NURSING PROCESS (NURS110).docx

NURSING PROCESS Nursing is the process of by which nurses deliver care to patient, supported by using nursing models and philosophies nurse profession. To adapt form of problem solving and is classified as deductive theory Is a patient centred and goal-oriented method of caring It involves five...

NURSING PROCESS Nursing is the process of by which nurses deliver care to patient, supported by using nursing models and philosophies nurse profession. To adapt form of problem solving and is classified as deductive theory Is a patient centred and goal-oriented method of caring It involves five (5) major steps of ADPIE **History of Nursing Process** - In 1955, Hall oriented the term (care, cure, core) and developed the three (3) steps - Observation - Ministration - Validation - In 1959, Johnson concludes Nursing seen as fostering the behavioural functioning of a client. - In 1961, Orlando identified three (3) steps. Clints behaviour, nurse's reaction, and nurses action. - In 1963, Weidenbach were among the first to use it to refer to a series of phases describing the process. - In 1967, Wiche defined nursing as an interactive process between client and nurse. Four (4) steps - Perception - Communication - Interpretation - Evaluation - In 1967, Yura and Walsh suggested the four (4) components-APIE. **Process** **NURSING PROCESS** The nursing process is a systematic method nurses use to provide individualized care by collecting data, identifying issues or problems, setting goals, implementing interventions, and evaluating outcomes. It is a cyclic and dynamic problem-solving approach that is client-centered **PURPOSE OF NURSING PROCESS** - To identify a client's health status, actual or potential health care problems or needs, to establish plans to meet the identified need, and to deliver specific nursing intervention to meet those needs. - It helps nurses in arriving at decision and predicting and evaluating consequences. - It developed as a specific method of applying a scientific approach or a problem-solving approach to nursing practices - To establish a database about the client's health status, health concerns, response to illness, and the ability to manage health care needs. - Assessment - Diagnosis - Planning - Implementation - Evaluation - **Dynamic and Cyclical:** The nursing process is a dynamic process as it is constantly affected by the patient\'s needs, circumstances impacting their needs, and the environment in which care is applied. It encompasses emotional, physical, social, and medical aspects. Each phase of the nursing process interacts with and is influenced by other phases in a cycle of activity. From the time of admission until the patient is discharged from care, the dynamics of the cycle of nursing care continues. - **Client Centeredness:** nurses consider clients\' individual needs and preferences, and ensure clients are active participants in all aspects of their health care decisions. - **Goal-directed:** care is a form of nursing care delivery based on achieving individualized goals to achieve desired patient outcomes. Goals are created through the collaborative efforts of nurses, other members of the healthcare team, and patients. - Focus on solving problems and decision making - Assessment Is the systematic and continuous collection, organizing, validation and documentation of data - **Initial Nursing Assessment** Initial assessment is performed within a specific time after admitted to establish a complete database for identify problem. E.g. Nursing assessment admission - **Problem- Focused Assessment** To identify or determining the status of a specific problem in earlier assessment for checking of vital sign of a patient. E.g. checking vital signs of a fever patient. - **Emergency Assessment** To identify any life-threatening situation for rapid assessment of an individual's airways, breathing status, and circulation during a cardiac arrest. - **Time-Elapsed Reassessment** Time-elapsed for several month after initial assessment to compare current client health status with the previous data or information obtained. **COLLECTION OF DATA** Data collection is gathering information about client's health status which includes the health history, physical examination, results of laboratory and diagnostic tests, and materials contribute by health personnel. **TYPES OF DATA** Two types of data subjective and and objective data - **Subjective Data** Refers to as convert data, that are clear only to the affected patient and can be described as only by that person. E.g. pain, Itching and feelings of worry. - **Objective Data** Refers to as signs or overt data, that can be measured or tested against an accepted standard. They can be seen, heard, felt, or smelled and they obtained by physical examination or observation. E.g. blood pressure reading **SOURCES OF DATA** Sources of data are primary and secondary. - Primary Data are direct source of information from the client. - Secondary Data are indirect source of information other than the client. They are family members, health professionals, records and reports, laboratory and diagnostic results. **METHODS OF DATA COLLECTION** The method used to collect data are observation, interview and examination. - Observation is gathering data or information by using the senses, vision, smell and hearing are used. - Interview is planned communication with a purpose. There are two approaches to interviewing. Directive and nondirective. - The directive interview is structured and directly ask questions and the nurse controls the interview. - Non-directive interviews the nurses allow the client to control the interview **STAGES OF INTERVIEW** - The introduction or opening - The body or development - The closing - **Examination:** physical examination is a systematic method of collecting data use to detect health problem. To conduct the examination, the nurse uses techniques of inspection, palpation, percussion and auscultation **ORGANIZATION OF DATA** The nurses use a format that organizes the assessment data systematically. **VALIDATION OF DATA** The information gathering during the assessment is verified to confirm that it is accurate and complete. **DOCUMENTATION OF DATA** Is the recording of data accumulated during the initial assessment to complete the nurse's records client data. **QUESTION** Why the assessment phase is important in nursing process? I. To reduce risks of patient safety which occur when other factors or symptoms are not considered II. It helps nurses to gather all the necessary information or data from the patient to establish a care plan. What does tertiary sources of data mean? I. Tertiary data are data gathered from sources such as the patient\'s chart, lab, or x-ray reports. II. Nurses may also use tertiary sources such as diagnostic manuals or textbooks to verify or compare information. - **NURSING DIAGNOSIS** - **PLANNING** Is the process of formulating client goals and designing the nursing interventions required to prevent, reduce, or eliminate the client's health problem. It involves the decision making and problem solving. **TYPES OF PLANNING** There are types of planning, initial, ongoing and discharge planning - Initial Planning is done after the initial assessment in order to prioritize problem, identify goals and correlate nursing care to resolve problems. - Ongoing Planning involves continuous updating of clients plan of care. Every nurse who cares for the client is involved in ongoing planning - Discharge planning involves the anticipation and planning for the client's needs after discharge. **PLANNING PROCESS** - **Setting Priorities:** involves process of establishing the preference order for nursing strategies. The nurse begins planning by deciding which nursing diagnosis requires attention first, which second and so on. Nurses frequently use Maslow's hierarchy of needs when setting priorities. - **Establishing Client Goals/Desired Outcomes:** after establishing priorities, the nurses set goals for each nursing diagnosis, they provide a clear focus for the type of intervention necessary to care for the client when goals are met the problem are solved. - **Selecting Nursing Strategies:** interventions are nursing action chosen to treat a specific nursing diagnosis in order to achieve client goals. - **Writing Nursing Orders:** are specific actions the nurse takes to help the client meet established health care goals.