Nursing Process: Definition and History

Nursing Process

• A systematic and rational method used for planning and providing individualized nursing care.
• The purposes are to identify a client's health status, actual or potential health care problems or needs, establish plans to meet the identified needs, and to deliver specific nursing interventions to meet those needs.
• The client can be an individual, family, community, or group.

History of the Nursing Process

• Lydia Hall originated the term "Nursing Process" in 1955 and introduced the three steps of observation, ministration of care, and validation.
• Dorothy Johnson introduced the three steps of assessment, decision, and nursing action in 1959.
• Ida Jean Orlando identified the three steps of client's behavior, nurse's reaction, and nursing action in 1967.
• Yura and Walsh suggested the four components of assessing, planning, implementing, and evaluating.
• Knowles described the nursing process as discover, delve, decide, do, discriminate(1967).
• The American Nurses Association introduced innovations with diagnosis as a separate step in 1973, diagnosis of actual/potential health problems as integral in 1980, and outcome identification as distinct, leading to the six steps of assessment, diagnosis, outcome identification, planning, implementation, and evaluation in 1991.

Characteristics of the Nursing Process

• Organized, systematic, goal-oriented, and focused on humanistic care.
• Nursing process consists of sequential and interrelated steps.
• The plan of care is developed and implemented with the unique needs and concerns of the client in consideration.
• Efficient in being relevant to the needs of the client.
• Effective in utilizing resources wisely in terms of human hours, time, and cost.

Nursing Process Steps

• Assessment involves collecting, organizing, validating, and documenting data
• Diagnosing involves analyzing data, identifying health problems/risks/strengths, and formulating diagnostic statements
• Planning involves prioritizing problems/diagnoses, formulating goals/desired outcomes, selecting nursing interventions, and writing nursing interventions
• Implementing involves reassessing the client, determining the need for assistance, implementing interventions, supervising delegated care, and documenting activities
• Evaluating involves collecting data related to outcomes, comparing data with outcomes, relating actions to client goals/outcomes, drawing conclusions about problem status, and deciding whether to continue/modify/terminate the care plan.

Assessing

• A systematic and continuous process of data collection, organization, validation, and documentation of information.
• Databases contain all the information about a client, including nursing health history, physical assessment, information from the primary care provider, lab results, diagnostic tests, and material contributed by other health personnel.

Types of Data

• Subjective data (covert/symptoms) is described or verified only by the person affected, such as itching, pain, etc.
• Objective data (overt/signs) is detectable by an observer or can be measured/tested against accepted standards.

Types of Assessment

• Initial assessment is performed within a specified time after admission to a health agency
• Problem-focused assessment is an ongoing process integrated with nursing care(example, hourly assessment of patient's fluid output in ICU).
• Emergency assessment occurs during any physiological or psychological crisis.
• Time-lapsed reassessment occurs several months after the initial assessment.

Data Sources

• Primary source of data is the client.
• Secondary sources of data include family members, other health professionals, records and reports, laboratory and diagnostic analyses, and relevant literature.
• All data from secondary sources should be validated if possible.

Data Collection Methods

• Observing occurs anytime the nurse is in contact with the client or support persons.
• Interviewing is used mainly while taking the nursing health history.
• Examining is the major method used in physical health assessment.
• Vision: Overall appearance, posture, grooming, signs of distress or discomfort, facial and body gestures, skin color and lesions, abnormalities of movement nonverbal demeanor, and religious or cultural artifacts
• Smell: Body and breath odors.
• Hearing: Lung and heart sounds, bowel sounds, ability to communicate, language spoken, ability to initiate a conversation, ability to respond when spoken to, orientation to time person and place, thoughts and feelings about self others and help systems
• Touch: skin temperature and moisture, muscle strength, pulse rate, rhythm, volume, and palpable lesion.

Interviewing

• Interview is planned communication or a conversation with a purpose, for getting or giving information, identifying problems, evaluating change, teaching, providing support, or providing therapy.
• Focused interviews involve the nurse asking the client specific questions related to the client's problem.
• Directive interviews are highly structured and elicit specific information.
• Nondirective interviews allow the client to control the subject matter and pacing; rapport is an understanding between two or more people.
• Closed questions are restrictive and answered with "yes" or "no," and are used in directive interviews.
• Open-ended questions are associated with nondirective interviews where client's discover, explore, and elaborate.

Planning the Interview and Setting

• Nurses need to plan interviews with clients when the client is physically comfortable and free of pain, and when interruptions by friends, family, and other health professionals are minimal.
• The setting should be a well-lighted, well-ventilated room that is relatively free of noise, movements, and distractions.
• The nurse risks intimidating the client standing and looking down at a client; sit at a 45-degree angle to the bed from the patient.
• The distance between the interviewer and interviewee should be neither too small nor too great, because people feel uncomfortable when talking to someone who is too close or too far away.
• Proxemics is the study of the use of space.
• Failure to communicate in a language the client can understand is a form of discrimination, which includes converting complicated medical terminology into common English.

