NURSING PROCESS

Claudette McGregor-Coombs, MSN, ARNP

Nursing Process

The nursing process is a framework for providing professional, quality nursing Care.

It directs nursing activities for health promotion and disease prevention.

NURSING PROCESS

The nursing process is a series of steps that lead to accomplishment of goals or purposes.

The nursing process is designed to be used with clients throughout their life span.

The nursing process is not linear, but lead to overlapping steps.

Nursing ProcessThe nursing process is a systematic

problem-solving process that guides nurses in the provision of goal-directed, client-centered care.

It consists of six phases:1.Assessment. 4. Planning

interventions2.Diagnosis 5. Implementation3.Planning Outcomes 6. Evaluation.

NURSING PROCESS

NURSING PROCESS

An organized, systematic method of delivering goal oriented, humanistic care that is both effective and efficient.

R. Alfaro-Le Fevre

Nursing Process

1. Encountering a problem– data collection

2. Analyzing data 3. Plan of action 4. Putting into action 5. Evaluation

THE NURSING PROCESS

determines the need for patient

care

allows for planning, implementation and evaluation

THE NURSING PROCESS IS:

Purposeful

Systematic

Dynamic

THE NURSING PROCESS IS: (Characteristics)

Interactive

Flexible

Theoretically based

PURPOSE OF THE NURSING PROCESS…

Provide a framework within which the individual, family & community needs can be met.

NURSING PROCESS

Influenced by the nurse’s:

a. beliefs b. knowledge c. skills

NURSING PROCESS IS BASED ON:

PRINCIPLES

RULES

PRINCIPLES AND RULESTHE APPLICATION OF THESE

PRINCIPLES PROVIDE NURSES WITH ESSENCIAL TOOLS NEEDED TO:

assess, identify & solve problems…

NURSING PROCESS

THE AMERICAN NURSES ASSOCIATION STANDARDS OF PRACTICE INCLUDED DIAGNOSING AS A FUNCTION OF PROFESSIONAL NURSING. (1973)

Standards of PracticeThe American Nurses Association

(ANA,2004) revised practice standards outlined the steps for the nursing process as:1.Assessment.2.Diagnosis3.Outcome identification and planning.4.Implementation5.Evaluation.

Assessment

Assessment is defined as the use of a systematic and ongoing process to:

Collect data. Categorize data. Validate data. Record data.

Assessment

Methods of assessment:1.Inspection.2.Palpation.3.Auscultation4.Percussion.

Inspection

Palpation

Auscultation

Percussion

NURSING PROCESS

Assessment:

1. Objective data

2. Subjective data

Objective Data

Objective data are observable and measurable.

They are obtained through physical examinations and diagnostic tests.

Subjective Data

Subjective data is information provided in relation to a condition by the patient, spouse, caregiver or paramedics.

ASSESSMENT:

GATHERING AND

EXAMINING DATA

Assessment

Methods of data collectionObservation.Interview.Health History.Physical Examination.

Data Organization

Data is organized into clusters. Clusters are groups of related signs/symptoms.

Clusters also can be formed by

organizing data based on strengths and weaknesses.

DIAGNOSING:

ANALYZING DATA TO IDENTIFY ACTUAL OR POTENCIAL PROBLEMS

Diagnosis

Diagnosis is the science or art of identifying problems or conditions based on certain features or presentations.

Nursing Diagnosis

Nursing Diagnosis was formulated by the North America Nursing Diagnosis Association ( NANDA).

The definition of a Nursing Diagnosis evolved over time.

In 1994 NANDA revised the nursing diagnosis and provided a description for Nursing Diagnosis.

Nursing Diagnosis

Example: Ineffective tissue perfusion ( cardiac)

r/t Coronary ischemia AEB chest pain, shortness of breath and pain.

Nursing Diagnosis

A nursing diagnosis is a statement that describes a clinical judgment about individual, family and community’s

( health-state or actual/potential altered interaction pattern).

It provides the basis for selecting interventions.

Sample Two-Part Diagnostic Statement

Problem Related to Etiology

Constipation Related to Prolonged laxative use

Severe anxiety Related to Threat to physiologic integrity; possible cancer diagnosis.

Nursing Diagnosis ( Two-Part Statement)

Component of a Nursing DiagnosisDiagnostic label or NANDA statement (or

concept) describes the patient’s responses.

Related factor ( Etiology/contributing factor).

Example: Fluid volume deficit related to frequent watery stools.

Nursing Diagnosis (Three-Part Statement)NANDA STATEMENT( problem)

Related to Etiology Manifestations

Fluid volume deficit

Related to Frequent urination

Thirst, dried skin

Nursing Diagnosis (Three-Part Statement)

Diagnostic label or NANDA statement ( or concept).

Related Factors.AEB ( defining characteristics).

Example: Fluid volume deficit related to frequent urination AEB thirst, dry skin.

