Nursing Process: A Guide

Nursing Process

• Nursing process is a systematic and rational method of individualized nursing care planning and delivery.
• Nursing care involves assessment, diagnosis, planning, implementation, and evaluation to address client's health needs.
• The process ensures effective, client-centered, goal-oriented and dynamic nursing care.
• Throughout the nursing process, nurses involve patients in decision-making.

Purposes of Nursing Process

• Identification of client health status, potential or actual healthcare problems and needs.
• Development of specific nursing intervention plans to address those needs.
• Patient can be an individual, family, community, or group.

Nursing Process Phases

• Nursing process happens in five steps: assessment, diagnosis, planning, implementation, and evaluation.

Characteristics of Nursing Process

• Process is cyclic, dynamic, and client-centered.
• The nursing process focuses on problem-solving and decision-making using interpersonal and collaborative approach.
• Nursing process has universal applicability.
• Utilizes critical thinking and clinical reasoning.

Nursing Assessment

• Nursing assessment collects, validates, organizes and documents data systematically.
• It is a continuous process throughout all nursing process phases.

Types of Nursing Assessment

• Four assessment types exist: initial, problem-focused, emergency, and time-lapsed reassessment.
• The initial nursing assessment is performed within a specified timeframe after admission to establish a complete database for problem identification.
• Nursing admission assessment serves as an example of initial assessment.
• Problem-focused assessment is an ongoing process integrated with nursing care to determine specific problem status.
• Hourly checking of vital signs for a patient with a fever exemplifies this.
• Emergency assessment occurs during psychological or physiological crisis to identify life-threatening situations.
• Rapid airway, breathing, and circulation assessment during cardiac arrest is an example.
• Time-lapsed reassessment occurs several months after the initial assessment.
• Objective is to compare current client health status with previously obtained data.

Components of Nursing Assessment

• Nursing Assessment includes: data collection, organization, validation, and documentation.

Data Collection

• Gathering client's health information.
• Data collection includes health history, physical examinations, lab/diagnostic test results, and other health personnel contributions.

Types of Data

• Subjective and objective data exist.
• Subjective data, referred to as symptoms or covert data, are described only by the affected person.
• Itching, worries, and pain are subjective data examples.
• Objective data, also referred to as signs or overt data, are detectable/ measurable against accepted standards.
• Objective data can be seen, heard, felt, or smelled through observation or physical examination.
• Skin discoloration or blood pressure readings exemplifies objective data.

Sources of Data

• Data come from primary or secondary sources.
• Primary sources come directly from the client.
• Secondary sources come indirectly from other sources i.e. family, health professionals, records, reports, and lab results.

Methods of Data Collection

• Observation, examination and interviews are used to collect data.
• Gathering data with senses like vision, smell, and hearing is observation.
• Examination, a systematic data collection method to detect health problems, involves inspection, palpation, percussion, and auscultation techniques.
• Planned communication for a purpose is an interview.
• There are two interviewing approaches exist: directive and non-directive.
• The directive interview is structured, and the nurse asks the questions.
• With a non-directive or rapport building interview the client controls it.
• Stages of interview consist of the intro, the development, and the closing parts.

Organization of Data

• Using written or electronic formats for organizing assessment data systematically.
• Such formats are called nursing health history or nursing assessment form.

Validation of Data

• Double-checking/verifying collected client data to ensure accuracy and completeness.

Documentation of Data

• Recording client data accurately is essential.
• Documentation should include all collected data on client's health status.

Nursing Diagnosis

• In the nursing process' second phase, nurses use critical thinking to assess data and identify client problems.
• Nursing diagnoses are defined/refined by the North American Nursing Diagnosis Association (NANDA).
• NANDA defines nursing diagnosis as concerning human response to health conditions/life processes or vulnerabilities by individuals, families, groups, or communities.

Status of the Nursing Diagnosis

• The status of nursing diagnoses include actual, health promotion and risk.
• Actual diagnosis is a client problem at assessment time.
• Health promotion diagnosis relates to improving client health conditions preparedness.
• Risk diagnosis is when a problem does not exist, yet risk factors indicate a problem may develop without care.
• A syndrome diagnosis describes a cluster of nursing diagnoses with similar interventions.

Components of a NANDA Nursing Diagnosis

• Includes the problem, its causes, and its defining characteristics.
• Problem statement describes the client's health problem.
• The etiology component identifies the problem's causes.
• Defining characteristics are the cluster of signs/symptoms indicating the health distress presence.

