Nursing Process Overview

Nursing Process Overview

• The nursing process is a systematic, rational method for planning and providing care.
• Its purpose is to identify clients' health status, actual or potential health problems.
• It establishes plans to meet identified needs to deliver specific nursing interventions to address those needs.

Phases of the Nursing Process

• The five phases are assessment, diagnosis, planning, implementation, and evaluation.
• Each phase is closely interrelated and affects the others.

Characteristics of the Nursing Process

• The nursing process is cyclical and dynamic.
• It is client-centered.
• It is an adaptation of problem-solving.
• Decision-making is involved in every phase.
• It is interpersonal and collaborative.
• It employs critical thinking skills.

Assessment

• Assessment is the systematic and continuous collection, organization, validation and documentation of data.
• It aims to prevent omitting significant data and reflect changing health status.
• Types of assessment include initial, problem-focused, emergency, and time-lapsed assessments.

Types of Assessment

• Initial Assessment: Performed after admission to identify problems, reference, and compare with future data (e.g., nursing admission assessment).
• Problem-focused Assessment: Ongoing process integrated with nursing care, focusing on specific identified problems, such as hourly assessment in Intensive Care Units.
• Emergency Assessment: Used during crises (physiological or psychological) to identify life-threatening problems. Examples include assessing airway, breathing, and circulation during cardiac arrest.
• Time-lapsed Assessment: Carried out months after initial assessment to compare current status with previous baseline data, such as reassessing functional health patterns in outpatient settings.

Assessment Activities

• Collecting Data: The process of gathering client health status information.
• Data Base: All client information, including nursing health history, physical assessments, care provider history and physical examinations, laboratory and diagnostic test results.

Types of Data

• Subjective Data (Symptoms): Information described/verified only by the affected person including sensations, feelings, values, beliefs, attitudes and perceptions of personal health status. Examples include itching, pain, and worry.
• Objective Data (Signs): Information that can be observed, measured or tested against standards (e.g., discoloration of skin, blood pressure reading).

Source of Data

• Primary Source: The client.
• Secondary Sources: Family, support persons, other healthcare professionals, records, reports, laboratory and diagnostic analyses (indirect).

Methods of Data Collection

• Observation: Gathering information using senses. (Vision, Smell, Hearing).
• Interview: Planned communication/conversation.
• Examination: Diagnostic procedures and lab investigations
• Physical Examination Techniques:
  • Inspection
  • Palpation
  • Percussion
  • Auscultation

Data Analysis

• Organize data.
• Validate data (double-check accuracy).
• Document data.

Nursing Diagnosis

• Definition: Clinical judgment about individual, family, or community responses to actual and potential health problems/life processes.
• NANDA (North American Nursing Diagnosis Association): The organization that provides a working definition of nursing diagnosis.
• Types:
  • Actual Diagnosis: Client problem present during assessment (e.g. ineffective breathing pattern, anxiety).
  • Risk (Potential) Diagnosis: No problem exists, but risk factors are present, indicating the likelihood of problem development (e.g., risk for infection)
  • Health Promotion Diagnosis: Relates to the client's readiness to improve their health condition. (e.g. readiness for enhanced nutrition).

Components of a NANDA Diagnosis

• Problem (diagnostic label): Describes health problem (e.g., Deficient Knowledge, Medication).
• Etiology (related factors/risk factors): Identifies probable causes of problems, guiding therapy.
• Defining Characteristics (Signs & Symptoms): Cluster of signs and symptoms that indicate a health problem in actual diagnosis. No signs or symptoms are present in risk nursing diagnoses.
• Statement Format: The diagnostic statement follows a “PES” format (Problem-Etiology-Signs).

Planning

• Formulating client goals.
• Designing nursing interventions.
• Prevent, reduce, or eliminate client health problems.

Types of Planning

• Initial Planning
• Ongoing Planning
• Discharge Planning

Maslow's Hierarchy of Needs

• This hierarchy prioritizes human needs, beginning with physiological requirements (air, water, food, shelter). Higher levels include safety, love/belonging, esteem, and self-actualization.

Guidelines for Writing Nursing Care Plans

• Date and sign the plan.
• Use standardized medical or English symbols and key words.
• Specify the timing of an intervention
• Refer to guidelines.

Ongoing Interventions and Plans

• Ensure plan covers ongoing assessment.
• Include collaborative activities.
• Include discharge/home care plans.

Nursing Interventions

• Interventions are any treatments performed by nurses to improve patients' health.

Implementation

• Implementation includes doing and documenting activities.
• This involves performing nursing interventions and documenting implemented activities.

Evaluation

• Evaluation is a planned, ongoing, purposeful activity.
• It determines the client's progress toward achieving goals; it also evaluates the effectiveness of the care plan.

Evaluation Contents

• Identify evaluation criteria and standards.
• Collect evaluation data.
• Interpret and summarize the findings.
• Document findings.
• Care plan revision can include:
  • Terminating the care plan.
  • Modifying the care plan.
  • Continuing the care plan.

Explore the systematic approach to nursing care through this quiz on the nursing process. Understand the five key phases: assessment, diagnosis, planning, implementation, and evaluation. Each phase plays a crucial role in providing optimal patient care.