Culturally Responsive Care

• Accepted distance between individuals in conversation varies with ethnicity.
  • In some cultures, the distance may be closer than a foot (Middle Eastern), greater than a foot (European), or up to 3 feet (Asian cultures).
• Men usually require more space than women.
• Anxiety and direct eye contact increases the need for space.
• Physical contact is used only if it has a therapeutic purpose.

Diagnosis

• The diagnosis process involves the clinical act of analyzing assessment information and deriving meaning from it as a diagnostic statement or nursing diagnosis
• Status of Nursing Diagnoses refers to the actuality or potentiality of the problem/syndrome or the categorization of the diagnosis as a health promotion diagnosis.

Types of Nursing Diagnoses

• Actual diagnosis is a client problem that is present at the time of the nursing assessment.
  • Ineffective Breathing Pattern and Anxiety are examples.
  • Actual nursing diagnosis is based on the presence of associated signs and symptoms.
• A health promotion diagnosis relates to a clients' preparedness to implement behaviors to improve their health condition.
  • These diagnosis labels begin with the phrase Readiness for Enhanced.
  • Readiness for Enhanced Nutrition is an example.
• The risk nursing diagnosis is a clinical judgment that a problem does not exist, but the presence of risk factors indicates a problem is likely to develop if the nurse doesn't intervene.
• A syndrome diagnosis is assigned by a nurse's clinical judgment to describe a cluster of nursing diagnoses that have similar interventions.
• Nursing Diagnosis is a statement of a client's potential or actual alteration of health status.
  • It uses the critical-thinking skills of analysis and synthesis.
  • Can use PRS/PES format.
    • P – Problem.
    • R – Related to factors.
    • S – Signs and symptoms.
    • E - Etiology

Activities during Diagnosing

• Organize cluster or group data like pallor, dyspnea, weakness, fatigue, RBC=4 M/cu.mm, Hgb=10g/dl., pertaining to problems with oxygenation.
• Compare data against accepted standards, norms, measures, or patterns for comparison like standard color of urine as amber and sclera as white
• Analyze data after comparing to standards.
• Identify gaps and inconsistencies in data.
• Determine client's health problems, health risks, and strengths.
• Formulate nursing diagnoses statements.

Examples of Nursing Diagnoses

• Anxiety related to insufficient knowledge regarding surgical experience.
• Risk for injury related to sensory and integrative dysfunction, manifested by altered mobility and faulty judgment.
• Ineffective airway clearance related to tracheobronchial infection, manifested by weak cough, adventitious breath
• Correct: High risk for ineffective airway clearance related to thick, copious mucus secretions.
• Incorrect: High risk for ineffective airway clearance related to pneumonia.
• Correct: High risk injury related to disorientation.
• Incorrect: High risk for injury related to absence of side rails.
• Correct: High risk for self-concept disturbance related to the effects of mastectomy (surgical removal of breast).
• Incorrect: Mastectomy related to cancer.

Planning Phase

• It involves strategizing actions before implementing nursing care, with the client and their family involved.
• Planning purposes include identifying client's goals and interventions, directing care activities, promoting continuity of care, focusing charting requirements and delegating specific activities.

Plan Nursing Intervention

• Direct actions during the implementation phase.
• Nursing interventions are “any treatment based upon clinical outcomes", and they are used to monitor health status, prevent or resolve a problem, assist with daily living (ADL's), or promote optimum health.
• Nursing interventions are also called nursing orders and are independent, dependent, and interdependent activities to provide client care.
• Write nursing interventions related to the goal. Interventions include who, what, when, and how the order is to be carried out; it's important to note it's related Scientific Rationale
• Gives the reason for carrying out the intervention. Demonstrates synthesis of physiologic, psychological, and pathophysiological concepts.

Examples of Nursing/Scientific Interventions Rationale

Implementation

• Implementation is putting the nursing care plan into action to help the client attain goals and achieve an optimal level of health.
• Activities: Reassessing ensures prompt attention to emerging problems. Priority setting helps determine the order in which nursing interventions are carried out, actions, and record. Nursing interventions are independent, dependent, or collaborative measures, and relevant documentation should be performed.

What to remember

• Critical to remember that if it is not written it is considered not done. Requirement
• Knowledge: includes intellectual skills
• Technical skills: carry outs treatment
• Communication skills:: use verbal and non-verbal communication
• Therapeutic use: willing and able to care

Evaluation

• This is assessing the response to nursing interventions; The response is compared to the criteria
• Purpose of evaluation is to appraise the extent to which goals and outcome criteria of nursing care have been achieved.
• Two activities which occur during this phase are collected data about the client's response and the compared goals/outcomes.
• There are four judgments
  • The goal was completely met -The goal was partially met -The goal was unmet
  • New problems or nursing diagnoses have developed.
• Analyze the reasons for the outcomes and Modify the care plan as needed.

Characteristics of Nursing Process

• It is Comparable with scientific problem-solving and Goal-oriented
• Orderly, planned, and step by step (systematic).
• Open to accepting new information during its application. It adapts to meet client's needs
• Interpersonal. It requires communication
• Permits creativity among nurses/clients in devising solutions to problems.
• Cyclical. Steps may overlap because interrelated.
• Universal in its application to individuals, families, and communities

Benefits of Nursing Process