The Nursing Process

Resources

Andrea Ackermann, Mount St. Mary College, Critical-thinking-the-nursingprocess 2001. http://www.umanitoba.ca/nursing/courses/1 28,(2005) Sara-jo Wiscombe, Nursing Process ,Wallace Community College ,May 22,2001.
Tucker C, MODULE A INTRODUCTION TO NURSING Process, August 21, 2002 .

The Nursing Process

organizational framework for the practice of nursing Orderly, systematic Central to all nursing care Encompasses all steps taken by the nurse in caring for a patient
An

Definition of the Nursing Process

An

organized sequence of problemsolving steps used to identify and to manage the health problems of clients It is accepted for clinical practice established by the American Nurses Association

Benefits of Nursing Process

Provides an orderly & systematic method for planning & providing care Enhances nursing efficiency by standardizing nursing practice Facilitates documentation of care Provides a unity of language for the nursing profession Is economical Stresses the independent function of nurses Increases care quality through the use of deliberate actions

The Nursing Process Utilizes The Following

Assessment Nursing

Diagnosis Planning Implementation Evaluation

Characteristics of the Nursing Process

Within

the legal scope of nursing Based on knowledge-requiring critical thinking Planned-organized and systematic Client-centered Goal-directed Prioritized Dynamic

Benefits of using the nursing process

Continuity of care Prevention of duplication Individualized care Standards of care

Increased client participation Collaboration of care

Being Accountable
Using critical thinking before taking actions Being responsible for your actions Entering the professional role Working at the level of your peers Using the nursing process

Something to think about:

Nurses are responsible for a unique dimension of healthcare the diagnosis and treatment of human responses to actual or potential health problems

MARTHA ROGERS, NURSE THEORIST

When

an apple is cut, others see seeds in the apple. We, as nurses, see apples in the seeds.

What Are Your Responsibilities?

Recognize health problems. Anticipate complications. Initiate actions to ensure appropriate and timely treatment.

Begin to think CRITICALLY !!!!!!

Critical Thinking

MENTAL OPERATIONS decision making & reasoning KNOWLEDGE-having the facts & understanding the reason behind the knowledge ATTITUDES- curious/open-minded/nonjudgmental.

Critical Thinking

Critical thinking in nursing is an essential component of professional accountability and quality nursing care.

Critical thinking is careful, deliberate, and goal directed.

Assessment of Well-Being
According

to the World Health Organization is well-being in these domains:

 Emotional  Physical  Social  Spiritual

Lets Get Started :

       

Nurse collects background info from previous charts Ensure environment is conducive Arrange seating Allow adequate time Nurse introduces self Identifies purpose of interview Ensure confidentiality of information Provide for patient needs before starting

TYPES OF INTERVIEWS

DIRECTED NON-DIRECTED

THINGS THAT IMPAIR COMMUNICATION: PRESENTING QUICK SOLUTIONS UNWARRANTED CHEERFULNESS FALSE REASSURANCE GIVING ADVICE CHANGING THE SUBJECT

ASSESSMENT
Observation Interview

 Types

of questions  Environment (physical and emotional) Spiritual conciderations

Examination

Types of Data To Collect:

Objective

data-observable and measurable facts (Signs) Subjective data-information that only the client feels and can describe (Symptoms)

CULTURAL DIVERSITY

MUST PROVIDE CARE CONGRUENT WITH A CLIENTS EXPECTATIONS This is not about you ? Respect INDIVIDUALS DIFFERENCES, What is the significance of the problem or illness to the client? What does it mean in the family/community?

COMMON Challenges: Defense Mechanisms

COMPENSATION DENIAL DISPLACEMENT RATIONALIZATION

PROJECTION REPRESSION SUPPRESSION REGRESSION

Continued

THE NURSING PROCESS HELPS NURSES UNDERSTAND THE STRATEGIES CLIENTS USE IN their attempt at coping: This knowledge will help you FURTHER INDIVIDUALIZE THEIR CARE

Resources

Client Other individuals Previous records Consultations Diagnostics studies Relevant literature

Assessment

Data base assessment comprehensive information you gather on initial contact with the person to assess all aspects of health status. Focus assessment the data you gather to determine the status of a specific condition.

Sources of Data
Primary

source: Client Secondary source: Clients family, reports, test results, information in current and past medical records, and discussions with other health care workers

Disease Prevention

Primary prevention protection from a disease while still in a healthy state. Secondary prevention early detection and treatment of disease. Tertiary prevention prevent complications and to maintain health once the disease process has occurred.

Verifying Data

Essential in critical thinking!!!!! Measurable data Double check personal observations Double check equipment Check with experts and team members Recheck out-liers Compare objective and subjective data Clarify statements

Planning
Establish

the goals, interventions and outcomes

General Guidelines for Setting Priorities

1. 2. 3. 4.

Take care of immediate life-threatening issues. Safety issues. Patient-identified issues. Nurse-identified priorities based on the overall picture, the patient as a whole person, and availability of time and resources.

Nurse Identified Priorities

Composite of all patients strengths and health concerns. Moral and ethical issues. Time, resources, and setting. Hierarchy of needs. Interdisciplinary planning.

