THE NURSING PROCESS

Becoming familiar with the nursing process has many benefits. It will allow you to apply your knowledge and skills in an organized, goal-oriented manner. It will also enable you to communicate about professional topics with colleagues from all clinical specialties and practice settings.

THE NURSING PROCESS

Using the nursing process is essential to documenting nursing’s role in the provision of comprehensive, quality patient care.

The growing recognition of the nursing process is an important development in the struggle for greater professional autonomy.

THE NURSING PROCESS

By clearly defining problems a nurse may treat independently, the nursing process has helped to dispel the notion that nursing practice is based solely on carrying out doctor’s orders.

Despite recent advances, nursing is still in a state of professional evolution.

THE NURSING PROCESS

In the years ahead, researchers and expert practitioners will continue to develop a body of knowledge specific to the nursing field. A strong foundation in the nursing process will enable you to better assimilate emerging concepts and to incorporate these concepts into your own nursing practice.

THE NURSING PROCESS

The cornerstone of clinical nursing, the nursing process is a systematic method for taking independent nursing actions. These phases of the nursing process are dynamic and flexible; they often overlap.

NURSING PROCESS STEPS

(1) Assessing the patient’s problems (2) Forming a Diagnostic Statement (3) Identify Expected Outcomes (Goals) (4) Create a plan to achieve expected

outcomes to solve the patient’s problems and implement that plan

(5) Evaluate the plan’s effectiveness

ASSESSMENT

The vital first phase in the nursing process, assessment consists of the patient history, consultations, lab findings, pharmacological requisites, and the nurse’s physical examination. The next 4 phases of the Nursing Process depend on the quality of the assessment data for their effectiveness.

ASSESSMENT DEFINED

Nursing assessment is the systematic process of gathering, verifying and communicating data about a patient. It includes 2 steps (1) collection of data from a primary source (patient), and (2) collection of data from a secondary source (family, health professionals).

ASSESSMENT

The purpose of assessment is to establish a data base about the client’s perceived needs, health problems, related experiences, health practices, goals, values, and lifestyle.

ASSESSMENT DATA BASE

The information contained in the DATA BASE is the basis for an individualized plan of nursing care, developed and refined throughout the time the nurse cares for the client.

To be most useful, data collection must pertain to a particular health problem.

ASSESSMENT

During assessment, the nurse obtains 2 types of data: Subjective & Objective.

SUBJECTIVE DATA

Client’s perceptions about their health problems. Only clients can provide this kind of information. Subjective date usually include feelings of anxiety, physical discomfort, or mental stress. The client’s history, embodying a personal perspective of problems is the most important assessment data source.

SUBJECTIVE DATA

Because subjective data is also the most subjective source of patient information, it must be interpreted carefully.

OBJECTIVE DATA

Observations or measurements made by the data collector. The measurement of objective data is based on an accepted standard, such as the Fahrenheit or celsius measure on a thermometer.

Besides adding to your patient data base, this information helps you interpret the patient’s history more accurately by providing a basis for comparison.

OBJECTIVE DATA

In the physical examination of a patient – involving inspection, palpation, percussion and auscultation – you collect objective data about your patient’s health status or about the pathologic processes that may be related to his illness or injury.

NURSING DIAGNOSIS

According to the North American Nursing Diagnosis Association (NANDA), the nursing diagnosis is a “clinical judgment about individual, family, or community responses to actual or potential health problems or life processes. Nursing diagnoses provide the basis for selection of nursing interventions to achieve outcomes for which the nurse is accountable.”

NURSING DIAGNOSIS

The nursing diagnosis must be supported by clinical information obtained during patient assessment.

Each nursing diagnosis describes a patient problem that a nurse can legally manage.

A nursing diagnosis is a statement that describes the patient’s actual or potential response to a health problem that the nurse is licensed and competent to treat.

NURSING DIAGNOSIS

The client’s actual and potential responses are obtained from the assessment data base, a review of pertinent literature, the client’s past medical records, and consultation with other professional, all of which are collected during assessment.

NURSING DIAGNOSIS VS MEDICAL DIAGNOSIS

MEDICINE focuses on curing disease NURSING focuses on holistic care that

includes cure and comfort. Nurses can independently diagnose and treat the patient’s response to illness, certain health problems, and the need for patient education.

NURSING DIAGNOSIS VS MEDICAL DIAGNOSIS

NURSES comfort, counsel, and care for patients and their families until they are physically and emotionally ready to provide self-care.

NURSING VS MEDICINE

Nursing diagnosis focuses on and defines the nursing needs of the client. It reflects the client’s level of health or response to a disease of pathological process, an emotional state, a socio-cultural phenomenon, or a developmental state.

NURSING VS MEDICINE

A medical diagnosis predominately identifies a specific disease state. The medical focus is on the diagnosis and treatment of the disease.

Medical & Nursing diagnoses are developed using assessment data bases. In both professions the diagnostic label directs the direction of care.

NURSING VS MEDICINE

However, the nursing data base is global, and includes an in-depth assessment of the physiological, psychological, socio-cultural, developmental, and spiritual dimensions of the client. Medicine’s data base includes the physiological systems and the personal and social systems. The personal & social systems may be limited to a family medical history & the economic & insurance history of the client.

NURSING VS MEDICINE

The goals/objectives of a nursing diagnosis differ from those of a medical diagnosis.

The goal of a nursing is to direct a plan of care to assist clients and their families to adapt to their illness & to resolve health care problems.

The goal of medicine is to identify & to design a treatment plan for curing the disease of the pathological process.

NURSING VS MEDICINE

Nursing Objective: development of an individualized plan of care so that the client & family are able to cope with changes & to meet the challenges resulting from health problems.

