NURSING PROCESS DR REEM ALI Fall Semester 2011

NURSING PROCESS DR. REEM ALI Fall Semester 2011 -2012

Nursing Process Objectives Define the Nursing Process Describe the phases of the nursing process Identify the characteristics of the nursing process Identify the purposes of each phase of the nursing process. Identify activities that occur in each phase of the nursing process.

Nursing Process Required Readings Kozier & Erb's Fundamentals of Nursing: Concepts, Process and Practice(2012) (9 th ed. ) Chapter Number 11 - 14; Assessing; Diagnosing; Planning; Implementing & Evaluation

Nursing Process 4 Nursing process Is a systematic , rational method of planning and providing individualized nursing care. Purpose of the nursing process: Identify client’s health status Identify actual or potential health problems or needs Establish plans to meet the identified needs Deliver specific nursing interventions to meet those needs.

Nursing Process 5 Consists of 5 phases Assessment Diagnosis (outcomes identification & analysis) Planning Implementation Evaluation The phases of the nursing process are: Not separate entities but overlapping Each phase or step affects the others Closely interrelated for example if the assessment is incomplete the diagnosis, planning will be incomplete

Characteristics of Nursing Process 6 A cycle (regularly repeated event or sequence of events) and dynamic (continuously changing) nature An adaptation of problem solving and system theory (parallel to but separate from the medical model). Nursing Model Medical Model Nursing process and medical model both have data gathering & analysis, intervention, problem statement and evaluation directed toward client’s Focuses on physiological responses to real or potential systems and the disease and illness processes

Characteristics of Nursing Process 7 Client-centered (nurse organizes the plan of care according to client problems rather than nursing goals). Incorporate client’s routine into the care plan Decision making is involved in every phase of the process. Interpersonal (nurse communicate with client and families) and collaborative (with the health care team) Universally applicable (it is used as a framework for nursing care in all settings and clients of all age groups) Nurses must use a variety of critical thinking skills to carry out the process

Nursing Process 8

Assessment 9 Involves Collecting data (from variety of sources) Organizing the client data (information) Validating the client data Documenting the client data Purpose Establish information (data base) about person’s response to health concerns and ability to manage health care needs

Assessment 10 Types of assessment: Initial assessment (e. g nursing admission) Problem-focused assessment ongoing process integrated with nursing care (Hourly assessment of I &O in ICU) Emergency assessment. During any physiologic or psychologic crises (emergency assessment of ABC[Airway, Breathing Circulation]) Time-lapsed reassessment. Several months after initial assessment (reassessment of client’s condition at each shift)

Collecting Data 11 Data collection is a systematic and continuous gathering of information about a client's health status. Data base contains all the information about a client; it includes nursing health history, physical assessment, primary care provider's history and physical examination, lab and diagnostic test (see Box 11 -1). Types of data Subjective data Objective data

Collecting Data: Subjective & Objective data 12 Subjective symptoms or covert data Data from the client’s point of view It include the client’s feelings, perceptions, and concerns Main way to collect subjective data is the interview Example: “I feel weak when I try to walk”; pain, feeling of worry, itching

Collecting Data: Subjective & Objective data 13 Objective Signs or overt data Observable, testable, & measurable data Can be seen, heard, felt, or smelled Main way to collect objective data: Observation or physical assessment Lab and diagnostic testing Example: color of skin, blood pressure

Types of Data 14 Constant data is the data that doesn’t change over time such as race, blood type. Variable data is the data that can change quickly, frequently, or rarely such as blood pressue, age, level of pain

Sources of Data 15 Primary sources (direct) Client (the best source) Can be obtained by Interview Physical examination Secondary sources (Indirect) Family members Other health care providers Medical records Lab and diagnostic analyses Relevant literature.

Assessment 16 Organizing the Data: Systematic organization of the assessment data using: Written Format Computerized Format Validating the data: The act of “double-checking” or verifying data to confirm that it is accurate and factual. Not all data require validation such as height, weight, birth date & lab results Data validated when there is a discrepancies between subjective and objective data

Assessment 17 Documenting the Data: Recording all the collected data about the client Data should be recorded in factual manner and not interpreted by the nurse. Example the nurse should write the client had breakfast ( 1 egg, 1 slice of toast , juice 120 ml) NOT the client has good appetite Subjective data should be recorded in the client own words using quotation marks example “ I feel very worried”

Diagnosing 18 Consists of Analyze data Indentify health problems, risk and strengths Formulate diagnostic statements

Diagnosing 19 NANDA (North American Nursing Diagnosis Association) provide a diagnostic labels (names for the diagnosis) A classification system of nursing diagnoses (ND) Currently provided more than 200 of nursing diagnostic lables Example of ND: Activity intolerance Anxiety constipation

Diagnosing 20 Nursing diagnosis is the clinical judgment about client’s response to health problems Nursing diagnosis provides the bases for the selection of nursing interventions to achieve outcomes Nursing diagnosis consists of: diagnostic label + etiology (casual relationship between the problem and its related or risk factors) Example Constipation related to long-term laxative use Constipation related to inactivity & insufficient fluid intake signs and symptoms