Identifying Client-centered Outcomes

State what the patient will do or experience at the completion of care. Give direction to the patients overall care. Patient behaviors not nurse behaviors!! The patient will

DIAGNOSIS
Sort, cluster, analyze information Identify potential problems and strengths Write statement of problem or strength Risk of infection related to compromised nutrition

Nursing Diagnosis (cont.)

Potential for effective breastfeeding related to knowledge level and support system Prioritize the problems Not a medical diagnosis

Steps for deriving outcomes from Nursing Diagnosis

Look at the first clause of the nursing dx and restate in a statement that describes improvement, control or absence of the problem. Risk for infection r/t surgical procedure. The client will demonstrate no signs or symptoms of infection.

Components of Outcomes

Subject: who is the person expected to achieve the outcome? Verb: what actions must the person take to achieve the outcome? Condition: under what circumstances is the person to perform the actions? Performance criteria: how well is the person to perform the actions? Target time: by when is the person expected to be able to perform the actions?

Nursing Interventions

1. 2. 3. 4. 5.

Road maps directing the best ways to provide nursing care. Evidence based nursing. Monitor health status. Minimize risks. Resolve or control a problem. Assist with ADLs. Promote optimum health and independence.

Interventions

Direct interventions: actions performed through interaction with clients. Indirect interventions: actions performed away from the client, on behalf of a client or group of clients.

Nursing Diagnosis
Health

issue that can be prevented, reduced, resolved, or enhanced through independent nursing measures

Documenting the Plan of Care

1.

2. 3.

To ensure continuity of care, the plan must be written and shared with all health care personnel caring for the client. Consists of: Prioritized nursing diagnostic statements. Outcomes. Interventions.

Documentation
Clear and concise Appropriate terminology


Usually on a designated form Usually by Review of Systems Overview of symptoms Diet Each body system

Physical assessment


Documentation
Use patients own words in subjective data enclose in ___ (quotation marks) Avoid generalizations be specific Dont make summative statements describe - e.g. patient is being ornery should be patient resists instruction or patient states Dont talk to me, I dont care about that

Evaluation
1. 2.

3.

Determining outcome achievement Identifying the variables affecting outcome achievement Deciding whether to continue, modify, or terminate the plan

Determining Outcome Achievement

Must be aware of outcomes set for the client. Must be sure patient is ready for evaluation. Is patient able to meet outcome criteria? Is it: Completely met? Partially met? Not met at all? Record in progress in notes. Update care plan.

Identifying Variable Affecting Outcome Achievement

Maintain individuality of care plan: 1. Is the plan realistic for the client? 2. Is the plan appropriate at the time for this particular client? 3. Were changes made in the plan when needed? 4. How does the client feel about the plan?

Predict, Prevent, and Manage

Focus on early intervention Based on research Predict and anticipate problems Look for risk factors

Diagnostic Statements
Name

of the health-related issue or problem as identified in the NANDA list Etiology (its cause) Signs and Symptoms The name of the nursing diagnosis is linked to the etiology with the phrase related to, and the signs and symptoms are identified with the phrase as manifested (or evidenced) by

Collaborative ProblemsNurses Responsibility

Correlating

medical diagnoses or medical treatment measures with the risk for unique complications Documenting the complications for which clients are at risk Making pertinent assessments to detect complications

Continued
Reporting trends that suggest development of complications Managing the emerging problem with nurse- and physician-prescribed measures Evaluating the outcomes

The Nursing Process

Nursing Diagnosis
Judgment

or conclusion about the risk for or actualneed/problem of the patient NANDA format

NANDA North American Nursing Diagnosis Association

Identifies nursing functions Creates classification system Establishes diagnostic labels Risk of infection related to compromised nutritional state Potential complication of seizure disorder related to medication compliance

Planning
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.

Setting Priorities
Determine

problems that require immediate action Maslows Hierarchy of Human Needs

Short-Term Goals
Outcomes

achievable in a few days or

1 week Developed form the problem portion of the diagnostic statement Client-centered Measurable Realistic Accompanied by a target date

Long-Term Goals
Desirable

outcomes that take weeks or months to accomplish for clients with chronic health problems

The Nursing Process

Planning
Identification Prioritization Time

of goals and outcome criteria

frame

Selecting Nursing Interventions

Planning

the measures that the client and nurse will use to accomplish identified goals involves critical thinking. Nursing interventions are directed at eliminating the etiologies.

Selecting an intervention
The nurse selects strategies based on the knowledge that certain nursing actions produce desired effects. Nursing interventions must be safe, within the legal scope of nursing practice, and compatible with medical orders.

Communicating The Plan

The

nurse shares the plan of care with nursing team members, the client, and clients family. The plan is a permanent part of the record.

Evaluation
The

way nurses determine whether a client has reached a goal. It is the analysis of the clients response, evaluation helps to determine the effectiveness of nursing care.

The Nursing Process

Evaluation
Ongoing

part of the nursing process Determining the status of the goals and outcomes of care Monitoring the patients response to drug therapy

Documentation
Clear and concise Appropriate terminology


Usually on a designated form Usually by Review of Systems Overview of symptoms Diet Each body system

Physical assessment