Formulating Diagnostic Statements

• The PES format is a three-part diagnostic statement
• Formats include: the problem (NANDA label), the etiology (causes), and the signs/symptoms (defining characteristics).
• Example: Acute pain related to abdominal surgery as evidenced by patient discomfort and pain scale.

Differentiating Nursing Diagnosis from Medical Diagnosis

• Nursing diagnoses are statements of nursing judgment made by nurses, per their education, experience, and expertise.
• Nursing diagnoses describe human response to illnesses or health problems and may evolve with response changes.
• Medical diagnoses are made by physicians, reference disease processes, and remain as long as the disease is present.
• Altered breathing patterns, activity intolerance and acute pain are nursing diagnoses.
• Examples of medical diagnoses include asthma, cerebrovascular accident, appendicitis, and amputation.

Nursing Planning

• The third nursing process phase, involving decision-making and problem-solving.
• Involves formulating client goals and designing interventions to prevent, reduce, or eliminate health problems.

Types of Planning

• Planning could be initial, ongoing, or for discharge.
• Initial planning occurs post-initial assessment.
• Ongoing planning is continuous.
• Planning for needs after discharge is discharge planning.

Planning Process

• The process includes setting priorities, goals/desired outcomes, selecting nursing interventions/activities, and individualized interventions.
• Nurses prioritize by deciding which nursing diagnoses need attention first.
• Maslow's hierarchy of needs guides prioritization.
• After establishing priorities, nurses set goals for each diagnosis.
• Goals can be short or long term.
• Nursing intervention is any treatment performed to improve health.

Types of Nursing Intervention

• Independent interventions: Nurses are licensed to initiate based on knowledge and skills.
• Dependent interventions: Activities are under licensed physician's orders or supervision.
• Collaborative interventions: Nurse performs in collaboration with health team members.
• After intervention, nurses write them on client's care plan.
• The care plan is a written/computerized account of client needs.

Nursing Implementation

• Action phase where nurses perform interventions.
• Implementation involves doing/documenting actions needed to carry out interventions.
• Nurses perform or delegate nursing activities and concludes by recording activities.

Process of Implementing

• Reassessing the client, determining need for assistance, interventions, supervising delegated care, and documenting activities.
• Just before intervention, nurses reassess client intervention is needed.
• Nurses might need help with interventions they cannot safely do alone, if it would reduce stress on client, or if they don't know how to do it.
• Explaining interventions, expected sensations/client role/outcomes to the client is necessary.
• Ensuring client privacy is also important for many nursing activities.

Delegated Cares

• When care is delegated, those responsible must ensure that the actions are implemented.
• Caregivers must communicate by documenting, reporting verbally, or written forms.
• Nurses validates/responds to any findings or client responses, modifying the nursing care plan if.
• Nurses complete the phase by recording interventions and client responses.

Necessary Implementation Skills

• Cognitive, interpersonal and technical skills are needed.

Nursing Evaluation

• Involves judging or appraising the client's progress towards achieving goals and care plan effectiveness.
• Evaluation has five components: data collection, comparing data with outcomes, relating activities to outcomes, drawing conclusions about problem status, and continuing/modifying/terminating the care plan.

Process of Evaluation

• The nurse collects data for conclusions about goals and collects both objective and subjective data.
• Evaluating outcomes from activity relations and comparing to actual clients responses .
• It is to assumed not that any nursing activity was the cause or main factor in not meeting a goal.
• Judgments on achievment determine if the plan was effective in resolution of client problems.
• When the nurse has met the goals, the can be drawn about a client's statuses.
• Whether ir not you meet the goals, several things must be considered; continuing, modifying, and terminating a care plan.
• Overall effectiveness to determine the entire nursing and critique plan.

Characteristics of Evaluation

• Evaluation occurs continuously and immediately to make spot-on meds.
• Evaluation is performed/continues until client health goals or discharge.
• Includes goal achievement/self-care abilities.
• Nurses show that actions have responsibility and accountability which points to nursing activities results.

Documentation and Reporting

• Important along professionals which allows communication among health professionals essential in client care.
• Generally through discussions or reports. or records.
• Not communicating may cause med errors that causes potential injury.
• Effective communication is through recording and reporting.

Documentation

• Records or proofs of patient actions and activities written or printed.

Documentation System

• There are seven documentation systems that are current.
• Source oriented record
• Problem-oriented medical record
• Problems, interventions, evaluation (PIE) model
• Focus charting
• Charting by exception (CBE)
• Computerized documentation
• Case management

Source Orientation Record

• Each person/department makes annotations on separate chart sections.
• Narrative charting is writing down care, findings and client problems.
• Although normally chronological based, there is no right or wrong order.

