Nursing ProcessNursing Process

Back GroundBack Ground

The nursing process is based on a nursing theory The nursing process is based on a nursing theory developed by developed by Ida Jean OrlandoIda Jean Orlando. She developed this . She developed this theory in the late 1950's as she observed nurses in theory in the late 1950's as she observed nurses in action. She saw "good" nursing and "bad" nursing. action. She saw "good" nursing and "bad" nursing.

From her observations she learned that the patient From her observations she learned that the patient must be the central character. must be the central character. – Nursing care needs to be directed at improving Nursing care needs to be directed at improving

outcomes for the patient, and not about nursing goalsoutcomes for the patient, and not about nursing goals. .

– The nursing process is an essential part of the nursing The nursing process is an essential part of the nursing care plan. care plan.

Definition of the Nursing ProcessDefinition of the Nursing Process::

An organized sequence of problem-solving steps used to identify and to manage the health problems of clientsAn organized sequence of problem-solving steps used to identify and to manage the health problems of clients

A systematic, rational method of planning and providing individualized nursing care.A systematic, rational method of planning and providing individualized nursing care.

Purposes of Nursing ProcessPurposes of Nursing Process

1- 1- Identify a client health status and actual or Identify a client health status and actual or potential health care problems and needs.potential health care problems and needs.

2- Establish plans to meet the identifying needs.2- Establish plans to meet the identifying needs.

3- Deliver specific nursing intervention to meet 3- Deliver specific nursing intervention to meet needs.needs.

CharacteristicsCharacteristics a.a. SystematicSystematic

– The nursing process has an ordered sequence of activities and The nursing process has an ordered sequence of activities and each activity depends on the accuracy of the activity that each activity depends on the accuracy of the activity that precedes it and influences the activity following it.precedes it and influences the activity following it.

b.b. DynamicDynamic– The nursing process has great interaction and overlapping The nursing process has great interaction and overlapping

among the activities and each activity is fluid and flows into the among the activities and each activity is fluid and flows into the next activitynext activity

c.c. InterpersonalInterpersonal– The nursing process ensures that nurses are client-centered The nursing process ensures that nurses are client-centered

rather than task-centered and encourages them to work to rather than task-centered and encourages them to work to enhance client’s strengths and meet human needsenhance client’s strengths and meet human needs

d.d. Goal-directedGoal-directed– The nursing process is a means for nurses and clients to work The nursing process is a means for nurses and clients to work

together to identify specific goals (wellness promotion, disease together to identify specific goals (wellness promotion, disease and illness prevention, health restoration, coping and altered and illness prevention, health restoration, coping and altered functioning) that are most important to the client, and to match functioning) that are most important to the client, and to match them with the appropriate nursing actionsthem with the appropriate nursing actions

e.e. Universally applicableUniversally applicable– The nursing process allows nurses to practice nursing with well The nursing process allows nurses to practice nursing with well

or ill people, young or old, in any type of practice settingor ill people, young or old, in any type of practice setting

Benefits of Nursing ProcessBenefits of Nursing Process Provides an orderly & systematic method for planning & Provides an orderly & systematic method for planning &

providing care.providing care.

Enhances nursing efficiency by standardizing nursing Enhances nursing efficiency by standardizing nursing

practice.practice.

Facilitates documentation of care.Facilitates documentation of care.

Provides a unity of language for the nursing profession.Provides a unity of language for the nursing profession.

Stresses the independent function of nurses.Stresses the independent function of nurses.

Increases care quality through the use of deliberate Increases care quality through the use of deliberate

actions.actions.

5 Steps of the Nursing Process:5 Steps of the Nursing Process:

1.1. AssessmentAssessment

2.2. DiagnosisDiagnosis

3.3. PlanningPlanning

4.4. ImplementingImplementing

5.5. EvaluatingEvaluating

DiagnosisDiagnosis

11stst Step of the Nursing Process Step of the Nursing Process ASSESSMENT:

Is a systematic collection of facts or dataIs a systematic collection of facts or data

Types of Data

1. Objective data-observable and measurable facts (Signs)

Main way to collect objective data:Physical assessmentLab and diagnostic testingPatient record

AssessmentAssessment

2. 2. SubjectiveSubjective data-information that only the data-information that only the client feels and can describe client feels and can describe ((SymptomsSymptoms))

PrimaryPrimary source source - the client’s point of view, - the client’s point of view, Feelings, Perceptions, Concerns Feelings, Perceptions, Concerns