Medical Objective: to prescribe treatment.

NURSING VS MEDICINE (Example)

20 year old student with right quadrant pain. MD diagnosis: Appendicitis MD intervention: Appendectomy Nurse diagnosis: Impaired physical mobility, pain,

altered skin integrity, risk for infection, altered “role”, etc. etc. etc

Nurse intervention: Gradually improving health status on the health-illness continuum of self-care.

PLANNING

A category of nursing behavior in which client-centered goals & expected outcomes are established & nursing interventions are selected to achieve the goals. During planning, priorities are set. The nurse consults with the client, family, and other members of the health care team during this phase of the nursing process.

PLANNING

The nursing plan of care refers to a WRITTEN PLAN of action designed to help nurses deliver quality patient care. It usually becomes part of the permanent part of the patient’s health record and will be used by other members of the nursing team.

PLANNING

The plan of care may be integrated into an interdisciplinary plan for the patient. Because of this, clear guidelines should outline the role of each member of the health care team in providing safe and appropriate patient care.

PLANNING STAGES

(1) Assign priorities to the nursing diagnosis (2) Select appropriate nursing interventions (3) Document the nursing diagnosis,

expected outcomes and interventions. (4) Evaluate the effectiveness of the plan of

care

BENEFITS OF WRITING A PLAN OF CARE

To provide quality care for each patient, you must plan & direct that care. Writing a plan of care lets you document the scientific method you’ve used throughout the nursing process. On the plan of care, nurse summarize the patient’s problems & needs (diagnosis) & identify appropriate nursing interventions & expected outcomes.

BENEFITS OF A WRITTEN CARE PLAN

A care plan that is well conceived & properly written helps decrease the risk of incomplete or incorrect patient care by:

(1) giving direction (2) providing continuity of care (3) establishing professional communication (4) serving as a key for patient assignments

GOALS/EXPECTED OUTCOMES

An expected outcome is the specific, step-by-step objective that leads to attainment of the goal & the resolution of the etiology for the nursing diagnosis. An outcome is a measurable change of the client’s status in response to nursing care.

GOALS/EXPECTED OUTCOME

During this phase of the nursing process, the nurse identifies expected outcomes for the patient. Expected outcomes are measurable, patient-focused goals that are derived from the patient’s nursing diagnosis.

GOALS/EXPECTED OUTCOMES

Outcomes are the desired responses of a client’s condition in the physiological, social, emotional, developmental, or spiritual dimensions. This change in condition is documented through observable or measurable client responses.

GOALS/EXPECTED OUTCOMES

The expected outcomes determine when a specific, client centered goal has been met and later assist in evaluating the response to nursing care and resolution of the nursing diagnosis.

Projected before nursing actions are selected, expected outcomes provide a direction for nursing activities.

GOALS/EXPECTED OUTCOMES

Patient goals or expected outcomes may be either short term or long term.

SHORT TERM GOALS

A short-term goal is an objective that is expected to be achieved in a short period of time, usually less than a week. With the present health care system and shorter hospital stays, short-term goals are the direction for the immediate care plan.

Immediate concerns/achieved quickly.

LONG TERM GOALS

A long-term goal is an objective that is expected to be achieved over a longer period of time, usually over weeks or months. Long-term goals may be carried over into discharge to skilled nursing facilities, rehabilitation settings, or return to the home.

LONG TERM GOALS

Long-term goals take more time to achieve and often focus on prevention, rehabilitation, discharge, and health education. Failure to set long-term goals may prevent the client from receiving continuity of care.

IMPLEMENTATION

Implementation, a component of the nursing process, is a category of nursing behavior in which the actions necessary for achieving the goals and expected outcomes of nursing care are initiated and completed.

During this phase, the nurse puts your plan of care into action.

IMPLEMENTATION

Implementation includes performing, assisting, or directing the performance of activities of daily living, counseling and teaching the client or family, giving direct care to achieve client-centered self-care goals, supervising & evaluating the work of staff members, & recording & exchanging information relevant to the client’s continued health care.

IMPLEMENTATION & INTERVENTIONS

A nursing intervention is any action taken by the nurse to help the client move from a present health state to the health state described in the expected outcomes. The client may require intervention in the form of support, medication, treatment for the current condition, client-family education, or treatment to prevent future health problems.

IMPLEMENTATION

Implementation is continuous and interactive with the other components of the nursing process.

During implementation, the nurse reassesses the client, modifies the care plan, and rewrites expected outcomes as necessary.

Nurse must be knowledgeable re: intervention, implementation process/method

IMPLEMENTATION

Implementation requires some of the following interventions:

Assessing/monitoring Therapeutic interventions (meds admin) Patient comfort Supporting body systems Giving emotional support Teaching and counseling Referring to appropriate agencies/services

EVALUATION

Measures the client’s response to nursing actions and the client’s progress toward achieving goals.

Evaluation occurs whenever the nurse has contact with a client.

Emphasis is on client outcomes

EVALUATION

The nurse evaluates whether the client’s behaviors or responses reflect a reversal or improvement in a nursing diagnosis or maintenance of a health state.

Nurse evaluates if the previous steps of the nursing process were effective by examining the client’s responses & comparing them with the behaviors stated in the goal.

EVALUATION STEPS

The nurse assesses the effectiveness of the plan of care by answering questions like these:

(1) How has the patient progressed in terms of the plan’s projected outcomes?

(2) Does the patient have new needs? (3) Does the plan of care need revision?

EVALUATION

The final step of the nursing process, a systematic method for organizing & delivering nursing care. The exclusion of evaluation from the nursing process prevents the nurse from evaluating nursing practice and determining whether the outcomes of client care are beneficial. Regular application of evaluation ensures that a client’s care plan is current and appropriate.