Nursing Process PDF

# Nursing Process ## Nursing Process: Systematic rational series of sequence of steps or method of problem solving approach to meet the health care needs of the patient. ## Advantages - Systematic, orderly - Encourage Team work - Identify health care status - Actual problem/potential problem - Co...

# Nursing Process ## Nursing Process: Systematic rational series of sequence of steps or method of problem solving approach to meet the health care needs of the patient. ## Advantages - Systematic, orderly - Encourage Team work - Identify health care status - Actual problem/potential problem - Continuity of care - Identify the needs - Patient centered care - dynamic - Improves quality of care - Participatory approach - Universally applicable - Consistent & systematic nursing education - Job satisfaction - Legal safety - Improves professional growth - Nurses become accountable for pt. care ## Components of nursing process **OR** Phases # The Nursing Process is a Systematic Five Step Process - Assessment - Diagnosis - Planning - Implementation - Evaluation # The Nursing Process in Action The nursing process is a systematic, rational method of planning and providing nursing care. Its goal is to identify a client's healthcare status, and actual or potential health problems, to establish plans to meet the identified needs, and to deliver specific nursing interventions to address those needs. The nursing process is cyclical; that is, its components follow a logical sequence, but more than one component may be involved at one time. At the end of the first cycle, care may be terminated if goals are achieved, or the cycle may continue with reassessment, or the plan of care may be modified. | **Step** | **Activities** | |---|---| | **Assessing** | - Collect data - Organize data - Validate data - Document data | | **Diagnosing** | - Analyze data - Identify health problems, risks, and strengths - Formulate diagnostic statements | | **Planning** | - Prioritize problems/diagnoses - Formulate goals/desired outcomes - Select nursing interventions - Write nursing orders | | **Implementing** | - Reassess the client - Determine the client's need for assistance - Implement the nursing interventions - Supervise delegated cases - Document nursing activities | | **Evaluating** | - Collect data related to outcomes - Compare data with outcomes - Relate nursing actions to client goals/outcomes - Draw conclusions about problem status - Continue, modify, or terminate the client's care plan | # Assessment - Assessing - Collect data - Organize data - Validate data - Document data - Evaluating - Implementing - Diagnosing - Planning ## Assessment: The first step in determining a patient's health status - Systematic collection of data - Gather information, put pieces of the health puzzle together.  - Entire plan is based on the data you collect, data needs to be complete and accurate  - Collect, verify, and organize data, identify patterns, report and record the data.  - Report significant abnormalities immediately. ## 2 steps in assessment - Collection & verification of data - Primary sources - Secondary sources -Analysis of data & develop nursing diagnosis ## Data - Objective data- observed & measured(temp)  - Subjective data – patient's description (pain) ## Sources of data - Patient - Family/ significant others - Health care team - Medical records - Other records & literature ## Method of data collection - Interview - Structured - Semi structured - Non structured - Observation - Examination - Inspection, palpatopn, percussion, auscultation & smell, vital signs, head to foot examination ## What's important data? - Name, age, gender, admitting diagnosis - Medical/surgical history, chronic illnesses - Advanced Directives - Laboratory Data/Diagnostic tests - Medications - Allergies - Support Services - Psychosocial/Cultural Assessment - Emotional state - Comprehensive Physical Assessment ## Comprehensive Physical Assessment - Vital signs - Height & weight - Review of systems (neurological/mental status, musculoskeletal, cardiovascular, respiratory, GI, GU, skin and wounds. - Standardized risk assessments: - Pressure ulcers, falls, DVT # Nursing Diagnosis - Evaluating - Assessing - Diagnosing - Analyze data - Identify health problems, risks, and strengths - Formulate diagnostic statements - Implementing - Planning ## Nursing Diagnosis - Assessment: Critical analysis of data - Diagnosis or Problem Identification - Is a clinical judgment about individual, family or community responses to actual or potential health problems or life processes ## Purposes - Nursing Diagnosis - Common language for nurses - A clinical judgment about an individual, family or community response to an actual or potential health problem or life process, - Nursing diagnosis provide a basis for selection of nursing interventions so that goals and outcomes can be achieved - NANDA list of acceptable diagnoses, updated every 2 years. ## Components of nursing diagnosis - Problem statement - Etiology - Defining characteristics ## Nursing Diagnosis - Actual or Potential problems identified - Actual: actual evidence of signs/ symptoms of diagnosis exist. (Fluid Volume Deficit) -Potential/Risk for Diagnosis: client's data base contains risk factors of diagnosis, but no true evidence (Risk for altered skin integrity) ## Writing a Nursing Diagnosis - Actual Problems: Problem (NANDA label) & Etiology & Supporting Signs and Symptoms - Impaired Communication related to language barrier as evidenced by inability to speak English ## Writing a Nursing Diagnosis - Potential or Risk Problems: Problem (NANDA label) & etiology or problem & risk factors with related to statement linking problem to risk factors.  - Risk for Impaired skin integrity related to obesity, excessive diaphoresis, and immobility. ## Writing A Nursing Diagnosis - Use accepted qualifying terms (Altered, Decreased, Increased, Impaired) - Don't use Medical Diagnosis (Altered Nutritional Status related to Cancer) - Don't state 2 separate problems in one diagnosis # Planning - Evaluating - Assessing - Implementing - Diagnosing - Planning - Prioritize problems/diagnoses - Formulate goals/desired outcomes - Select nursing interventions - Write nursing orders ## Planning process - Set your priorities of care, what needs to be done first, what can wait. - Select Nursing Standards, Nurse Practice Act, National practice guidelines, hospital policy and procedure manuals. - Identify your goals & outcomes, derive them from nursing diagnosis/problem. Determine interventions, based on goals. - Record the plan (develop nursing care plan/concept map) ## Planning - Risk for Impaired skin integrity related to immobility - Now restate the first clause in a statement that describes improvement, control or absence of problem - The patient will have no signs of skin breakdown during hospital stay. - Outcome needs to be time related. ( state time period to achieve goal) ## Short Term vs. Long Term Goals - Short term goal can be achieved in a reasonable amount of time ( few hours to few days) - Long term goals may take weeks/months to be achieved - Client will ambulate down the hall within 2 days. - Client will walk the length of the hallway independently by the end of 2 weeks ## Achieving Goals/Outcomes - Be realistic in setting goals. (look at overall health state, growth & development level, prognosis) - Set goals mutually with client - Goals should be measurable, use measurable, observable verbs - Identify one behavior per outcome - When indicated use short-term vs. long term goals ## Plan Interventions - Nursing interventions are actions performed by nurse to reach goal or outcome - Monitor health status - Minimize client risks - Direct Care Intervention: Direct action performed to client (inserting foley catheter)  - Indirect Care Intervention: actions performed away from client ( looking at ... lab results) ## Plan Interventions - Interventions will be collaborative, combining nursing actions and physician orders. - Ineffective Airway Clearance related to incisional pain - Nursing Actions: Ascultate breath sounds every four hours, Assist with coughing and deep breathing every hour etc. - Physician orders: pain medication, . . . activity orders ## Types of nursing action - Independent nursing action(sponge for fever - Dependent nursing action( carry out doctors order) - Collaborative nursing action (physiotherapy) - Standing orders- written document with rules & policies of a hospital (shock for VF) - Protocols – guidelines for medical treatment (algorithms for rx) ## PLANNING - Initial [planning - On going planning - Discharge planning # Implementation - Evaluating - Assessing - Diagnosing - Implementing - Reassessing the client - Determining the nurse's need for assistance - Implementing the nursing interventions - Supervising the delegated care - Documenting nursing activities - Planning ## Implementation - Putting your plan into action - Set priorities after report - Assess and reassess - Perform interventions - Chart client responses - Give report to next shift ## Implementation of Nursing Interventions - Describes a category of nursing behaviors in which the actions necessary for achieving the goals and outcomes are initiated and completed - Action taken by nurse ## Implementation Process involves: - Reassessing the client - Reviewing and revising the existing care plan - Organizing resources and care delivery (equipment, personnel, environment) # Evaluation - Evaluating - Collecting data related to outcomes - Comparing data with outcomes - Relating nursing activities to outcomes - Drawing conclusions about problem status - Continuing, modifying, or terminating the nursing care plan - Assessing - Diagnosing - Implementing - Planning ## Evaluation - Evaluation of individual plan of care includes determining outcome achievement - Identify variables/factors affecting outcome achievement - Decide where to continue/modify/terminate plan - Continue/modify/terminate plan based on whether outcome has been met (partially or completely) - Ongoing evaluation, intermittent evaluation, . . . terminal evaluation ## Evaluation - Step of the nursing process that measures the client's response to nursing actions and the client's progress toward achieving goals - Data collected on an on-going basis - Supports the basis of the usefulness and effectiveness of nursing practice - Involves measurement of Quality of Care # Nursing Care Plans - Innovative approach to planning & organizing nursing care. Guide for nursing action & care - Essentially a diagram of patient problems and interventions - Communicates a client's nursing care to all members of the health care team. - Enhances critical thinking and clinical reasoning - Used to organize patient data, analyze relationships, establish priorities ## Student care plans - Assessment - Nursing diagnosis - Plan interventions with Rationale - Intervention - Evaluation ## Sequence - Demographic data - Present medical history/chief complaints - Past medical/ surgical history  - Personal history/diet/education/habits etc - Family history/ hereditary - Socioeconomic status - Investigations - Medications # Thank you.