Nursing Process Overview

Nursing Process Overview

• The nursing process is a systematic, rational method for planning and delivering nursing care.
• Its purpose is to identify a client's health status, actual or potential health problems, establish plans to meet these needs, and provide specific nursing interventions for those needs.
• The process involves five phases: assessment, diagnosis, planning, implementation, and evaluation.
• These phases are closely interrelated, with each phase affecting the others.

Characteristics of the Nursing Process

• Cyclic dynamic: The process is cyclical, with continuous assessment throughout.
• Client-centered: Focuses on the client's specific needs and health concerns.
• Problem-solving: Adaptable for a variety of problems and situations, allowing nurses to take a problem-solving approach.
• Decision-making: Decision-making is a key element at every step of the process.
• Interpersonal and Collaborative: The nature of nursing involves interpersonal interactions and teamwork.
• Critical Thinking Skills: Utilizing critical-thinking skills is essential for all aspects of the nursing process.

Assessment

• Systematic and continuous collection, organization, validation, and documentation of data.
• Types of assessment: initial, problem-focused, emergency, and time-lapsed.
• Initial assessment is performed after admission, establishing a complete data base.
• Problem-focused assessment is ongoing, monitoring a specific identified problem.
• Emergency assessment is applied during crises (physical or mental health).
• Time-lapsed assessment is conducted months after the initial assessment for comparison and possible changes.

Components of Assessment

• Collecting data: Gathering information about client health status to prevent the omission of significant data.
• Data base: All information about the client. This includes nursing health history, physical assessment, primary care provider's history and physical examination, and results of laboratory and diagnostic tests.

Types of Data

• Subjective data (symptoms): Perceived sensations, feelings, values, beliefs, and perceptions of health status. Examples include itching, pain, or feeling worried.
• Objective data (signs): Observed data that can be measured or tested against a standard. Examples include blood pressure readings or skin discoloration.

Source of Data

• Primary source: The client.
• Secondary sources: Family members, support persons, other health professionals, medical records, reports, laboratory, and diagnostic analyses.

Methods of Data Collection

• Observation: Using senses (sight, smell, hearing) to gather data.
• Interview: A planned communication or conversation with a purpose.
• Examination: Applying various techniques to collect data.
• Diagnostic procedures: Specific tests or procedures to obtain information.
• Lab investigations: Laboratory tests for data.

Physical Examination Techniques

• Inspection: Carefully looking, listening, and smelling.
• Palpation: Using the sense of touch to gather information.
• Percussion: Tapping the skin to vibrate underlying tissues and organs.
• Auscultation: Listening to sounds made by the body.

Organizing and Validating Data

• Organizing data: Using a written or computerized format to systematically organize the assessment.
• Validating data: Double-checking or verifying data to ensure accuracy and completeness.
• Documenting data: Recording all collected data about the client's health status.

Nursing Diagnosis

• North American Nursing Diagnosis Association (NANDA): An official working definition of nursing diagnosis.
• A clinical judgment about individual, family, and community responses to actual or potential health problems/life processes.
• Types of Nursing Diagnosis: actual, risk (potential). - Actual diagnosis: identifies a problem present during assessment. Example: ineffective breathing pattern, anxiety. - Risk diagnosis: Identifies factors that increase the chance for a problem to develop. Example: risk of infection. - Health Promotion Diagnosis: focuses on client's readiness to improve health. Ex: Readiness for Enhanced Nutrition.

Components of a NANDA Nursing Diagnosis (PES)

• Problem (diagnostic label and definition): Describes a client's health problem or response. Examples: Deficient Knowledge, or Impaired Skin Integrity.
• Etiology (related factors): Identify possible causes of a health problem.
• Defining characteristics (signs and symptoms): Physical and subjective manifestations of a problem.

Basic Two-Part Statements

• Used for potential (risk) problems.
• Problem statement (P) and etiology statement (E). E.g., Risk for Impaired Skin Integrity related to immobility.

Medical Diagnosis

• Made by a physician.
• Refers to disease processes.
• Remains the same as long as the disease is present.

Formulating Diagnostic Statements

• Basic three-part statements (problem, etiology, and defining characteristics).

Planning

• Involves decision-making and problem-solving.
• Formulating client goals.
• Designing nursing interventions.
• Prevent, reduce, or eliminate client's health problems.

Types of Planning

• Initial Planning: Planning done after initial assessment.
• Ongoing Planning: Continuous, ongoing planning.
• Discharge Planning: Planning for needs after discharge.

Maslow's Hierarchy of Needs

(Basic to complex):

• Physiological needs
• Safety needs
• Love and belonging needs
• Esteem needs
• Self-actualization needs

Guidelines for Writing Nursing Care Plans

• Date and sign the plan.
• Use standardized medical symbols and keywords.
• Be specific about the expected timing of intervention.
• Refer to procedure books or other references.
• Include interventions for ongoing assessment.
• Include collaborative and coordination activities in the plan.
• Include plans for client discharge and home care needs.

Implementation

• Consists of doing and documenting nursing activities.
• Implementing nursing interventions.
• Documenting nursing activities.

Evaluation

• A planned, ongoing, purposeful activity.
• Nurse determines client's progress towards achieving goals and outcomes.
• Assesses the effectiveness of the nursing care plan.
• Includes identifying criteria and standards, collecting evaluation data, interpreting and summarizing findings, and documenting findings.
• Care plan revision options: terminate, modify, or continue.

Example of a Nursing Care Plan

Provided at the end of the notes.