Nursing process

OBJECTIVES By the end of this lecture, the postgraduate student will be able to understand the following: 1. Identify nursing process 2. Explain characteristics of the nursing process 3. Discuss the components of nursing process

Out lines: 1. Over-view. 2. Definition of nursing process 3. Characteristics of the nursing process 4. Components of nursing process

Back Ground
The 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, and not about nursing goals. The nursing process is an essential part of the nursing care plan.

Definition of nursing process: Nursing process is a systematic method of planning, delivering, and evaluating individualized care for clients in any state of health or illness. Based on the scientific problem-solving method, it constitutes the foundation for nursing practice

Characteristics of the nursing process:

1- cyclic with each phase leading logically to the next. Each phase is dependent on the accuracy of the preceding one. For example, appropriate nursing diagnoses cannot be identified without accurate assessment data.

2- purposeful and goal-directed. That goal is to provide quality, individualized, clientcentered care.

Cont.
3- dynamic to meet the ever changing needs of the client.
4- interactive because it involves the interpersonal relationships between the nurse and the client, family, significant others, and other health team members.

Cont.
5-theoretically based The nurse must incorporate knowledge of the sciences and the humanities from many areas in order to deliver holistic care, that is, to meet the total needs of the client.

6- flexible can be used effectively in any health care setting. It is appropriate for use with individual clients, families and communities. It can be used with the acutely or chronically ill

Components of nursing process:

1-Assessment
First step of the Nursing Process Gather Information/Collect Data The purpose of assessment 1. to collect adequate data 2. to identify current problems 3. to determine nursing diagnoses, 4. to establish priorities, 5. to plan appropriate interventions. 6. provides and opportunity for nurse/client interaction and the beginning of a therapeutic relationship.

Source of information: 1. Primary Source - Client / Family 2. Secondary Source Medical records, nursing history, team members, lab reports, diagnostic tests..

Methods of data collection

1-Interview should be conducted as soon as possible after the initial contact with the client. introduce yourself and explain the purpose of the interview. Assure the client that all information is confidential and direct all questions to the client. create an atmosphere that will promote the development of a therapeutic nurse-client relationship. begin to focus in order to obtain the necessary information. such areas as past medical history, family history, and religious and cultural information

2-Observation
In making observations, use sight, hearing, smell, and touch. To be most useful, observations must first be scientific; that is, they must be Objective and based on knowledge of the biological, physical,and social sciences. Systematic: Systematic observation involves the use of the senses to obtain information about the client, his environment, significant others, and the interaction of all these factors.

3-Physical assessment

The physical assessment will yield necessary Four techniques are used: inspection, palpation, percussion, and auscultation

Type of data objective data (what you observe, measure) (sign) subjective data (what the client states regarding his health status). (symptom)

2- Nursing Diagnosis

is clinical judgment about individual, family, or community responses to actual or potential health problems processes. it is providing the basis for selection of nursing interventions to achieve outcomes for which the nurse is accountable.

Elements of a nursing diagnosis statement

Nursing diagnosis = problems + its etiology or cause (if known) A-The Problem:patient is experiencing or may experience . There are five types of problems. 1. Actual: Problem present at the time of the assessment Examples: Alteration in nutrition, less than body requirement.

2. Risk/High Risk: a problem which may develop in the future due to the presence of certain risk factors. Examples: Risk for fluid volume deficit related to prolonged vomiting.
3. Possible: a problem which may exist, but additional data is needed to confirm its presence. Example: Possible self-care deficit related to IV in right hand

4. Wellness: Is a diagnostic statement that describe the human response to levels of wellness in an individual, family, or community that have a potential for enhancement to a higher state (NANDA, 2005).
Wellness nursing diagnosis are one part statement includes diagnostic label.

Example Readiness for enhanced spiritual well being - Readiness for Enhanced Self-Esteem.

5. Syndrome:

this type of diagnosis is a combination or group of actual or high-risk nursing diagnoses that all relate to a certain event or situation. These diagnoses are usually one-part statements that actually include the etiology and contributing factors in the actual diagnostic statement Example: (risk for disuse syndrome)

 B-Cause of Etiological Factors

The second element of the nursing diagnosis statement consists of the cause or etiology, contributing factors, or risk factors . It is preceded in the nursing diagnosis statement by the phrase related to. Example: Incorrect: Ineffective airway clearance related thoracotomy. Correct: Ineffective airway clearance related to incisional pain secondary to thoracotomy

The Three-Part Statement

As in the two-part statement, the first two components are the problem and the etiology. The third component consists of defining characteristics (collected data that are also known as signs and symptoms, subjective and objective data, or clinical manifestations). Example: Ineffective airway clearance related to incisional pain as evidenced by poor cough, patient complains of increased pain when coughing.

Writing nursing diagnoses

In 1973 the ANA mandated the use of nursing diagnosis in nursing practice. the North American Nursing Diagnosis Association (NANDA) was established as the formal body for the promotion, review, and endorsement of the current list of nursing diagnoses used by nurses in practice. Every two years NANDA meets to consider revisions and additions.

