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Is an organized systematic method of giving individualized nursing care that focuses on identifying and treating unique responses Provides organization of care in every clinical setting Helps in resolving health problems Provides a framework with which individualized needs of the patient/family/community can be met Is an efficient method of organizing thought process for clinical decision making and problem solving
LYDIA HALL was one of the first nurses to use term nursing process in the early 1955, since
then nursing process has been used to describe the accepted method of delivering nurse care. She introduced 3 steps: Note observation Ministration of care Validation
March 2-April 27, 1967- a continuing education series was conducted by the Catholic University of America, 7 HelenYura and 8 Mary Walsh suggested the four components of the Nursing Process:
Assessing Planning Implementing Evaluation
These five steps are performed by the nurse to achieve the ultimate goal of nursing. They are: 1. To promote, maintain/restore health, or to assist patient to achieve a peaceful death, when their condition is terminal 2. To enable patient/family/community to manage their own health care to the best of their ability
The assessment process involves 4 closely related activities: 1. 2. 3. 4. Collecting data Organizing data Validating data Documenting data 3
Types of data
1. SUBJECTIVE ( symptoms or covert data ) Include the client's sensation, beliefs, values, feelings, attitudes and perception of health status and life situation. Consists of information given verbally by the patient Can be described and verified by the person affected are the facts presented by the patient in her or his perception
Ex. itching, pain, feelings of worry
Sources of data:
PRIMARY : 1. Patient / Client best source of data; can provide subjective data that no one else can offer SECONDARY: 1. Support people - family members, friends and caregivers who know the client 2. Client records - medical records, record of therapies and laboratory records. 3. Health care professionals - nurses, physicians, therapist 4. Literature - professional journals and related text
Rapport - is an understanding between two or more people. b. OBSERVATION use of five senses, use of units of measure, physical examination techniques, interpretation of laboratory reports is a conscious, deliberate skill that is developed through effort and with an organized approach. 4
c. ORGANIZING DATA clustering facts into groups of information The nurse uses a written format that organizes the assessment data systematically. often referred to as a nursing health history, nursing assessment, or nursing database. Ways of Clustering Data: 1. Clustering data according to body system 2. Clustering data according to human needs ( Maslows ) 3. Clustering data according to a nursing theory 4. Clustering data according to functional health pattern based on a theory d. VALIDATING Validation is the act of double-checking or verifying data to confirm that it is accurate or factual. Validating data helps the nurse complete these tasks: Ensure that assessment information is complete. Ensure that objective and related subjective data agree. Obtain additional information that may be overlooked. Differentiate between cues and inferences. Cues - are subjective or objective data that can be directly observed by the nurse, that is, what the client says and what the nurse can see, hear, feel, smell or measure. Inferences - are the nurse's interpretation or conclusions made based on the cues. Example: The nurse observes the cues that the incision is swollen; the nurse makes an inference that the incision is infected. * Avoid jumping to conclusions and focusing in the wrong direction to identify the problems. e. DOCUMENTATION To complete the assessment phase, the nurse records client data. Accurate documentation is essential and should include all data collected from the client's health status. Data are recorded in a factual manner and not interpreted by the nurse. Ex. The nurse records the client's breakfast intake as coffee 240ml, juice 120ml, 1 egg and a slice of bread (objective data ) rather than as "appetite good" ( a judgment) which may have different meanings for other people.
NURSING DIAGNOSIS
the second step in the nursing process is the phase during which the nurse analyzes the data gathered during assessment and identifies problem areas for the client. is the process of data analysis and problem identification. PURPOSE: to identify the client s health care needs to prepare diagnostic statements 5
In 1990, NANDA adopted a working definition of Nursing Diagnosis is defined as a clinical judgment about the individual, family or community responses to actual and potential health problems/life processes. It is a cluster of signs and symptoms of an actual and potential health problems in which the nurse by virtue of his/her profession is licensed and able to treat. It provides a basis for the selection of nursing interventions to achieve outcome for which the nurse is accountable. 6
Types of Nursing Diagnosis 1. Actual diagnosis - is a client problem is present at the time of the nursing assessment ,based on the presence of actual signs and symptoms. ex. Ineffective breathing pattern 2. Potential (Risk) nursing diagnosis is a clinical judgment that a problem does not exist, but the presence of risk factors indicates that a problem is likely to develop unless the nurse intervenes. ex. A 78 y/o male client with diabetes was admitted, the nurse would appropriately use the label Risk for Infection. 3. Wellness diagnosis - describes human responses to levels of wellness in an individual, family or community where the nurse can intervene to promote growth and maintain health ex. Readiness for Enhanced Spiritual Well-being. Effective Therapeutic Regimen Management Readiness for Enhanced Nutrition 4. Possible nursing diagnosis - is one in which evidence about a health problem is incomplete or unclear; requires more data either to support or to refute it. ex. An elderly woman who lives alone is admitted to the hospital. The nurse notices she has no visitors and is pleased with the attention given to her by the nursing staff. Until more data are collected, the nurse may write: Possible social isolation related to unknown etiology 5. Syndrome diagnosis - a diagnosis that is associated with a cluster of other diagnoses. ex. Risk for disuse syndrome may be experienced by a long term bed-ridden client. Cluster of diagnosis may include: Impaired physical mobility, Risk for impaired tissue integrity, Risk for constipation, Risk for infection etc. NURSING DIAGNOSIS A statement of client s potential or actual alteration of health status Uses the critical thinking skills of analysis and synthesis Uses PRS / PES format P problem ; diagnostic label R related or risk factors S signs and symptoms ; defining characteristics P problem E Etiology S signs and symptoms 7
2. Etiology (Related or risk factors) Identifies one or more probable causes of the health problem, gives direction to the required nursing therapy and enables the nurse to individualize the client s care. Ex. Presence of thick mucus secretion Vomiting, insufficient fluid intake Pain right arm, immobility 3. Defining Characteristics Clusters of signs and symptoms that indicate the presence of a health problem Ex. Fatigue Weakness Difficulty of breathing Abnormal BP 150/100mmHg Nasal congestion
Medical Diagnosis
Used to define the disease process; focus on function and malfunction of a specific organ system 8
PLANNING
Nurse develops plan of care that prescribes intervention to attain the expected outcome It includes setting priorities and establishing target dates, nursing actions and evaluations by setting standards is a deliberate, systematic phase of the nursing process that involves decision making and problem-solving. In planning, the nurse refers to the client s assessment data and diagnostic statements for direction in formulating client s goals and designing the nursing strategies required to prevent, reduce or eliminate the client s health problem. The product of the planning phase is a client care plan.