Usually BEST sourceUsually BEST source Main way to collect Main way to collect subjective datasubjective data::

– Interview with Family & significant othersInterview with Family & significant others When patient is a child or impaired adultWhen patient is a child or impaired adult Spouses Spouses Consider confidentiality when including Consider confidentiality when including

friends friends

Subjective VS. objectiveSubjective VS. objective

ExampleExample:: Patient comes to the ER because he cannot Patient comes to the ER because he cannot

move his arm, stating, “it happened about move his arm, stating, “it happened about an hour ago when headache got worse. Now an hour ago when headache got worse. Now I’m nauseated and dizzyI’m nauseated and dizzy”. (”. (SubjectiveSubjective))

The nurse takes his vital signs: T 37.9, P The nurse takes his vital signs: T 37.9, P 100, BP 170/95, and observes that he 100, BP 170/95, and observes that he cannot move his left arm and his face is cannot move his left arm and his face is flushedflushed. (. (objectiveobjective))

AssessmentAssessment Sources of DataSources of Data

– Primary sourcesPrimary sources ClientClient InterviewInterview Physical examination & vital signsPhysical examination & vital signs

– Secondary sourcesSecondary sources Family membersFamily members Other health care providersOther health care providers Medical recordsMedical records test resultstest results

AssessmentAssessment Step #1Step #1 InvolvesInvolves

– CollectingCollecting data (from variety of sources) data (from variety of sources)– ValidatingValidating the data the data

OrganizingOrganizing the data Grouping of related the data Grouping of related information information

Organization of assessment data into small Organization of assessment data into small groups to be analyzedgroups to be analyzed– InterpretingInterpreting the the datadata– DocumentingDocumenting the data the data

AssessmentAssessment Data CollectionData Collection

– Assessment involves taking vital signs (TPR BP & Pain Assessment involves taking vital signs (TPR BP & Pain assessment.assessment.

– Performing a head to toe assessmentPerforming a head to toe assessment

– Listening to the patient's comments and questions about his health Listening to the patient's comments and questions about his health statusstatus

– Observing his reactions and interactions with others. It involves Observing his reactions and interactions with others. It involves asking pertinent questions about his signs (observable) and asking pertinent questions about his signs (observable) and symptoms (Non-observable), and listening carefully to the answers. symptoms (Non-observable), and listening carefully to the answers.

Data CollectionData Collection

DemographicsDemographics Medical historyMedical history HabitsHabits Medications, allergiesMedications, allergies Environmental/familial factorsEnvironmental/familial factors Potential for injuryPotential for injury Ability to participate in plan of careAbility to participate in plan of care

AssessmentAssessment

Types of AssessmentTypes of Assessment::1.1. Comprehensive AssessmentComprehensive Assessment

2.2. Focused AssessmentFocused Assessment

3.3. Ongoing AssessmentOngoing Assessment

Types of AssessmentTypes of Assessment

1. 1. Comprehensive assessment Comprehensive assessment “Initial”“Initial”– Performed on entry to healthcare facilityPerformed on entry to healthcare facility– Information you gather on initial contact Information you gather on initial contact

with the person to assess all aspects of with the person to assess all aspects of health status is the health status is the Baseline.Baseline.

– Often includes:Often includes:Health history Health history Physical exam andPhysical exam and psychosocial assessmentpsychosocial assessment

Types of AssessmentTypes of Assessment

2. 2. Focused AssessmentFocused Assessment– The data you gather to determine the The data you gather to determine the

status of a specific condition.status of a specific condition.– Occurs after initial assessment and

period of time.– LimitedLimited in scope in scope– Screening for a Screening for a specificspecific problem problem– ShortShort stay stay

Types of AssessmentTypes of Assessment

3. 3. Ongoing assessmentOngoing assessment– Follow-Follow-upup– Monitoring and Monitoring and observationobservation related to related to

specific problemsspecific problems

ASSESSMENTASSESSMENT ObservationObservation InterviewInterview Physical ExaminationPhysical Examination

Is a systematic data collection method that uses the senses Is a systematic data collection method that uses the senses of sight, hearing, smell, and touch to detect health of sight, hearing, smell, and touch to detect health problems. problems. Four techniquesFour techniques are used: are used: inspectioninspection, , palpationpalpation, , percussionpercussion, and , and auscultationauscultation

A physical assessment may be carried out before, during, A physical assessment may be carried out before, during, or after the health history, depending on a patient’s or after the health history, depending on a patient’s physical and emotional status and the immediate priorities physical and emotional status and the immediate priorities of the situation.of the situation.

