Nursing process

Nursing Process

• The nursing process is a systematic, problem-solving approach used by nurses to provide individualized care for patients
• It has five key phases: assessment, diagnosis, planning, implementation, and evaluation
• This framework helps nurses organize and deliver quality care while improving patient outcomes
• The process is cyclical, continually adapting and improving care
• The process is dynamic; it adapts to patient needs as they change
• It is patient-centered; care is tailored to the individual patient's needs and preferences
• It is collaborative, involving healthcare professionals working together
• It is evidence-based; care is informed by research and clinical expertise
• It ensures a structured and organized approach to patient care

5 Essential Steps of Nursing Process

• Assessment: Systematic and continuous collection, organization, validation and documentation of patient data. This is the first step in the process, providing a foundation for subsequent actions. Different assessment types include: initial, focused, emergency, and time-lapsed assessments
• Diagnosis: Clinical judgment about the patient's response to actual or potential health conditions/life processes. It differs from a medical diagnosis (focuses on patient responses rather than diseases), and guides the development of the nursing care plan
• Planning: Developing a comprehensive care plan to address identified patient needs and achieve desired outcomes. Prioritization of patient needs is key, often using Maslow's Hierarchy of Needs or the ABCDE framework (Airway, Breathing, Circulation, Disability, Exposure). SMART goals are used to set clear, measurable, achievable, relevant, and time-bound objectives
• Implementation: Specific actions nurses take to address patient needs and achieve desired outcomes. These actions are evidence-based, consider patient preferences, involve collaboration with the healthcare team, and are documented in a clear and concise manner
• Evaluation: The final step, involving collecting data, comparing it with expected outcomes, and drawing conclusions about the effectiveness of the nursing interventions. It involves reassessing the patient, modifying the plan as necessary, and documenting all assessments, interventions, and evaluations.

Types of Nursing Assessments

• Initial Assessment: Comprehensive assessment conducted soon after patient admission. Collects baseline data.
• Focused Assessment: More targeted assessment focusing on a specific problem or body system.
• Emergency Assessment: Rapid assessment for life-threatening situations. Concentrates on identifying and addressing immediate threats to the patient's life.
• Time-lapsed Assessment: Reassessment of the initial assessment at regular intervals to monitor progress and identify changes in condition

Methods of Nursing Assessment

• Observation:
  • Direct: Observing patient's behavior, appearance, and interactions with the environment
  • Indirect: Reviewing medical records, diagnostic tests, and other available information
• Interview:
  • Patient Interview: Gathering information directly from the patient about health history, current symptoms, and concerns.
  • Family/Significant Other Interview: Gathering information from family or significant others about the patient's health and well-being

Components of a Physical Examination

• Inspection: Visual examination for abnormalities
• Palpation: Using hands to feel for abnormalities such as tenderness, masses, or texture changes
• Percussion: Tapping on the body to assess underlying structures and identify changes in resonance.
• Auscultation: Listening to sounds produced within the body using a stethoscope (e.g heart, lung, bowel sounds)
• Diagnostic Tests: Using various tests (blood tests, X-rays, electrocardiograms) to obtain objective data about patient health status
• Review of Systems: A systematic review of all body systems to identify any potential health problems

Types of Data in Nursing Assessment

• Subjective Data: Patient's own perceptions, feelings, beliefs, and statements. Influenced by personal interpretation of health status. Examples include pain level, anxiety, depression, and description of symptoms.
• Objective Data: Observable, measurable, and verifiable facts. Examples include vital signs, physical examination findings, laboratory test results, and diagnostic imaging results.

Data Collection, Interpretation and Validation

• Data collection involves collecting information from patients, such as subjective and objective data
• Interpretation of data involves recognizing patterns and trends, differentiating important data and drawing inferences
• Data validation involves confirming the collected information and avoiding incorrect inferences. It checks data accuracy and comparing them with another source

Nursing Diagnoses

• A clinical judgment about the patient's response to actual or potential health conditions/life processes
• Differentiates from medical diagnoses, emphasizing patient responses rather than diseases.
• Classified into actual, risk, and wellness diagnoses

Components of Nursing Diagnosis

• Problem Statement: Describes the patient's health problem or need (e.g., acute pain, impaired skin integrity, risk for falls)
• Etiology/Related Factors: Identifies the factors contributing to the problem (e.g., related to surgical incision, related to immobility, related to history of falls)
• Defining Characteristics: Signs and symptoms supporting the diagnosis (e.g., self-reported pain, redness/swelling at incision site, use of assistive devices)

Types of Nursing Diagnoses

• Actual Diagnoses: Describe existing problems (e.g., impaired skin integrity, acute pain)
• Risk Diagnoses: Identify potential problems (e.g., risk for falls)
• Wellness Diagnoses: Focus on strengths and healthy responses (e.g., readiness for enhanced nutrition)

Nursing Planning

• The third step in the nursing process; following assessment and diagnosis
• Involves developing a comprehensive care plan to address identified patient needs and achieve desired outcomes
• Prioritizes patient needs using models like Maslow's Hierarchy or the ABCDE principle
• Establishes SMART goals for interventions
• Choosing nursing interventions based on evidence-based practice, clinical expertise, and patient preferences

Steps of Nursing Planning

• Prioritization of Patient Needs: Maslow's hierarchy or the ABCDE principle (Airway, breathing, circulation, disability, exposure)
• Setting Patient-Centered Goals: SMART goals are used (Specific, Measurable, Attainable, Relevant, Time-bound).
• Selecting Nursing Interventions: Best practices are used in conjunction with clinical expertise and patient preferences
• Documenting the Care Plan: A standardized format is used for documentation to maintain continuity and clear communication

Nursing Interventions

• The specific actions taken by nurses to address patient needs and achieve desired outcomes.
• They are the "how" of the nursing process, translating diagnoses and goals into concrete actions.
• Interventions are evidence-based, patient-centered, realistic, and achievable.
• They often involve collaboration with other healthcare team members.

Key Characteristics of Nursing Interventions

• Evidence-Based: Use best available evidence
• Patient-Centered: Tailored to individual needs and preferences
• Realistic and Achievable: Realistic within the patient's condition and healthcare setting
• Collaborative: Involve collaboration with other healthcare team members

Nursing Evaluation

• The final step in the nursing process.
• Involves collecting data, comparing it with expected outcomes, and drawing conclusions about interventions' effectiveness.
• Methods of Evaluation involve numerous ways to assess patient outcomes including: observation, interview, physical examination, diagnostic tests, medical record review, and self-report.

Case Study Examples

• Provided examples of case studies including patient demographics, subjective data (e.g., symptoms, medical history), objective data (e.g., vital signs, physical exam findings), nursing diagnoses, goals, interventions, and evaluation. Important to note that these examples are for educational purposes only and should never be used in real-life clinical practice without proper guidance.