Nursing Process PDF

Nursing Process Prepared by Mr/Khaled Metwaly Lecturer-Nursing program. Objectives : At the end of this lecturer , the student will : 1- Understand definition , importance and characteristics of the nursing process. 2- Understand the five components of nursing process. 3- Understand the assessme...

Nursing Process Prepared by Mr/Khaled Metwaly Lecturer-Nursing program. Objectives : At the end of this lecturer , the student will : 1- Understand definition , importance and characteristics of the nursing process. 2- Understand the five components of nursing process. 3- Understand the assessment process and methods of data collection. 4-Understand how to formulate nursing diagnoses based on the data collected from the assessment process. 5- will be able to create nursing care plan and expected out comes. 6- Understand the nursing intervention process. Outlines :  Definition of Nursing process.  Characteristics of the Nursing Process  Importance of the Nursing Process  Nursing assessment  Nursing diagnosis  Nursing planning  Nursing intervention  Nursing evaluation  References Definition of Nursing process. Nursing process is a systematic, critical thinking approach used by nurses to provide patient-centered care. It is a cyclical process that involves five main steps: assessment, diagnosis, planning, implementation, and evaluation. Nursing process is a systematic, problem-solving approach that nurses use to provide individualized care for patients. It encompasses five key phases: assessment, diagnosis, planning, implementation, and evaluation. This framework helps nurses to organize and deliver quality care while improving patient outcomes. Nursing process consists of :  Nursing assessment  Nursing diagnosis  Nursing planning  Nursing intervention Characteristics of the Nursing Process Systematic: The nursing process follows a structured and organized approach, ensuring that all aspects of patient care are addressed in a logical manner. Dynamic: The nursing process is not a static process but rather a dynamic one that adapts to the changing needs of the patient. Patient-Centered: The nursing process focuses on the individual needs and preferences of the patient, ensuring that care is tailored to their specific situation. Collaborative: The nursing process involves collaboration among the healthcare team, including physicians, nurses, and other healthcare professionals, to ensure coordinated and comprehensive care. Evidence-Based: The nursing process is based on the best available evidence, ensuring that care is informed by research and clinical expertise. Cyclical: The nursing process is a cyclical process, meaning that it is  Importance of the Nursing Process The nursing process is essential for providing high-quality patient care. It helps nurses to: Identify and address patient needs: By systematically assessing the patient's condition, nurses can identify their needs and develop appropriate interventions. Develop individualized care plans: The nursing process allows nurses to develop care plans that are tailored to the specific needs and preferences of each patient. Promote patient safety: By following a structured approach, nurses can reduce the risk of errors and ensure that patient safety is maintained. Improve communication: The nursing process facilitates communication among the healthcare team, ensuring that everyone is  Nursing Assessment Definition A nursing assessment is the systematic and continuous collection, organization, validation, and documentation of patient data. It is the first step in the nursing process and provides the foundation for all subsequent nursing actions.  Types of Nursing Assessments There are several types of nursing assessments, each with a specific purpose: 1.Initial Assessment: This is a comprehensive assessment performed shortly after the patient is admitted to a healthcare facility. It collects baseline data about the patient's health status. 2.Focused Assessment: This is a more targeted assessment that focuses on a specific problem or body system. It is often used to monitor a patient's condition or to identify changes in their status. 3.Emergency Assessment: This is a rapid assessment performed in life-threatening situations. It focuses on identifying and addressing immediate threats to the patient's life. 4.Time-lapsed Assessment: This is a reassessment of the patient's initial assessment at regular intervals. It is used to monitor the patient's progress and identify any changes in their condition.  Methods of Nursing Assessment Nursing assessments utilize a variety of methods to gather comprehensive patient data. These methods include: 1.Observation: 1.Direct observation: Involves observing the patient's behavior, appearance, and interactions with the environment. 2.Indirect observation: Involves reviewing medical records, diagnostic tests, and other available information. 2.Interview: 1.Patient interview: Involves gathering information directly from the patient about their health history, current symptoms, and concerns. 