Physical Assessment Physical Assessment TechniquesTechniques

1. Inspection Inspection – – critical observationcritical observation “ “to see”to see”– Take time to “observe” with eyes, ears, noseTake time to “observe” with eyes, ears, nose

– Use appropriate lightingUse appropriate lighting– Look at color, shape, symmetry, positionLook at color, shape, symmetry, position– Odors from skin, breath, woundOdors from skin, breath, wound

– Provide privacy for clientProvide privacy for client

– Expose body areas adequatelyExpose body areas adequately

– Use instruments when appropriate, i.e. otoscope, ophthalmoscope, Use instruments when appropriate, i.e. otoscope, ophthalmoscope, penlightpenlight

InspectionInspection is done alone and in combination with other assessment is done alone and in combination with other assessment techniquestechniques

2. 2. Palpation - light and deep touchPalpation - light and deep touch– Uses the sense of touch Uses the sense of touch – Back of hand to assess skin temperatureBack of hand to assess skin temperature– Fingers to assess texture, moisture, areas of tendernessFingers to assess texture, moisture, areas of tenderness– Assess organ location, size, shape, and consistency of Assess organ location, size, shape, and consistency of

lesions, swelling, masses, and tenderness. lesions, swelling, masses, and tenderness. – Palpation requires a calm, gentle approach and is used Palpation requires a calm, gentle approach and is used

systematically, with light palpation preceding deep systematically, with light palpation preceding deep palpation and palpation of tender areas performed last.palpation and palpation of tender areas performed last.

Physical Assessment Physical Assessment TechniquesTechniques

3- 3- Percussion Percussion – to tap

Uses short, tapping strokes on Uses short, tapping strokes on the surface of the skin to the surface of the skin to create vibrations of underlying create vibrations of underlying organs. It is used for assessing organs. It is used for assessing the density of structures or the density of structures or determining the location and determining the location and the size of organs in the body.the size of organs in the body.

Physical Assessment Physical Assessment TechniquesTechniques

Percuss – to tapPercuss – to tap

Percussion Sounds - elicits 4 percussion notes Percussion Sounds - elicits 4 percussion notes on selected body surfaceson selected body surfaces– FlatnessFlatness (thigh muscle) elicit and describe sound (thigh muscle) elicit and describe sound– DullnessDullness (liver) elicit and describe sound (liver) elicit and describe sound– ResonanceResonance (normal lung) elicit and describe sound. (normal lung) elicit and describe sound.– TympaniTympani (gastric air bubble) elicit and describe (gastric air bubble) elicit and describe

soundsound

4- 4- Auscultation - listening to sounds produced to sounds produced

by the bodyby the body that are created by movement of air or that are created by movement of air or

fluid. fluid.

Direct auscultation Direct auscultation – sounds are audible – sounds are audible

without stethoscopewithout stethoscope

Indirect auscultation Indirect auscultation – uses stethoscope– uses stethoscope

Physical Assessment Physical Assessment TechniquesTechniques

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Assessment techniques - Cont.Assessment techniques - Cont.AuscultationAuscultation

Instrument: stethoscope (to Instrument: stethoscope (to skin)skin)

DiaphragmDiaphragm –high –high pitched soundspitched sounds– HeartHeart– LungsLungs– AbdomenAbdomen

Bell Bell – low pitched – low pitched soundssounds

- Blood vessels- Blood vessels

Nursing DiagnosisNursing Diagnosis Step 2 in the nursing processStep 2 in the nursing process

The purpose of this stage is to identify the The purpose of this stage is to identify the

patient's nursing problempatient's nursing problem

Nursing diagnosis: Nursing diagnosis: actualactual or or potential potential health health

problems that can be managed by problems that can be managed by

independent nursing interventions .independent nursing interventions .

It contains three parts:It contains three parts: PProblemroblem: Name of the health-related issue or problem: Name of the health-related issue or problem

EEtiologytiology: (its cause): (its cause)

SSign and symptom ign and symptom

It called It called PESPES system.system.