Components of Nursing Diagnosis 21 Problem statement from NANDA label Related factors (Etiology) Defining characteristics (Signs and Symptoms) Example : Noncompliance (Diabetic diet) related to unresolved anger about the diagnosis as manifested OR evidenced by patient’s verbalization “ I forget to take my bills ; weight gain of 4. 5 kg; blood pressure 190/100 Nursing Diagnosis vs. Medical Diagnosis Medical diagnosis (Amputation) Nursing diagnosis (Body image disturbance)

Types of Nursing Diagnosis 22 Actual diagnosis – problem is present Risk nursing diagnosis does not exist but there are risk factors e. g. (Risk for infection) Health promotion diagnosis Problem present at the time of nursing assessment e. g. (Ineffective breathing pattern ; anxiety) Client’s preparedness to implement behaviors to improve health e. g. (Readiness for Enhanced Nutrition) Wellness diagnosis Describe human response to levels of wellness e. g. (Readiness for enhanced family coping)

Planning 23 Consists of The process of prioritizing nursing diagnoses Formulate goals/desired outcomes Selecting appropriate interventions Write nursing interventions. The nurse consults with the client while developing and revising the plan.

Types of Planning 24 Initial planning Done immediately after the initial assessment Ongoing planning Done by all nurses who work with the patient as well as at the beginning of a shift Discharge planning The process of anticipating and planning for needs after discharge

The Planning Process 25 Establishes Priorities Establish client goals/desired outcomes Goals Ø An aim, intent or end. Short term goals Ø Hours to days (less than a week) Ø e. g. reduce temperature Long term goals Ø Weeks to months Ø weight gain

The Planning Process 26 Selects Nursing Interventions Independent nursing interventions Collaborative nursing interventions In conjunction with an interdisciplinary team member (assist client with physical therapy exercises) Dependent nursing interventions No order needed (elevate edematous legs) Require physician order or supervision (Administering of medications) Writing individualized nursing intervention on care plan

Implementation 27 The action phase that consists of : Reassessing the client (Continue to collect data) Determining the nurse’s need for assistance (Assist person to meet goals; facilitate coping) Implementing the nursing interventions (Carry out the plan) Supervising the delegated care Documenting nursing activities

Implementation 28 Implementation skills Cognitive (intellectual skills) e. g. problem solving, decision making Interpersonal: important for all nursing activities Technical: purposeful “hands- on” skills e. g. giving injection, moving, bandaging. (psychomotor skills)

Evaluation 29 Collecting data related to desired outcome Comparing data with desired outcomes Relating nursing activities to outcomes Drawing conclusions about problem status Continuing, modifying, or terminating the nursing care plan

Evaluation 30 Determining whether the clients goals have been met, partially met or not met Should care continue Modify plan if necessary The evaluation incorporates all input from the entire health care team, including the patient.

Quiz 31 This stage involves delivering the plan of care using evidence-based nursing interventions to achieve the goals. What stages of the nursing process is this? Nursing diagnosis Implementation Assessment Evaluation Planning

Quiz 32 This stage involves delivering the plan of care using evidence-based nursing interventions to achieve the goals. What stages of the nursing process is this? Nursing diagnosis Implementation Assessment Evaluation Planning

Quiz 33 This stage involves identifying the patient’s nursing problems/needs, both actual and potential, which will require nursing interventions. What stage of the nursing process is this? Nursing diagnosis Implementation Assessment Evaluation Planning

Quiz 34 This stage involves identifying the patient’s nursing problems/needs, both actual and potential, which will require nursing interventions. What stage of the nursing process is this? Nursing diagnosis Implementation Assessment Evaluation Planning

Quiz 35 This stage is when the nurse reviews the care plan to see whether the goals have been met or partially met and whether the care that was planned was appropriate & effective. If the goal has not been fully or partially achieved re-assessment may be necessary and the nursing process begins again. What stage of the nursing process is this? Nursing diagnosis Implementation Assessment Evaluation Planning

Quiz 36 This stage is when the nurse reviews the care plan to see whether the goals have been met or partially met and whether the care that was planned was appropriate & effective. If the goal has not been fully or partially achieved re-assessment may be necessary and the nursing process begins again. What stage of the nursing process is this? Nursing diagnosis Implementation Assessment Evaluation Planning

Quiz 37 This stage involves the setting of appropriate goals and the nursing care required to meet the goal. A goal should be specific, measurable, achievable & realistic and timeoriented. Goals can be short term of long terms so there must be an indication of when the goal should be achieved. What stage of the nursing process is this? Nursing diagnosis Implementation Assessment Evaluation Planning

Quiz 38 This stage involves the setting of appropriate goals and the nursing care required to meet the goal. A goal should be specific, measurable, achievable & realistic and timeoriented. Goals can be short term of long terms so there must be an indication of when the goal should be achieved. What stage of the nursing process is this? Nursing diagnosis Implementation Assessment Evaluation Planning

Quiz 39 This stage is crucial to the whole nursing process and involves collection of data from a variety of sources and is structured according to the nursing model being used. What stage of the nursing process is this? Nursing diagnosis Implementation Assessment Evaluation Planning

Quiz 40 This stage is crucial to the whole nursing process and involves collection of data from a variety of sources and is structured according to the nursing model being used. What stage of the nursing process is this? Nursing diagnosis Implementation Assessment Evaluation Planning