Nursing Process

Introduction The term Nursing Process was first used/ mentioned by Lydia Hall, a nursing theorist, in 1955 wherein she introduced 3 STEPs: observation, administration of care and validation. Since then, nursing process continue to evolve: it used to be a 3-step process, then a 4-step process (APIE), then a 5-step (ADPIE), now a 6-step process(ADOPIE) Assessment, Diagnosis, Outcome, Identification, Planning, Implementaton and Evaluation. Definition Is a systematic, organized method of planning, and providing quality and individualized nursing care. It is synonymous with the PROBLEM SOLVING APPROACH that directs the nurse and the client to determine the need for nursing care, to plan and implement the care and evaluate the result.

It is a G O S H approach (goal-oriented, organized, systematic and humanistic care) for efficient and effective provision of nursing care.

Goal-oriented nurse make her objective based on clients health needs. Remember: Goals and plan of care should be base according to clients problems/needs NOT according to your own problem as the nurse. Organized/Systematic the nursing process is composed of 6 sequential and interrelated steps and these 6 phases follow a logical sequence. Humanistic care Plan to care is developed and implemented taking into consideration the unique needs of the individual client. plan of care therefore is individualized (no 2 person has the same health needs even with same health condition/illness)

in providing care, it involves respect of human dignity Efficient plan of case is relevant/ related to the needs of the client thereby promoting client satisfaction and progress. Effective in planning care, utilized resources wisely (staff, time, money/cost)

Aside from GOSH, other characteristic of Nursing Process: Cyclic and Dynamic in nature data from each phase provides the input into the next phase so that is becomes a sequence of events (cycle) that are constantly changing (dynamic) base on clients health status. Involves skill in Decision-making nurse makes important decisions related to client care, she choose the best action/steps to meet a desired goal or to solve a problem. She must make decisions whenever several choices or options are available.

Uses Critical Thinking skills the nurse may encounter new ideas or less-than-routine or nonordinary situations where decisions must be made using critical thinking.

Purpose of Nursing Process: 1. To identify a clients health status; his Actual/Present and potential/possible health problems or needs. 2. To establish a plan of care to meet identified needs. 3. 4. To provide nursing interventions to meet those needs. To provide an individualized, holistic, effective and efficient nursing care.

Steps/Phases of the Nursing Process: 1. Assessment 2. Diagnosis 3. 4. 5. 6. Outcome Identification Planning Implementation Evaluation

Assessment - First Step in the Nursing Process

It is systematic and continuous collection, validation and communication of client data as compared to what is standard/norm. It includes the clients perceived needs, health problems, related experiences, health practices, values and lifestyles.

Purpose: To establish a data base (all the information about the client):

nursing health history physical assessment the physicians history & physical examination results of laboratory & diagnostic tests material from other health personnel

FOUR Types of Assessment 1. 2. Initial assessment assessment performed within a specified time on admission o Ex: nursing admission assessment Problem-focused assessment use to determine status of a specific problem identified in an earlier assessment

o
3.

Ex: problem on urination-assess on fluid intake & urine output hourly

Emergency assessment rapid assessment done during any physiologic/physiologic crisis of the client to identify life threatening problems.

o
4.

Ex: assessment of a clients airway, breathing status & circulation after a cardiac arrest.

Time-lapsed assessment reassessment of clients functional health pattern done several months after initial assessment to compare the clients current status to baseline data previously obtained.

Activities 1. 2. 3. 4. 5. Collection of data Validation of data Organization of data Analyzing of data Recording/documentation of data

Assessment Observation of the patient + Interview of patient, family & SO + examination of the patient + Review of medical record

Collection of data gathering of information about the client includes physical, psychological, emotion, socio-cultural, spiritual factors that may affect clients health status

includes past health history of client (allergies, past surgeries, chronic diseases, use of folk healing methods) includes current/present problems of client (pain, nausea, sleep pattern, religious practices, meds or treatment the client is taking now)

Types of Data 1. Subjective data o also referred to as Symptom/Covert data

o o o
2.

