client response to expected outcome 2. Analyzing reasons for results and conclusions 3. Modifying nursing care plan