NURSING PROCESS

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NURSING PROCESS

• Five Steps to Organize and Deliver Client Care

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Nursing Process

• The purpose of the nursing process is to
  diagnose and treat human responses to actual or
  potential health problems (ANA)

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Nursing Process Systematic Approach

• Gathering, critically examining, and analyzing
  data
• Identifying client response to health problem(s)
• Determining priorities
• Establishing goals and expected outcomes
• Taking appropriate actions
• Evaluating effectiveness

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Nursing Process

• Focuses on the unique needs of individual
  patients
• Applied every time a nurse interacts with a
  patient
• Allows client to be an active participant
• A dynamic process
• Can be applied to all client systems
  (individuals, families, groups, communities)

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Step 1 Assessment

• Deliberate and systematic data collection
• To determine clients current and past health and
  functional status
• To determine present and past coping patterns
• Includes two steps
• Collection and verification of data from primary
  /or secondary source
• Data analysis as basis for developing nursing
  diagnoses and plan of care

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Assessment Approaches

• Use of structured database form
• Problem oriented

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Purpose of Assessment

• Establish Client Database
• Perceived needs
• Health problems
• Responses to health problems
• Related experiences
• Health practices
• Goals
• Values
• Expectations about the health care system

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Assessment Data Collection

• Types of data
• Objective
• Subjective
• Sources of data
• Primary
• Secondary

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Assessment Methods of Data Collection

• Interview
• Nursing health history
• Physical examination
• Diagnostic and laboratory results

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Assessment Process

• Nursing judgments
• Data validation and interpretation
• Data clustering
• Documentation

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Step 2 Nursing Diagnosis

• A clinical judgment about individual, family, or
  community responses to actual and potential
  health problems or life processes (NANDA
  International, 2003)
• A statement that describes the clients actual or
  potential response to a health problem that the
  nurse is licensed and competent to treat.

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Diagnostic Approach

• Analysis and interpretation of data
• Identification of client needs

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Steps of Data Analysis

• Recognize a pattern or trend
• Compare with standards for normal
• Make a reasoned conclusion

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Types of Diagnoses

• Actual
• Risk (potential)
• Wellness

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Components

• Diagnostic label
• Related factors etiology
• Definition
• Risk Factors
• Support of the statement

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Nursing Diagnosis Statement

• Acute pain related to mechanical tissue damage
  (incision) manifested by facial grimace with
  movement and stating my incision really hurts.

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Step 3 Planning

• Establishing priorities
• Determining client-centered goals and outcomes
• Selecting nursing interventions

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Planning Priorities

• High
• Intermediate
• Low

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Planning Goals

• Guidelines
• Time limited
• Short term
• Long term

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Outcomes

• Progressive steps
• Linked to goals and nursing diagnoses
• Guidelines

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Goals and Outcomes

• Client centered
• Singular
• Observable
• Measurable
• Time limited
• Mutual
• Realistic

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Nursing Interventions

• Types
• Nurse initiated
• Physician initiated
• Collaborative

• Selection Criteria
• Characteristics of nursing diagnosis
• Expected outcomes
• Research base
• Feasibility
• Acceptability to the client
• Nurse competencies

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Care Plans

• Student
• Institution
• Community-based settings
• Critical pathways
• Concept maps

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Step 4 Implementation

• Types of nursing interventions
• Direct and indirect
• Protocols and standing orders

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Nursing Interventions

• Critical thinking and selection of nursing
  interventions
• Nursing diagnosis
• Expected outcomes
• Evidence based
• Feasibility
• Acceptability
• Nurse competencies

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Implementation Process

• Reassessing the client
• Reviewing and revising the existing care plan
• Organizing resources and care delivery
• Equipment
• Personnel
• Environment
• Client
• Anticipating and preventing complications
• Identifying areas of assistance

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Direct Care Measures

• Activities of Daily Living (ADLs)
• Instrumental activities of daily living
• Physical care techniques
• Counseling
• Teaching
• Controlling for adverse reactions
• Preventive measures

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Indirect Care Measures

• Communicating nursing interventions
• Delegating, supervising, and evaluating the work
  of other team members

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Step 5 Evaluation

• Process
• Identifying evaluative criteria and standards
• Collecting data to determine if criteria or
  standards are met
• Interpreting and summarizing findings
• Documenting findings
• Terminating, continuing, or revising the care plan

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Success of Goals

• Examine the goal statement
• Assess the client
• Compare the outcome with client behavior or
  response
• Judge the degree of agreement between outcome and
  client response
• Determine reasons for no agreement or partial
  agreement

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Care Plan Revisions

• Discontinuing
• Modifying
• Reassessment
• Nursing diagnosis
• Client goals and outcomes
• Nursing interventions

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Quality Improvement

• Approach purpose
• Outcome management
• Professional outcomes
• Client outcomes

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Examples

• Goal clients pressure ulcer will heal within 7
  days.
• Outcome erythema will be reduced in 2 days.
• Evaluative measure inspect color, size,
  condition, and location of pressure ulcer