The name of the nursing diagnosis is linked to the etiology The name of the nursing diagnosis is linked to the etiology

with the phrase “related to,” and the signs and symptoms are with the phrase “related to,” and the signs and symptoms are

identified with the phrase “as manifested (or evidenced) by”identified with the phrase “as manifested (or evidenced) by”

Writing Diagnostic StatementsWriting Diagnostic Statements

Problem

Related

To

Etiology

As

manifested

By

Signs &

Symptoms

Diagnostic

Label

Contributing Factors

Nursing DiagnosisPrioritize the problemsNot a medical diagnosis

Medical vs. Nursing Medical vs. Nursing diagnosisdiagnosis

Medical diagnosis Nursing diagnosis

physician "clinical judgment of the disease- i.e. diabetes mellitus.

statement used to describe the client's actual or potential response to a health problem that a nurse is licensed and competent to treat i.e.-Impaired skin integrity, Risk for Infection, etc.

Focuses on illness, injury or disease processes

Focuses on the clients responses to actual or potential health / life problems

Medical vs. Nursing Medical vs. Nursing diagnosisdiagnosis

Medical diagnosis Nursing diagnosis

Remains constant until a cure is effected

Changes as the clients response and/or the health problem changes

i.e. Breast cancer i.e. Knowledge deficit

Powerlessness

Grieving, anticipatory

Body image disturbance

Individual coping, ineffective

Examples of DiagnosisExamples of DiagnosisNursing diagnosis Medical diagnosis

Breathing patterns, ineffective

Chronic obstructive pulmonary disease

Activity intolerance Cerebrovascular accident

Pain Appendectomy

Body image disturbance Amputation

Self-care deficit: bathing, Self-care deficit: bathing, related to joint stiffnessrelated to joint stiffness

Rheumatoid ArthritisRheumatoid Arthritis

Planning & Outcome Planning & Outcome identificationidentification

Step 3Step 3– Types of planningTypes of planning

InitialInitial planning planning OngoingOngoing planning planning DischargeDischarge planning planning

PlanningPlanning The 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.

Determine problems that require immediate action

Short-Term GoalsShort-Term Goals Outcomes achievable in a few days or 1 Outcomes achievable in a few days or 1

week week Developed from the problem portion of the Developed from the problem portion of the

diagnostic statementdiagnostic statement Client-centeredClient-centered MeasurableMeasurable RealisticRealistic Accompanied by a target dateAccompanied by a target date

Long-Term GoalsLong-Term Goals Desirable outcomes that take weeks or Desirable outcomes that take weeks or

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

Formula for Writing Formula for Writing Goals/Outcomes:Goals/Outcomes:

Goal statement (long or short term) = patient behavior + criteria + time + conditions (if needed)

1. Subject -patient 2. Verb -action/behavior which pt performs 3. Criteria -acceptable performance 4. Within specified time period 5. Condition (if needed) circumstances under

which behavior performedExample: The patient (1) will walk (2) the length of the hall

(3) with a walker (5) by the end of the shift (4).

Prioritizing the nursing diagnosisPrioritizing the nursing diagnosis– Maslow’s hierarchy of needsMaslow’s hierarchy of needs

Priorities are classifiedPriorities are classified:: HighHigh: nursing diagnosis that if untreated, could : nursing diagnosis that if untreated, could

result in harm to the client or others have the result in harm to the client or others have the highest priorityhighest priority

IntermediateIntermediate: nursing diagnosis involves the : nursing diagnosis involves the non-emergency, non-life threatening needs of non-emergency, non-life threatening needs of the clientsthe clients

LowLow: nursing diagnosis are client’s needs that : nursing diagnosis are client’s needs that may not be directly to a specific illness or may not be directly to a specific illness or prognosisprognosis

ImplementationImplementation

44thth step of Nursing Process: step of Nursing Process:– Put the plan of nursing care into actionPut the plan of nursing care into action

– DO ITDO IT– DO IT RIGHTDO IT RIGHT– DO IT RIGHT NOW!DO IT RIGHT NOW!

Nursing ImplementationNursing Implementation

Direct interventionsDirect interventions::

Actions performed through interaction Actions performed through interaction with clients.with clients.

Indirect interventionsIndirect interventions::

Actions performed away from the Actions performed away from the client, on behalf of a client or group client, on behalf of a client or group of clients.of clients.

EvaluationEvaluation 55th th and final stepand final step

– It is the analysis of It is the analysis of the client’s response, the client’s response, evaluation helps to evaluation helps to determine the determine the effectiveness of effectiveness of nursing care.nursing care.

– Determining whether Determining whether the clients the clients goalsgoals have have been been metmet, , partially partially metmet or or not metnot met. .

Example: NURSING DIAGNOSIS: Disturbed Sleep PatternGoal: Client will sleep uninterrupted for 6 hours.EXPECTED OUTCOMES • Client will request back massage for relaxation.• Client will set limits to family and significant other visits.