Problem Oriented Medical Record

• Data ordered regarding client problems
• Health members include problem lists and plan of care
• The plans and progress notes contain, databases problem list, plans, and progress notes.

PIE Documentation

• Information categorizes into three.
• Acronym of PIE: problems, interventions, evaluation
• Includes a client care assessment flow sheet and progress notes.
• Human needs determine the flow sheet format

Focus Charting

• It emphasizes the client, client's concerns and focuses on strengths
• Columns consists of date and time reports
• Includes the conditions, behaviors, signs or symptoms which organize data, action, and response.

Charting By Exception

• Exception reports of when exceptional or abnormal findings occur.
• flow sheets, quality nursing standards, and bedside chart forms make it up.

Computerized Documenations

• With HER's they are used to manage the huge of information being tracked.
• Comp collects the databases and client progress. can use computer's to store it.

Case management

• It's emphasized with cost and effectiveness to care for
• Multidisciplinary allows you to keep with the client.
• The outcomes, days of care, along with daily interventions for each goal.

Record

• Formats of client's record, legally, as evidence for client.
• Reports, or writings oral based is meant to allow for information of client's care to others.
• Record making happens and the organization gives the policy.

Purpose of Recording

• Care recordings provides information to team members.
• For a number of purposes, data is important such as communication, planning, audits, etc.

Guideliness and Principles of Records

• accurate, timely, spelling, spelling is a must but accurate with concise information.

Principles of Records

• Records need to have factual and timely data
• Writing legibility by a person, which are accepted, and the right signatures.
• Accuracy over sequence, writing appropriately, completing concisely, legal.

Reporting

• Reporting transmits data and to group or people.
• concise reports are those which are only pertinent.

Critical Thinking

• Process to find a problem, analyze the practice to take action and find the care the cleint needs.
• The thinking strategies gather the most important pieces for client's actions in response to the client's psycho social or physoo outcome.

Critical Thinking Purposes

• Rapidly generate multiple ideas that are quick and rapidly easily
• Creativity allows for independence and self-confidence despite whatever is going on,

Critical Thinking Techniques

• Critical analysis, deductive reasoning, inferences, and clarifying information and making assessments come from knowledge

Nursing Process

• When using intentional thinking with skills, a connection of knowledge and nursing processes and problem exists.
• a mental activity of solving problems is a state of unstable activity.
• Requires a the source of a problem and solutions related to it.
• With the critical thought some actions may or may not be in actions.
• Nurse evlautes solutions and puts one together to action.

Approaches of Problem Solving

• Trail and error and in the end a solution might be made.
• Dangers when it isn't safe, nurses often use this method.
• The feeling of rely of nurses is intuition.
• Learning from experience for intuition.
• Inappropriate decision-making often results and others learn via that

Critical Thinking

• Rationales based learn with motivation.
• The trait will give a set a mindset to learn.

Clinical Reasoning Component

• It to use a skill to assess as the action occurs .
• Thinking and applying skills.
• Having an mindset to give the best care for the client

Value and Belief

• Beliefs and attitudes based on action is valuable.
• Underlying moral dilemmas are values from a person, an object, or an action.

Professional Standards

• Learning through life and peers, questions and values allows them to have morals over their values.
• Important over ethical reasons
• Not being about to see the point, and making a way to do things.

Professional Values

• Their belief in things that matter to themselves which actions are made.
• Helping others in action
• They act with honesty based an honest belief from the professions.
• The right to make decisions and being an autonomy person. respect and not doing that undermines that.
• And the dignity and worth regardless.

Value Conflict

• Valuing explains the difference between two people but in values no conflicts exists.
• It part of what an nurse has.
• Learn the warning and body language.
• Try the problem and the people the problem.
• Early stages will prevent a problem in the future
• Always use caution and the best answer should be for people around.
• Don't just listen attend. Try to understand their side and think calmly.

Value conflict and self reflection

• Trying to listen and hear things.
• Act calmly.
• Manage problems that can cause tension or issues.
• It to use ability to reflect and recognize from a experience.
• A perception is to reflect over it for experience to see it.
• Feeling from stimulus by sensory organs that perceive something.
• A stimuilus through thoughts and feelings to impression it.

Self Perception

• The self' mind image and the physical image.
• See themselves what it will affect and influence.

Self-Concept Dimensions

• Knowing, acting and having expectations.
• Being real with the facts being based on social evaluations.
• Mental picture of one's self.
• Ability to know and feel and give and do.
• Ability to think and do is one thing or change it.

Social Aspect:

• Interpersonally being involved it can affect both the status.
• Important is there self like they are with health involved, being physically responsible.
• Positive with having a strength and the body is capable.