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Fundamentals of Nursing Department Nursing Process
Foundation of Nursing Practice
1 2 Nursing Process: 3 A process is a series of steps or acts that lead to accomplishment of some 4 goal or purpose. Nursing process : is a systemic method for providing care to 5 clients. The purpose is to provide individualized , holistic, effective client care 6 efficiently. Although the steps of nursing process build on each other, each step 7 overlaps with the previous and subsequent steps. 8 Purposes of nursing process 9 1. Providing professional, quality nursing care.
10 2. Directs nursing activities for health promotion, health protection, and
11 disease prevention and is used by nurses in every practice setting and
12 specialty.
13 3. Provides the basis for critical thinking in nursing.
14 Phases of the nursing process:
15 1. A ssessment (of patient's needs).
16 2. D iagnosis (of human response needs that nurses can deal with).
17 3. P lanning (of patient's care).
18 4. I mplementation (of care).
19 5. E valuation (of the implemented care).
20 21 Figure (1) Components of the Nursing Process
Fundamentals of Nursing Department Nursing Process
Foundation of Nursing Practice
1 Steps (Phases) of nursing process: 2 1. Assessment: 3 Is the first step in the nursing process and includes systemic collection, 4 verification, organization, interpretation (analysis), and documentation of data. 5 The completeness and correctness of the information obtained during assessment 6 are directly related to the accuracy of the steps that follow. Assessment involves 7 several steps: 8 a. Data collection from a variety of sources. 9 b. Data validation. 10 c. Organizing the data. 11 d. Data interpretation (Data analysis). 12 e. Making initial inferences or impressions. 13 f. Recording or reporting data. 14 Purpose of assessment: 15 1. Organize a database regarding a client physical, psychological, and 16 emotional health. 17 2. Identified of health promoting behaviors and actual or potential health 18 problems. 19 3. The nurse can ascertains of the clients about: 20 a. Functional abilities, 21 b. Absence or the presence of dysfunction, 22 c. Normal activities of daily living, and 23 d. Lifestyle pattern. 24 4. Identifying the client strengths gives the nurse information about the 25 abilities, behavior, and skills the client can use during the treatment and 26 recovery process. 27 5. Provides an opportunity to form a therapeutic interpersonal relationship 28 with clients. 29 6. The client can discuss health care concerns and goals with the nurse. 30 Type of assessment: 31 The information needed for assessment is usually determined by health 32 care setting and needs of the clients. Three types of assessment includes: 33 1. Comprehensive assessment: 34 a. Provide baseline of client data including a complete health history and 35 current needs assessment. 36 b. Usually completed upon admission to health care agency. 37 c. Changes in the clients health status can be measured against this 38 database.
Fundamentals of Nursing Department Nursing Process
Foundation of Nursing Practice
1 health problems. The patient’s medical record may also be consulted for 2 background history information. 3 Examples of subjective information : 4 a. I have had pains in my legs for three days ago. 5 b. I have had headache, nausea, vomiting, dizziness for three hours ago. 6 c. I have had anxiety from surgery. WHAT’S UP? Guide to Symptom Assessment W—Where is it? H—How does it feel? Describe the quality. A—Aggravating and alleviating factors. What makes it worse? What makes it better? T—Timing. When did it start? How long does it last? S—Severity. How bad is it? This can often be rated on a scale of 0 to 10. U—Useful other data. What other symptoms are present that might be related? P—Patient’s perception of the problem. The patient often has an idea about what the problem is, or the cause, but may not believe that his or her thoughts are worth sharing unless specifically asked. 7 Table (1) Guide to Symptom Assessment 8 B. Objective data (also called signs): are observable and measurable data 9 that are obtained through both physical examination and the result of 10 laboratory and diagnostic tests. The primary method of collecting objective 11 information is the physical examination, which provides information about 12 the function of body systems. Inspection, palpation, percussion, and 13 auscultation techniques are used to collect objective data. 14 Examples of objective information include: 15 a. Temperature (37.3°C), Pulse rate (100 b/m), Respiration (18 T/m), 16 Blood pressure (130/76 mm/hg). 17 b. Positive bowel sounds. 18 c. Flushed face. 19 Validating the data: 20 Objective information may add to or validate subjective information. 21 Validation is a critical step in data collection to avoid omissions, prevent 22 misunderstandings, and avoid incorrect inferences and conclusions. 23 Organizing the data:
Fundamentals of Nursing Department Nursing Process
Foundation of Nursing Practice
1 Data that are collected must be organized to be useful to the health care 2 professional collecting the data as well as others involved with the client’s care. 3 Data should be organize through: 4 a. Data clustering (admission assessment format): is the process to putting 5 the data together in order to identify areas of the client problems and 6 strengths. 7 b. Assessment model: is a framework providing a systematic way to organize 8 data such as: 9 1. Hierarchy of needs: proposes that an individual basic needs 10 (physiological) must be meet before higher level can be meet. 11 2. Body system model: organizes data according to tissue and organ 12 function in the various body systems. 13 3. Functional health pattern: cluster information about client habitual 14 pattern and any change to determine if the clients current response is 15 functional or dysfunctional. 16 4. Theory of self care: based on the client ability to meet self care needs 17 and identifying existing self care deficits. 