Types of Planning
Planning begins with the first client contact and continues until the nurse-client relationship ends, usually when the client is discharged from the health care agency. 1. Initial Planning the nurse who performs the admission assessment usually develops the initial comprehensive plan of care; has the benefit of the client s body language as well as some intuitive kinds of information that are not available solely from the written database; use available information to develop preliminary plans and refine them as the missing data become available. 2. Ongoing Planning is done by all nurses who work with the client. The nurse carries out daily planning for the following purposes: a. to determine whether the client s health status has changed b. to set the priorities for the client s care during the shift c. to decide which problems to focus on during the shift d. to coordinate the nurse s activities so that more than one problem can be addressed at each client contact 3. Discharge Planning the process of anticipating and planning the needs after discharge. Each client should be assessed for potential health needs, availability and ability of the client s support network to assist with the needs and hoe the home environment supports the client. Effective discharge planning begins with the first client contact
Steps of Planning:
1. Setting Priorities: The problems which need immediate attention are taken care first is the process of establishing a preferential sequence or order for addressing nursing diagnoses and interventions. The nurse decides which nursing diagnosis requires attention first. Group them as high, medium, or low priority: Life-threatening problems are designated as high priority such as loss of respiratory or cardiac functioning Health-threatening problems are usually assigned as medium priority such as acute illness and decreased coping ability that may result in delayed development or cause destructive physical or emotional changes 9
A low priority problem is one that arises from normal developmental needs or that requires only minimal nursing support. Priority setting is a decision making process that ranks the order of nursing diagnosis in terms of importance to the client a. LIFE threatening situations should be given HIGHEST PRIORITY b. Use of Principles of ABC s Airway, Breathing , Circulation c. Use Maslow s Hierarchy of Needs physiologic needs are given priority over psychosocial needs d. Consider something that is very important to the client e. Clients with unstable condition should be given priority over stable conditions f. Actual problems take precedence over potential problems g. Attend to client before equipment 2. Establishing goals: This is what the nurse and patient expect to accomplish in a particular time framework Goal/desired outcomes describe what the nurse hopes to achieve by implementing nursing interventions *The term goal and expected outcome are sometimes use interchangeably Goals as broad statements about the effects of nursing interventions Ex. To improved nutritional status Expected outcomes are more specific, measurable criteria used to evaluate whether the goal has been met. Ex. To gain 5 lbs by March 27 3. Determining nursing interventions: The activities the nurse and patient will do to achieve the desired goals 4. Recording care plan: Other nurses need to know the plan of care that you have prescribed and the goals you expect to achieve
4.Criterion of desired performance indicates the standard by which a performance is evaluated or the level at which the client will perform the specified behavior. The criteria may specify time or speed, accuracy, distance and quality. Ex. Weighs 5lbs by March 25 (time) Lists five out of six signs of diabetes (accuracy) Walks one block per day ( time and distance) Administers insulin using aseptic technique (quality)
Impaired skin integrity related to immobility - Assess skin integrity over bony prominences q2hrs - Turn and change position q30mins - Pad pressure points
Dependent interventions
also called the physician-initiated treatments are activities carried out under the physician's orders or supervision include orders for medications, intravenous therapy, diagnostic tests, treatments diet and activity. the nurse is responsible for explaining, assessing the need for and administering the medical order are actions the nurse carries out in collaboration with other health team members, such as physical therapists, social workers, dietitians, and physicians. reflect overlapping responsibilities between health personnel. ex. The physician orders physical therapy to teach the patient crutch-walking. The nurse is responsible for informing physical therapy dept. and coordinating the client's care to include physical therapy sessions.
Collaborative interventions
Requirements of Implementation:
1. Knowledge 2. Technical skills 3. Communication skills 4. Therapeutic use of self
Nursing interventions are also called NURSING ORDERS. Nursing interventions are INDEPENDENT, DEPENDENT & INTERDEPENDENT/COLLABORATIVE activities that nurses carry out to provide client care. NURSING CARE PLAN is a written summary of the care that a client is to receive ; it is the Blueprint of the nursing process
EVALUATION
Is assessing the client s response to nursing intervention and then comparing the response to predetermined standards or outcome criteria. PURPOSE: to appraise the extent to which goals and outcome criteria of nursing care have been achieved