Information from the clients point of view or are described by the person experiencing it. Information supplied by family members, significant others; other health professionals are considered subjective data. Example: pain, dizziness, ringing of ears/Tinnitus

Objective data

o o o

also referred to as Sign/Overt data Those that can be detected observed or measured/tested using accepted standard or norm. Example: pallor, diaphoresis, BP=150/100, yellow discoloration of skin

Methods of Data Collection 1. Interview o A planned, purposeful conversation/communication with the client to get information, identify problems, evaluate change, to teach, or to provide support or counseling.

it is used while taking the nursing history of a client

2. Observation

Use to gather data by using the 5 senses and instruments.

3. Examination

o o

Systematic data collection to detect health problems using unit of measurements, physical examination techniques (IPPA), interpretation of laboratory results. should be conducted systematically: 1. 2. 3. Cephalocaudal approach head-to-toe assessment Body System approach examine all the body system Review of System approach examine only particular area affected

Source of data 1. 2. Primary source data directly gathered from the client using interview and physical examination. Secondary source data gathered from clients family members, significant others, clients medical records/chart, other members of health team, and related care literature/journals.

In the Assessment Phase, obtain a Nursing Health History - a structured interview designed to collect specific data and to obtain a detailed health record of a client.

Components of a Nursing Health History: o Biographic data name, address, age, sex, martial status, occupation, religion. o Reason for visit/Chief complaint primary reason why client seek consultation or hospitalization.

o o o o o o o o

History of present Illness includes: usual health status, chronological story, family history, disability assessment. Past Health History includes all previous immunizations, experiences with illness. Family History reveals risk factors for certain disease diseases (Diabetes, hypertension, cancer, mental illness). Review of systems review of all health problems by body systems Lifestyle include personal habits, diets, sleep or rest patterns, activities of daily living, recreation or hobbies. Social data include family relationships, ethnic and educational background, economic status, home and neighborhood conditions. Psychological data information about the clients emotional state. Pattern of health care includes all health care resources: hospitals, clinics, health centers, family doctors.

Validation of Data

The act of double-checking or verifying data to confirm that it is accurate and complete.

Purposes of data validation 1. 2. 3. ensure that data collection is complete ensure that objective and subjective data agree obtain additional data that may have been overlooked

4. 5. Cues

avoid jumping to conclusion differentiate cues and inferences

Subjective or objective data observed by the nurse; it is what the client says, or what the nurse can see, hear, feel, smell or measure.

Inferences

The nurse interpretation or conclusion based on the cues. Example:

o o

Red swollen wound = infected wound Dry skin = dehydrated

Organization of Data Uses a written or computerized format that organizes assessment data systematically. 1. Maslows basic needs 2. Body System Model 3. Gordons Functional Health Patterns:

Gordons Functional Health Patterns 1. Health perception-health management pattern. 2. Nutritional-metabolic pattern 3. 4. 5. 6. 7. 8. 9. Elimination pattern Activity-exercise pattern Sleep-rest pattern Cognitive-perceptual pattern Self-perception-concept pattern Role-relationship pattern Sexuality-reproductive pattern

10. Coping-stress tolerance pattern 11. Value-belief pattern

Analyze data

Compare data against standard and identify significant cues. Standard/norm are generally accepted measurements, model, pattern: o Ex: Normal vital signs, standard Weight and Height, normal laboratory/diagnostic values, normal growth and development pattern

Communicate/Record/Document Data

nurse records all data collected about the clients health status

data are recorded in a factual manner not as interpreted by the nurse Record subjective data in clients word; restating in other words what client says might change its original meaning.

Diagnosis - Second Step in the Nursing Process

Definition

Is the 2nd step of the nursing process. the process of reasoning or the clinical act of identifying problems

Purpose

To identify health care needs and prepare a Nursing Diagnosis. To diagnose in nursing It means to analyze assessment information and derive meaning from this analysis.

