Nursing Process

Nursing Process the Historical

Perspective
• Lydia Hall the nursing theorist , was the first
used the term of nursing process in 1955 .
• The step of nursing process were legitimized
in 1973 when American Nursing Association
congress for nursing practice developed
standards of practice to guide nursing
performance
 Definition of Nursing Process
• Is a set of actions leading to a particular goal the
nursing process is an organized sequence of
problem-solving steps used to identify and to
mange the health problems of the client (see box
pg 18)
• The nursing process is the framework for nursing
care in all health care setting and when the nurse
follows the nursing process , client receives
quality care in minimal time and maximal
efficiency
Characteristics of the Nursing Process
• Seven characteristics for the nursing process:
• 1-Within the legal scope of nursing : most
state nurse practice acts define nursing as an
independent problem-solving role that
involves the nursing diagnosis and treatment
of human responses to an actual or potential
health problems
• 2-Based on knowledge : The ability to
identified and to resolve client problem
requires critical thinking which is objective
reasoning and analyzing in order to reach to a
valid conclusion , through critical thinking the
nurse can judge which action should be
collaborate with the physician or using
independent nursing intervention
• 3-Planned : The steps of nursing process are
organized and systematic one step leads to
the next step in an order sequence manner
• 4-Client-Oriented : the nursing process makes
it easier to formulate a comprehensive and
unique plan of care for each client , client are
expected whenever possible to actively
participate in their care
• 5-Goal-Oriented : United effort between the
client and the nursing team to achieve desired
outcomes
• 6-Prioritized : The nursing process provides a
focused way to resolve the problems that
represent the greatest threat to health
• 7-Dynamic : In other way the nursing process
is open to a change.
Description of the Nursing process
• Nursing process is a systematic method that
directs the nurse and the patient as together
they accomplish the following :
• 1-Assess the patient to determine the need
for nursing care
• 2-Determine nursing diagnosis for actual and
potential health problem
• 3-Identify expected outcomes and plan of care
• 4-Implement the plan or carry out the plan
• 5-Evalutes the plan
• The process provides a framework that
enables the nurse and the pt. to accomplish
the following :
• Systematically collect patient data (Assessing)
• Clearly identify pt. strength and actual and
potential problems (Diagnosing)
• Develop a holistic plan of care that specifies
the desired goals and expected outcomes
(Planning)
• Execute the plan of care (Implementing)
• Evaluates the effectiveness of the plan of care
in term of goal achievement (Evaluation)
 Steps of Nursing Process
1-Assessment
• Is the first step in nursing process is a
systematic collection of facts or data ,
assessment begins with the nurse’s first
contact with the client and continues as long
as a need for health care exists , during
assessment the nurse collect data or
information to determine areas of abnormal
function , risk factors that contributes to
health problems and client strength
 Characteristics of Data
• Purposeful ; when preparing for the data
collection the nurse identifies the purpose of
the nursing assessment
• Complete as much as possible , to understand
a patient health problem and to develop a
plan of care
• Factual , Accurate & Relevant data
• (Types of data pg 19 box)
 Types of Data
• Objective data ; Observable and measurable
data , facts are referred to as a Signs , OVERT
DATA
• Subjective data ; consist of information that
only the client feels and can describe as a
Symptoms , COVERT data
• Subjective can be perceived by the pt. family
friends…
 Sources of Data
• The primary source is the CLIENT
• Client’s family & Friends
• Reports
• Tests results
• Current information and past medical history
• Discussion with other health care workers
 Types of Assessment
• 1-Data base assessment : is an initial
information about the client’s physical ,
emotional , social and spiritual health , the
nurse obtain this type of data during
admission through the interview and physical
examination , these data help for comparing
all future data and provides the evidence used
to identified the client’s initial problems .