Nursing Diagnosis

In order to formulate nursing diagnoses, subjective cues and objective cues must be organized in clusters.

Clue clusters are groups of conditions or manifestations that represent known health problem or situation.

For example: A sneeze, runny nose and a cough usually indicate respiratory disorder.

Examples of clue Clusters.

Condition/ NANDA Clue clusters (Objective)

Clue Clusters ( Subjective)

Possible dehydration Dried, pale mucus membrane, dry skin, poor skin turgor, decreased urine output

Daughter states , “my mother is always thirsty.”Patient states, “ I am drinking a lot.”

Fluid volume deficit Frequent loss stools, decreased urine output.

Patient states, “ I am urinating every 30-60 minutes

PLANNING:

SETTING GOALSPLAN OF ACTION.

IMPLEMENTATION:

PUTTING THE PLAN INTO ACTION AND OBSERVING INITIAL RESPONSES.

EVALUATION:

DETERMINING IF THE PLAN HAS

WORKED, MAKING NECESSARY

CHANGES.

STEP 1 : ASSESSMENT

ESTABLISHES THE DATA BASE:

NURSING HISTORY PHYSICAL

ASSESSMENT REVIEW OF CLIENT

RECORD

HEALTH CARE CONSULTATIONS

CONTINIOUS UPDATE OF DATA BASE

DATA VALIDATION COMMUNICATION

ASSESSMENT TOOLS

COMMUNICATION

INTERVIEW

SCIENTIFIC KNOWLEDGE

ASSESSMENT TOOLS

MEDICAL/SOCIAL KNOWLEDGE

NURSING KNOWLEDGE

PHYSICAL ASSESSMENT SKILLS

APPLICATION OF THE NURSING PROCESS

ASSESSMENT TECHNIQUES

INSPECTION

PALPATION

AUSCLUTATION

PERCUSSION

TIPS

3 S’s : Size, shape, symmetry

3 C‘s: Color, Contour, consistency

REVIEW: Steps of the Nursing Process

1. Assessment

2. Diagnosis

3. Planning

4. Implementation

5. Evaluation

AssessmentNursing assessment is a two-step

process. It includes: Collection and verification of data from a

primary source (a client) and secondary sources ( family, caregivers and health professionals).

The analysis of all data is a source for developing nursing diagnoses, identifying collaborative problems and develop a plan of care. ( Carpenito-Moyet, 2005).

Nursing Diagnosis

The Nursing Diagnosis provides the basis for selection of nursing interventions to achieve outcomes.

Nursing Diagnoses are a clinical judgments about an individual, family or community actual or potential health problem.

Planning Nursing Care

Nursing care is provided based on priority.

Prioritizing nursing care is accomplished through arranging actual/potential health problems in the order of severity or physiological importance.

Implementation

Implementation is the initiation of activities that will cause a positive change, or desired outcome in the identified nursing problem.

An example of implementation is administering an antipyretic to reduce fever.

Evaluation

Evaluation is determining if nursing goals are attained, based on the care implemented. The main question, “are the expected outcomes achieved?

Evaluation in nursing is a continuous process.

Identify Phases of Nursing Process:

1. Analyzing & interpreting data

2. Initiating nursing interventions

3. Performing a physical examination

4. Determining outcomes with patient

Cont.

5. Revising plan of care

6. Interviewing the client

7. Writing a nursing diagnosis

8. Outcomes achieved?

Cont.

9. Developing interventions to achieve outcomes

10. Recording care

11. Developing a plan of care

Critical Thinking ExampleMs X is brought to the emergency department

be her daughter. The daughter states, “ my mother is having diarrhea x 3 days, she is weak and has a fever. Upon assessment the nurse finds that the patient has:

T 102, P122, R22, BP 92/56, dry skin and dry mucosa.

1. What could be the problem?2. What do you assess?3. What are your interventions?

Format of the Critical Thinking Exercise

I. What are the possible problems based on a given scenario.

11. What would you assess ( based on the patient’s clinical presentation in the scenario).

III. What would you do. What are your priority interventions.

Nursing Care Plan Scenario

Ms X is brought to the emergency department be her daughter. The daughter states, “ my mother is having diarrhea x 3 days, she is weak and has a fever. Upon assessment the nurse finds that the patient has:

T 102, P122, R22, BP 92/56, dry skin and dry mucosa.

Format of the Nursing Care Plan Exercise

Assessment: 1. Subjective Data. 2. Objective Data.Nursing Diagnosis a.Two-part – Dehydration r/t excessive

fluid loss. Or b. Three-part – Dehydration r/t excessive

fluid loss AEB dried mucosa, dried skin and decreased urine output.

Format of the Nursing Care Plan Exercise (cont’d)

Expected Outcomes. ( Statement starting with patient will….. This statement must be measurable, feasible and timed).

Format of the Nursing Care Plan Exercise ( cont’d).

Interventions:1. What would you assess.2. What would you do. ( Prioritize)3. What would you teach.