Nursing Diagnosis

Is a statement of a clients potential or actual health problem resulting from analysis of data. Is a statement of clients potential or actual alterations/changes in his health status. A statement that describes a clients actual or potential health problems that a nurse can identify and for which she can order nursing interventions to maintain the health status, to reduce, eliminate or prevent alterations/changes. Is the problem statement that the nurse makes regarding a clients condition which she uses to communicate professionally. It uses the critical-thinking skills analysis and synthesis in order to identify client strengths & health problems that can be resolves/prevented by collaborative and independent nursing interventions.

o o

Analysis separation into components or the breaking down of the whole into its parts. Synthesis the putting together of parts into whole

Three Activities in Diagnosing: 1. Data Analysis 2. Problem Identification 3. Formulation of Nursing Diagnosis

Characteristics of Nursing Diagnosis

1. 2. 3.

It states a clear and concise health problem. It is derived from existing evidences about the client. It is potentially amenable to nursing therapy.

4.

It is the basis for planning and carrying out nursing care.

Components of A nursing diagnosis (PES or PE) 1. 2. 3. Problem statement/diagnostic label/definition = P Etiology/related factors/causes = E Defining characteristics/signs and symptoms = S *Therefore may be written as 2-Part or a 3-Part statement.

Types of Nursing Diagnosis 1. Actual Nursing Diagnosis a client problem that is present at the time of the nursing assessment. It is based on the presence of signs and symptoms. Examples: Imbalanced Nutrition: Less than body requirements r/t decreased appetite nausea. Disturbed Sleep Pattern r/t cough, fever and pain.

Constipation r/t long term use of laxative. Ineffective airway clearance r/t to viscous secretions Noncompliance (Medication) r/t unknown etiology Noncompliance (Diabetic diet) r/t unresolved anger about Diagnosis Acute Pain (Chest) r/t cough 2nrdary to pneumonia Activity Intolerance r/t general weakness. Anxiety r/t difficulty of breathing & concerns over work

2. Potential Nursing diagnosis one in which evidence about a health problem is incomplete or unclear therefore requires more data to support or reject it; or the causative factors are unknown but a problem is only considered possible to occur. Examples: Possible nutritional deficit Possible low self-esteem r/t loss job

Possible altered thought processes r/t unfamiliar surroundings

3. Risk Nursing diagnosis is a clinical judgment that a problem does not exist, therefore no S/S are present, but the presence of RISK FACTORS is indicates that a problem is only is likely to develop unless nurse intervene or do something about it. No subjective or objective cues are present therefore the factors that cause the client to be more vulnerable to the problem are the etiology of a risk nursing diagnosis. Examples: Risk for Impaired skin integrity (left ankle) r/t decrease peripheral circulation in diabetes. Risk for interrupted family processes r/t mothers illness & unavailability to provide child care.

Risk for Constipation r/t inactivity and insufficient fluid intake Risk for infection r/t compromised immune system.

Risk for injury r/t decreased vision after cataract surgery.

Formula in writing nursing diagnosis (PES or PE) 1. Actual nursing diagnosis = Patient problem + Etiology replace the (+) symbol with the words RELATED TO abbreviated as r/t. = Problem + Etiology + S/S 2. Risk Nursing diagnosis = Problem + Risk Factors 3. Possible nursing diagnosis = Problem + Etiology

Qualifiers words added to the diagnostic label/problem statement to gain additional meaning. deficient - inadequate in amount, quality, degree, insufficient, incomplete impaired made worse, weakened, damaged, reduced, deteriorated

decreased lesser in size, amount, degree ineffective not producing the desired effect

Activities during diagnosis: 1. Compare data against standards 2. Cluster or group data 3. 4. 5. 6. Data analysis after comparing with standards Identify gaps and inconsistencies in data Determine the clients health problems, health risks, strengths Formulate Nursing Diagnosis prioritize nursing diagnosis based on what problem endangers the clients life

Situation: Functional Health Pattern Activity/Exercise

Anna, 35 years of laundry woman seeks consultation at the Philippine General Hospital due to fever 2 days prior to admission PTA. She verbalizes: Bigla na lang ako giniginaw, masakit ang ulo at mainit ang pakiramdam pagkatapos kong maglaba sa kabilang kanto. (I suddenly felt cold, headache and warm after I done laundry). She has 3 children she walks off to school everyday before she goes to work

Vital Signs Temperature (T) =39.2C Respiratory Rate (RR) = 35 P = 96; with flush skin and warm to touch, teary eyed and with dry lips and mucous membrane.