2.Family/significant other interview: Involves gathering information from family members or significant others about the patient's health and well-being. 3- Physical Examination: Inspection: Visual examination of the patient's body for any abnormalities. Palpation: Using the hands to touch and feel the patient's body for any abnormalities, such as tenderness, masses, or changes in texture. Percussion: Tapping on the patient's body to assess underlying structures and identify any changes in resonance. Auscultation: Listening to the sounds produced within the body, such as heart, lung, and bowel sounds, using a stethoscope. 4- Diagnostic Tests: Utilizing various diagnostic tests, such as blood tests, X-rays, and electrocardiograms, to obtain objective data about the patient's health status. 5- Review of Systems: A systematic review of all body systems to identify any potential health problems. Types of Data in Nursing Assessment Data collected during a nursing assessment can be broadly classified into two main categories: 1.Subjective Data: 1.This type of data is based on the patient's own perceptions, feelings, beliefs, and statements. It is subjective because it is influenced by the patient's personal interpretation of their health status. 2.Examples: 1.Pain level (e.g., "My pain is a 7 out of 10.") 2.Feelings of anxiety or depression 3.Patient's description of their 1.Objective Data: 1.This type of data is based on observable, measurable, and verifiable facts. It is obtained through direct observation, physical examination, and diagnostic tests. 2.Examples: 1.Vital signs (e.g., blood pressure, temperature, pulse, respirations) 2.Height and weight 3.Physical exam findings (e.g., skin rash, abnormal lung sounds) 4.Laboratory test results (e.g., blood glucose levels, complete blood count) 5.Diagnostic imaging results (e.g., X-rays, CT scans)  Process of Assessment  Data collection , when you collect data from patient.  Interpretation , as you gather the data , you begin to differentiate important data from all the data you collected  Validation , before you complete data interpretation , validate the information you collected to avoid making incorrect inferences. Validation of assessment data is the comparison of data with another source to determine data accuracy.  Nursing Diagnosis Nursing diagnosis, it is a clinical judgment about the patient's response to actual or potential health conditions/life processes. Differentiate it from a medical diagnosis. Emphasize its focus on patient responses rather than diseases. Importance of Nursing Diagnosis:  Guides the development of the nursing care plan.  Ensures patient-centered care by focusing on individual needs.  Improves communication among healthcare providers.  Facilitates the delivery of quality care.  Components of a Nursing Diagnosis 1. Problem Statement: Describes the patient's health problem or need. Examples: Acute Pain Impaired Skin Integrity Risk for Falls 2. Etiology/Related Factors: Identifies the factors contributing to the problem. Examples: "Related to" surgical incision "Related to" immobility "Related to" history of falls  Cont. Components of a Nursing Diagnosis 3. Defining Characteristics: Signs and symptoms that support the diagnosis. Examples: Self-reported pain level of 8/10 Redness and swelling at incision site Use of assistive devices  Types of Nursing Diagnoses Actual Diagnoses: Describe existing problems. Example: Impaired Skin Integrity related to prolonged immobility as evidenced by reddened area over bony prominences. Risk Diagnoses: Identify potential problems. Example: Risk for Falls related to unsteady gait. Wellness Diagnoses: Focus on strengths and healthy responses. Example: Readiness for Enhanced Nutrition.  Nursing Planning Nursing planning is the third step in the nursing process, following assessment and diagnosis. It involves developing a comprehensive plan of care to address the patient's identified needs and achieve desired outcomes. The planning phase is a crucial step in the nursing process, following assessment and diagnosis. It involves developing a comprehensive plan of care to address the patient's identified needs and achieve desired outcomes. Effective planning ensures that nursing interventions are targeted, efficient, and patient-centered.  Steps of nursing planning 1.Prioritizing Patient Needs: 1.Maslow's Hierarchy of Needs: This model prioritizes needs based on their importance for survival and well- being, from physiological needs (e.g., air, water, food) to self-actualization. 2.ABCDE Principle: This prioritization framework focuses on: 1.Airway: Ensuring a patent airway. 2.Breathing: Assessing and supporting adequate breathing. 3.Circulation: Monitoring and maintaining adequate blood circulation. 4.Disability: Identifying and addressing neurological 2- Setting Patient-Centered Goals: 1.SMART Goals: These goals are: 1.Specific: Clearly defined and focused. 2.Measurable: Quantifiable and trackable. 3.Attainable: Realistic and achievable. 4.Relevant: Aligned with the patient's needs and priorities. 