3-Planning
It is deciding which actions will be used to help solve, lessen, or minimize the effects of the identified problems, or to prevent potential problems. There are four essential steps in the planning process: Prioritizing the identified nursing diagnoses. Developing goals/outcome statements. Planning nursing actions. Documentation-the Nursing Care Plan.

a) Prioritizing
After nursing diagnoses have been formulated, they must be ranked in order of priority. the RN must consider the needs of the client, the resources available, and the time constraints. Maslow: 1- Physiological: highest priority and are necessary for survival, oxygen, fluid, nutrition, Temperature. Example: Fluid volume deficit related to prolonged vomiting and diarrhea.

2. Safety and security needs: These include the need for both physical and psychological security. Example: Potential for injury related to disorientation.
3. Love and belongings: These are needs for friendship, social relationships, family, love, and sexual love. Example: Alteration in family processes related to effects of hospitalization of mother. 4. Self-esteem: This includes the needs for selfconfidence, usefulness, achievement, and self-worth. Example: Powerlessness related to immobility.

5. Self-actualization: This is the state of having fully achieved ones potential and having the capability to cope with lifes situations and solve problems. Self-actualization needs are meeting personal goals; order, harmony, truth, beauty, privacy, spirituality.

Example: Spiritual distress related to discrepancy between spiritual beliefs and Prescribed treatment. The hierarchy of needs is a theory and is generally true for people, but is not necessarily true for all persons.

b)Developing Goal/Outcome Statements

The second step in the planning phases Is details specific statement that describes the methods through which the goal will be achieved.

Goals may be either Short term goals are those which can be achieved fairly quickly, within hours or days. Long term goals cover a longer period of time and often require weeks or months to be achieved.

c) Planning Nursing Action

The nursing interventions identify what the nurse is to do to reduce, resolve, or prevent each of the problems expressed in the nursing diagnoses.

Guidelines 1. Put safety first! Remember that nursing actions must be safe. 2. Individualize the nursing actions for each client and be sure they are appropriate to the expected outcome for that particular client. 3. Base nursing actions on scientific rationale

4- State nursing actions clearly and specifically so that they may be interpreted in the same way by all nurses responsible for the clients care. 5. Make nursing actions realistic for: The client based on his/her limitations, age, developmental level, preferences, etc. The nurse based on his/her knowledge and capabilities. resources available (equipment, personnel)

6-Do not let nursing actions interfere with other therapies the client is receiving. 7. Whenever possible, involve the client in planning the nursing actions. Strive to help the client understand how nursing actions will result in achievement of a goal.

4-Implementation
During implementation, all the previous phases of the nursing process are integrated.

Preparation for implementation 1. Review the plan and validate with the client and other health team members that the plan is appropriate for the clients current health status. 2. Assess knowledge and skills which are needed to implement the plan. If knowledge or skills are lacking, you may choose to refer the plan to someone else or request assistance from other staff members.

3- Prepare the client. Explain the nursing actions, their purposes, and the clients role.

4. Prepare the environment in terms of space, lighting, equipment, and resources.

Action Guidelines Prior to performing any nursing action, always reassess the status of the client and determine whether the interventions are still appropriate. Before performing any nursing action, identify the rationale, expected results and possible side effects of the activity.

 When performing nursing activities, include the client and family as much as possible Provide a safe and therapeutic environment for delivery of nursing care. When implementing nursing interventions, refer to the institutional protocols and procedures to ascertain the appropriateness of the interventions

Documentation When interventions are completed, you must document the care appropriately, noting the specific actions along with the clients response. Documentation is essential in monitoring the clients progress toward achievement of goals/expected outcomes, and to assure continuity of care. Documentation of nursing care is a legal requirement of all health care systems.

5-Evaluation
It defined as planned, systematic comparison of the clients health status with the goals

The major purposes of evaluation are to: 1. Evaluate the status of the client 2. Determine the clients progress toward achievement of the stated goals/expected outcomes. 3. Judge the effectiveness of the nursing orders, strategies, and care plan.

Example Nursing diagnosis: Fluid volume deficit related to fluid loss associated with vomiting.
Expected outcome: The client will resume and maintain normal fluid balance by discharge as evidenced by: 1. normal skin turgor 2. moist mucous membranes 3. stable weight 4. BP and pulse within normal limits and stable with position change 5- urine specific gravity between 1.010 and 1.025. 6. absence of lethargy, confusion, excessive thirst.

Evaluation: On discharge, patient has normal skin turgor, mucous membranes are pink and moist. The patients weight has stabilized at 150# which is 5# less than normal weight. Vital signs are within normal limits. Urine specific gravity is 1.020-1.025. Patient is alert and oriented, with appropriate thirst.

When determining whether a goal has been achieved, the nurse can draw one of the three possible conclusions: The goal was met, that is the client response is the same as the desired outcomes.

The goal was partially met, that is either a short term goal was achieved but the long term was not, or the desired outcome was only partially attained. The goal was not met.

When goals have been partially met or when goals have not been met, two conclusions may be drawn: The care plan may need to be revised, since the problem is only partially resolved OR The care plan does not need revision, because the client merely needs more time to achieve the previously established goals. So the nurse must reassess why the goals are not being partially achieved.