18 Interpreting the data: when data are placed in clusters the nurse can : 19 a. Distinguish between relevant and irrelevant data. 20 b. Determine whether and where there are gaps in the data. 21 c. Identify patterns of cause and effect. 22 Documenting the data: 23 Assessment data must be recorded and reported. The nurse must make a 24 judgment about which data are to be reported immediately and which data 25 need only to be recorded at that time. Data that reflect a significant deviation 26 from the normal (for example, rapid heart rate with irregular rhythm, severe 27 difficulty in breathing, or high levels of anxiety) would need to be reported as 28 well as recorded. Examples of data that need only to be recorded at the time 29 include a report that prescribed medication has relieved a headache and a 30 determination that an abdominal dressing is dry and intact. 31 NOTE: Assessment does not end with the initial interview and physical 32 examination. Assessment is dynamic and continues with each nurse-client 33 interaction. 34 2. Nursing Diagnosis phase:
35 Involves further analysis and synthesis of the data that have been
36 collected. According to the North American Nursing Diagnosis Association 37 (NANDA) a nursing diagnosis: Is a clinical judgment about individual,
38 family, or community responses to actual or potential health problems / life
Fundamentals of Nursing Department Nursing Process
Foundation of Nursing Practice
1 f. An example of a possible diagnosis is: ( Possible Self-Esteem Disturbance 2 related to recent retirement and relocation). The nurse may not yet have 3 enough data to confirm this diagnosis or a more specific one. However, this 4 diagnosis will alert other nurses to collect data that will either confirm this 5 or another diagnosis, verify a risk diagnosis, or rule out the existence of a 6 problem. 7 3. Wellness nursing diagnosis (Wellness conditions): 8 a. Indicates the client’s expression of a desire to attain a higher level of 9 wellness in some area of function. 10 b. Composed of the diagnostic label preceded by the phrase “potential for 11 enhanced.” 12 c. For example a client who is neither overweight nor underweight tells the 13 nurse that she knows she could improve her diet in some ways. She 14 expresses a desire to know more about how to improve her diet. The nurse 15 would make a wellness diagnosis of Potential for Enhanced Nutrition. 16 4.Collaborative problems: 17 Are defined as physiologic complications monitored by nurses to assess 18 changes in client status. Usually collaborative problems involve alterations in 19 organ and/or system function or structure (e.g., myocardial infarction, duodenal 20 ulcer). Collaborative problems begin with the label potential complication 21 followed by the situation. for example, respiratory are the specific collaborative 22 problems of potential complication : hypoxemia. 23 3.Outcome Identification and Planning phase: 24 Includes the formulation of guidelines that establish the proposed course of 25 nursing action in the resolution of nursing diagnoses and the development of the 26 client’s plan of care. 27 The planning of nursing care occurs in three phases: 28 a. Initial planning: Developed by the nurse who performs the admission 29 assessment and gathers the comprehensive admission assessment data. 30 b. Ongoing planning : Updating of the client’s plan of care. 31 c. Discharge planning: Critical anticipation and planning for the client’s 32 needs after discharge. 33 The planning phase involves several tasks: 34 a. Establishing priorities of nursing diagnoses. 35 b. Setting goals and developing expected outcomes (outcome identification). 36 c. Planning nursing interventions (with collaboration and consultation as 37 needed). 38 d. Record the entire nursing care plan in the client record.
Fundamentals of Nursing Department Nursing Process
Foundation of Nursing Practice
1 There are a number of frameworks used to prioritize nursing diagnoses; 2 however, those diagnoses involving life-threatening situations are given the 3 highest priority. 4 A goal: is an aim, intent, or end. Goals are broad statements that describe 5 the intended or desired change in the client’s behavior. Expected outcomes: are 6 specific objectives related to the goals and are used to evaluate the nursing 7 interventions. They must be measurable, have a time limit, and be realistic. A 8 nursing intervention: is the activity that the nurse will perform for and with the 9 client to enable accomplishment of the goals. 10 4. Implementation phase: 11 Involves the execution of the nursing care plan derived during planning 12 phase. It consists of performing nursing activities that have been planned to meet 13 the goals set with the client. The implementation phase of the nursing process 14 requires cognitive (intellectual), psychomotor (technical), and interpersonal skills. 15 The nurse must continue to assess the client’s condition before, during, and after 16 the nursing intervention. 17 Nursing implementation activities include: 18 a. Ongoing assessment. 19 b. Establishment of priorities. 20 c. Allocation of resources. 21 d. Initiation of nursing interventions. 22 e. Documentation of interventions and client response. 23 5. Evaluation phase: 24 Involves determining whether the goals have been met, partially met, or 25 not met. 26 1. If the goal has been met, the nurse must then decide whether nursing 27 activities will stop or continue in order for status to be maintained. 28 2. If the goal has been partially met or not been met, the nurse must reassess 29 the situation and change the plan of care accordingly. New problems may 30 be identified at this stage, and thus the process will start all over again. 31 There are a number of possible reasons that goals are not met or are 32 only partially met, including: 33 a. The initial assessment data were incomplete. 34 b. The goals and expected outcomes were not realistic. 35 c. The time frame was too optimistic. 36 d. The goals and/or the nursing interventions planned were not appropriate 37 for the client. 38