Nursing Diagnosis Hyperthermia [related to (r/t)] environmental condition AMB T = 39C, flush skin, warm to touch, teary eyed and dry lip and mucous membrane. Situation: Functional Health Pattern = Nutritional/Metabolic

1. 2. 3. 4.

States, No appetite since having cough Has not eaten today; last fluids at noon today Has lost 8 lbs in past 2 weeks Nauseated x 2 days

Nursing Diagnosis

Imbalanced Nutrition: Less than body Requirements r/t decreased appetite and nausea 2ndary to disease process/cough

Situation: Functional Health Pattern = Activity/Exercise 1. Difficulty sleeping because of cough 2. States, Cant breath lying down 3. Report pain on chest when coughing

Nursing Diagnosis Disturbed Sleep Pattern r/t a disease process, orthopnea and pain. Acute Pain (chest) r/t pathologic condition 2ndary to pneumonia

Situation: Functional Health Pattern = Coping/Stress 1. 2. 3. 4. 5. Anxious State, I cant breath Facial muscles tense, trembling Expresses concern and worry over leaving daughter with neighbors Husband out of town, will be back next week.

Nursing Diagnosis

Anxiety r/t difficulty of breathing and concerns over parenting roles.

Outcome Identification
Definition Refers to formulating and documenting measurable, realistic and client-focused goals that will provide the basis for evaluating nursing diagnosis.

Purposes 1. To provide individualized care 2. To promote client participation 3. 4. To plan care that is realistic and measurable To allow involvement of support people

Activities during Outcome Identification 1. Establish clients goals and outcome criteria Client Goal Is an educated guess made as a broad statement about what the clients state or condition will be AFTER the nursing intervention is carried out. Are written to indicate a desired state. They contain action word/verb and a qualifier that indicate the level of performance that needs to be achieved. Example of verbs used in client goals: o Calculate

o o o o o o o o o o o o o o o o o o o o o o o o o o

Classify Communicate Compare Define Demonstrate Describe Construct Contrast Distinguish Draw Explain Express Identify List Name Maintain Perform Particular Practice Recall Recite Record State Use Verbalize Ambulates

*a Qualifier is a description of the parameter or criteria for achieving the goal. Example:

o o o

Ambulates safely with one-person assistance. Identifies actual & risk environmental hazards. Demonstrates signs of sufficient rest before Surgery.

Goals may be short term or long term

Short Term Goal (STG) can be met in a short period (within days or less than a week) Long Term Goal (LTG) requires more time (several weeks or months) Outcome Criteria are specific, measurable, realistic statements goal attainment. They are written in a manner that they answer the questions: who, what actions, under what circumstance, how well and when. Therefore the characteristic of well-stared outcome criteria are:

S = smart M = measurement A = attainable R = realistic T = time-framed

Example of Goals and Outcome Criteria 1. Goal The client will report a decreased anxiety level regarding Surgery. Possible Outcome Criteria: The client discusses fears & concern regarding surgical procedure after client teaching. After client teaching, the client verbalizes decreased anxiety.

The client identifies a support system and strategies to use to reduce stress and anxiety related to the surgical experience.

2. Goal The client will demonstrate safety habits when performing activities of daily living. Possible Outcome Criteria: Immediately after instruction by the nurse, the client uses call light system for assistance when needs to use the bathroom. The client demonstrates safety practices when dressing and doing personal hygiene.

The client uses over-the-bed lights, non-skid slippers when transferring to chair or getting out of bed. The client identifies modification for home safety (removal of throw pillows, installation of hand rails in hallway, better lighting of hallway and stairway), 12 hours after nurses instruction about home safety.

3. Goal The client will mobilize lung secretions. Possible Outcome Criteria: After teaching session, the client demonstrates proper coughing techniques. The client drinks at least 6 glasses of water per day while in the hospital.