• The comparisons of ongoing assessment with
baseline data help determine whether the
client’s health is improving , deteriorating or
remaining unchanged
• 2-Focus assessment , information that provides
more details about specific problems and
expands the original data base for example if
during initial interview the client tells us that
the/she suffers from constipation so the nurse
starts to obtain data about diet , activity ,
medications , fluid…
• 3-Emergency assessment ; we focus on the
problem in order to save life
• Organization of data ; Interpreting data is
easier if information is organized , organization
involves grouping of information , the nurse
organize data based on knowledge and past
experiences they cluster related
•
 Components of Data Collection
• Include nursing history & physical assessment
• Nursing History ; considers as subjective data ,
we obtained nursing history through interview
phase of interview:
• Preparatory phase : before the nurse should
review the records of the pt. , ensure relax and
privacy , arrangement the distance setting such
as the nurse sit or place the chair at the right
angles about 3 to 4 feet far , bed raise 45degree
• Introduction phase : introduce each other
• Working phase ; collect the data not more
than 10 to 20 minutes
• Termination phase
• Physical assessment :
• objective collecting data from head-to-toe
 2-Diagnosing
• The second step in the nursing process is the
identification of health-related problem ,
diagnosis results from analyzing the collected
data and determining whether they suggest
normal or abnormal findings
• Nursing Diagnosis ; is a health issue that can
be prevented , reduced , resolved or enhance
through independent nursing measures it is
nursing responsibility
• Nursing diagnosis are categorized into five
groups : Actual , Risk , Possible , or Potential ,
Syndrome & Wellness (see box pg 21)
• NANDA : North American Nursing Diagnosis
Association .
• Diagnostic Statement : An actual diagnosis
statement contains three parts :
• 1-Name of the health-related issue or problem
as identified by NANDA list
• 2-Etiology its cause
• 3-Signs & Symptoms
• Link with RELATED TO and the signs and
symptoms are identified with the phrase AS
MANIFESTED (box pg 21)
• Risk , Risk for example : Risk for impaired skin
related to inactivity
• Possible , indicate uncertainty for example
possible sexual dysfunction related to anxiety
• Wellness potential for enhancement
• Collaborative Problems : are physiologic
complication that require both nurse and
physician prescribed interventions , the nurse
is specifically responsible and accountable for:
• Correlating medical diagnosis or medical
treatment measures with the risk for unique
complications
• Documenting the complication for which
clients is at risk
• Making pertinent assessments to detect
complications
• Reporting trends that suggest development of
complications
• Managing the emerging problem with nurse
and physician prescribed measures
• Evaluating outcomes
Unique Focus of Nursing Diagnosis
• Nursing Diagnosis Versus Medical Diagnosis the
medical diagnosis identifies diseases , whereas
nursing diagnosis focus on unhealthy responses
to health and illness
• Medical diagnoses describe problems for which
the physician directs primary treatment
whereas nursing diagnosis describe problems
treated by nurses within the scope of
independent nursing practice
• A medical diagnosis remains the same for as
long as the disease is present , whereas a
nursing diagnosis may change from day to day
as the patient’s responses change
• (Note : Photocopy example of Nursing
Diagnosis formulation)
 3-Planning
• Planning is the process of prioritizing nursing
diagnosis and collaborative problems
• Identifying measurable goals or outcomes
• Selecting appropriate interventions
• Documenting the plan of care
• Whenever possible the nurse consults the
client while developing and revising the plan
• Setting Priorities : it is important to determine
which problems need immediate attention
and this is can be done by setting priorities ,
priorities can be done by using Abraham
Maslow and ranking can be changed as
problems are resolved or new problems
develop
• Establishing Goals : goal expected or desired
outcome , writing a goal accompanied each
nursing diagnosis , what is important that the
goal statement or outcome contains the
criteria or objective evidence for verifying that
the client has improved , so the nurse may
identify short-term goal or long-term goal or
both
 Short-Term Goal
• Nurses uses short-term goals outcomes
achievable in a few days to one week happen
most often in acute care settings because
most patients stay no longer than one week
• Short term goals has the following
characteristics :
• Developed from problem portion of the
following diagnostic statement
• Client-centered , reflecting what the client will
accomplish not the nurse
• Measurable , identifying specific criteria that
provide evidence of goal achievement
• Realistic
• Accompanied by a target date
 Long –Term Goal
• Desirable outcomes that takes weeks or
months to accomplish , usually with the
clients that has chronic health illness or
problems that require extended care in a
nursing home or who receive community
health or home health services such as CVA
 Goals for Collaborative Problems
• These goals are written from nursing rather
the client perspective , focus on what the
nurse monitor , report , record or to do early
promote detection and treatment , the format
for writing a nursing goal is : The nurse will
manage and minimize (identify complication)
by insert evidence of assessment ,
communication and treatment activities
• Example : pg 24 , box 2-6
• Box 2-7
 Selecting Nursing Intervention
• Planning the measures that the client and
nurse use to accomplish identified goals
involves critical thinking , nursing intervention
directed to eliminate the etiologies ,
interventions are selected based on
knowledge should be safe within the legal
scope of nursing practice and compatible with
medical orders.