The caregiver or significant other demonstrates proper technique of chest physiotherapy including percussion, vibration and postural drainage before discharge

Planning
Definition

Involves determining before and the strategies or course of actions to be taken before implementation of nursing care. To be effective, the client and his family should be involve in planning.

Purpose

To determine the goals of care and the course of actions to be undertaken during the implementation phase. To promote continuity of care. To focus charting requirements. To allow for delegation of specific activities.

1. Establish/Set priorities

Priority is something that takes precedence in position, and considered the most important among several items. It is a decision making process that ranks the order of nursing diagnosis in terms of importance to the client.

Guideline for setting priorities: 1. 2. 3. 4. 5. 6. 7. Life-threatening situations should be given highest priority. Use the principle of ABCs (airway, breathing, circulation) Use Maslows hierarchy of needs. Consider something that is very important to the client. Actual problems take precedence over potential concerns. Clients with unstable condition should be given priority over those with stable conditions. Ex: attend to client with fever before attending to client who is scheduled for physical therapy in the afternoon. Consider the amount of time, materials, equipment required to care for clients. Ex: attend to client who requires dressing change for postop wound before attending to client who requires health teachings & is ready to be discharged late in the afternoon. Attend to client before equipment. Ex: assess the client before checking IV fluids, urinary catheter, and drainage tube.

8.

2. Plan nursing interventions/nursing orders to direct activities to be carried out in the implementation phase. Nursing interventions Any treatment, based upon clinical judgment and knowledge, that a nurse performs to enhance client outcomes. They are used to monitor health status; prevent, resolve or control a problem; assist with activities of daily living; or promote optimum health and independence.

They maybe independent, dependent and independent/collaborative activities that nurses carry out to provide client care.

o o

Independent Nursing Intervention those activities that the nurse is licensed to initiate as a result of the nurses own knowledge and skills. Dependent Nursing Intervention those activities carried out on the order of a physician, under a physicians supervision, or according to specific routines.

Interdependent/Collaborative those activities the nurse carries out in collaboration or in relation with other members of the health care team.

3. Write a Nursing Care Plan Nursing Care Plan (NCP) A written summary of the care that a client is to receive. It is the blueprint of the nursing process.

It is nursing centered in that the nurse remains in the scope of nursing practice domain in treating human responses to actual or potential health problems. It is s step-by-step process as evidence by: 1. 2. 3. 4. 5. 6. Sufficient data are collected to substantiate nursing diagnosis. At least one goal must be stated for each nursing diagnosis. Outcome criteria must be identified for each goal. Nursing interventions must be specifically designed to meet the identified goal. Each intervention should be supported by a scientific rationale, which is the justification or reason for carrying out the intervention. Evaluation must address whether each goal was completely met, partially met or completely unmet.

Implementation
Definition Is putting the nursing care plan into action.

Purpose

To carry out planned nursing interventions to help the client attain goals and achieve optimal level of health.

Activities 1. 2. 3. 4. Reassessing to ensure prompt attention to emerging problems. Set priorities to determine the order in which nursing interventions are carried out. Perform nursing interventions these may be independent. Dependent or collaborative measures. Record actions to complete nursing interventions, relevant documentation should be done. Remember: Something that is NOT written is considered as NOT done at all.

Requirements of Implementation 1. 2. 3. 4. Knowledge include intellectual skills like problem-solving, decision-making and teaching. Technical skills to carry out treatment and procedures. Communication skills use of verbal and non-verbal communication to carry out planned nursing interventions. Therapeutic use of self is being willing and being able to care.

Evaluation
Definition

Is assessment the clients response to nursing interventions and then comparing that response to predetermined standards or outcome criteria.

Purpose:

To appraise the extent to which goals and outcome criteria of nursing care have been achieved.

Activities: 1. 2. 3. Collect data about the clients response. Compare the clients response to goals and outcome criteria. The four possible judgments that may be made are as follows:

o o o o
4. 5.

The goal was completely met. The goal was partially met. The goal was completely unmet. New problems & nursing diagnosis have developed.

Analyze the reasons for the outcomes. Modify plan of care as needed.