 Documenting the Plan of Care
• Plan of care can be written by hand see pg 25
standardized forms , computer generated , or
based on agency’s , written standards or
clinical pathways all these should provide
general suggestions for managing the nursing
care of clients with a particular problem and it
is up to the nurse to transform the generalized
intervention into specific nursing orders and
to eliminate whatever is inappropriate
• Or unnecessary , whatever the Joint
Commission on Accreditation of Health
Organizations JCAHO requires that ever
client’s medical record provide evidence of
the planned nursing interventions for meeting
client’s need
• Nursing order directions for a client’s care ,
identify the what , when , where and how for
performing nursing interventions , provide
specific instructions so that all health team
members understand exactly what to do for
the client , nursing orders are also signed to
indicate accountability
• Standards for care , policies that indicate which
activities will be provided to ensure quality client care
 Communicating the Plan of Care
• Sharing the plan of care with nursing team
members , with the client and with the client’s
family members , plan of care is a permanent
part of the client’s medical record usually placed
in the client’s chart or at the client bedside or
located in a temporary folders at the nurses’
station for easy access , the assigned nurse should
refers to the chart daily , reviews it for appropriateness
and revises it according to changes in the client’s
condition
 Types of Nursing Intervention
• 1-Nurse-initiate intervention : is an
autonomous action based on scientific
rational that a nurse executes to benefit the
patient in a predictable way related to the
nursing diagnosis and expected outcomes
• Nursing intervention is performed by the
nurse to :
• Monitor health status
• Reduce risks
• Resolve , prevent or manage problem
• Facilitate independence or assist with
activities of daily living
• Promote optimal sense of physical ,
psychological and spiritual well-being
• Nurse-Initiate interventions do not require a
physician’s order
• In writing nurse-initiate interventions in plan of
care , each nursing intervention should include :
• Date *Verb : Action to be performed
• Subject : Who is to do it
• Descriptive phrase ; how , where , how long, how
much
• 2-Physican-Initiated intervention : is an
intervention initiated by physician , the nurse
response to a medical diagnosis , carried out by
the nurse in response to a doctor’s order
• Here the physician and the nurse are legally
responsible for the intervention and the nurse
should be knowledgeable about how to
execute the interventions safely and effectively
• 3-Collaborative Interventions ; nurses also
carry out treatment initiated by other
providers such as pharmacists or respiratory
therapies or by physician or physician
assistants
• Procedures : is a et of how-to action steps for
performing a clinical activity or task
• Standards of care ; a description of an acceptable
level of patient care or professional practice .
 Kardex Plans of Care
• Many health institutions and agencies use
Kardex care plan , the outside of the card
contains basic information such as the patient
profile , admitting diagnosis , activity level , diet
, routine treatment , medications and
procedures
• The inside of the Kardex contains the nursing
care plan specifying at every minimum nursing
diagnoses or health and related outcome .
 Computerized Plans of Care
• The benefits from using computerized plans
include :
• Ready access to a large knowledge
• Improve record keeping and improve and
ensure quality assurance
• Documenting by all healthcare team can
printout and this reduce time in writing on
paper
 4-Implementation
• Means carry out the plan of care carry out from:
See figure pg 25 , the medical record is legal
evidence that there is a correlation between the
plan and the care that has been provided , in
other word the nurse chart or notes
• Note : AFTER THE IMPLEMENTATION IS A
DOCUMENTATION
• NOT WRITTEN NOT DONE
• Nurses are just as accountable for carrying out
nursing orders as they are for physician orders
• Appropriate documentation maintains open
lines of communication among members of
heath care team
• Nursing Intervention , as any treatment based
upon clinical judgment and knowledge that a
nurse performs to enhance patient/client
outcomes .
• When carrying out plan of care nurses use
specialized abilities to :
• Determine the patient’s new or continuing
need for nursing assistance
• Promote self-care
• Assist the pt. to achieve valued health outcome
• To implement nurses need intellectual ,
interpersonal ,technical and ethical /legal skills
 5-Evaluation
• Is the way by which nurses determine whether
a client has reached a goal , evaluation helps
to determine the effectiveness of nursing care
the nurse and the client will see which activity
need to discontinue , added or changed , or
consulted an expertise and in nursing team
conference we evaluate the progress
• Goal is met , not or partially → go to planning