5.Time-bound: With a specific timeframe for achievement. 3. selecting Nursing Interventions: Evidence-Based Practice: Using the best available evidence to guide the selection of interventions. Clinical Expertise: Drawing on the nurse's knowledge, skills, and experience to choose appropriate interventions. Patient Preferences: Considering the patient's values, beliefs, and preferences when selecting interventions. 4- Documenting the Care Plan: Using a standardized format to document the care plan, ensuring clear and concise communication among healthcare providers.  Nursing Interventions The Action Phase of the Nursing Process Nursing Interventions are the specific actions that nurses take to address patient needs and achieve desired outcomes. They are the "how" of the nursing process, translating the nursing diagnoses and goals into concrete actions. Key Characteristics of Nursing Interventions: Evidence-Based: Interventions should be based on the best available evidence, such as research studies and clinical guidelines. Patient-Centered: Interventions should be tailored to the individual needs and preferences of each patient. Realistic and Achievable: Interventions should be realistic and achievable within the context of the patient's condition and the healthcare setting. Collaborative: Interventions often involve collaboration with other members of the healthcare team, such as physicians, physical therapists, and social workers.  Nursing Evaluation Evaluation is the final step of nursing process , which involves collecting data, comparing it to the expected outcomes, and drawing conclusions about the effectiveness of the nursing interventions.  Methods of Evaluation Several methods can be used to evaluate patient outcomes: 1.Observation: Observing the patient's behavior, appearance, and interactions with the environment to assess their progress. 2.Interview: Interviewing the patient to gather their subjective assessment of their health status and progress. 3.Physical Examination: Conducting a physical examination to assess the patient's physiological status and identify any changes. 4.Diagnostic Tests: Utilizing diagnostic tests, such as blood tests or X-rays, to monitor the patient's progress and identify any complications. 5.Review of Medical Records: Reviewing the patient's medical records to track their progress over time and identify any patterns. 6.Patient Self-Report: Encouraging patients to self-report their progress and identify any challenges they are facing.  Case Study: Patient’s name : Mr. Jones Assessment: Subjective Data: 72-year-old male, admitted to the hospital with a diagnosis of pneumonia. Complains of shortness of breath, productive cough with green sputum, and fever. Reports fatigue, decreased appetite, and difficulty sleeping. Denies recent travel or exposure to sick individuals. Medical history: Hypertension, type 2 diabetes, and osteoarthritis. Medications: Lisinopril, Metformin, and Acetaminophen. Allergies: Penicillin. Objective Data: Vital signs: Temperature 101.2°F (38.4°C), Pulse 102 bpm, Respirations 24/min, Blood Pressure 140/90 mmHg, SpO2 90% on room air. Physical exam: Crackles in bilateral lung bases, decreased breath sounds, productive cough with green sputum. Laboratory results: White blood cell count elevated, C- reactive protein elevated. Chest X-ray: Evidence of pneumonia in the right lower lobe. Nursing Diagnoses: Ineffective Airway Clearance related to excessive mucus production as evidenced by productive cough with green sputum, crackles in lung bases. Impaired Gas Exchange related to alveolar-capillary membrane changes as evidenced by SpO2 90% on room air, tachypnea. Activity Intolerance related to fatigue and weakness as evidenced by reports of decreased energy and difficulty performing activities of daily living. Risk for Imbalanced Nutrition: Less Than Body Planning Goals: Ineffective Airway Clearance: The patient will demonstrate effective airway clearance as evidenced by clear breath sounds, productive cough, and expectoration of secretions within 48 hours. Impaired Gas Exchange: The patient will maintain SpO2 ≥ 92% on room air or prescribed oxygen therapy within 48 hours. Activity Intolerance: The patient will participate in activities of daily living with minimal fatigue within 72 hours. Risk for Imbalanced Nutrition: Less Than Body Requirements: The patient will maintain or increase nutritional intake as evidenced by adequate food and fluid intake, stable weight, and improved appetite Interventions: Ineffective Airway Clearance: Encourage deep breathing exercises and coughing techniques. Administer prescribed medications, such as antibiotics and bronchodilators. Provide chest physiotherapy as ordered. Monitor sputum production and characteristics.  Impaired Gas Exchange: Monitor respiratory status, including SpO2, respiratory rate, and work of breathing. Administer oxygen therapy as prescribed. Position patient in Fowler's or high-Fowler's position to facilitate breathing. Activity Intolerance: Assist with activities of daily living as needed. Encourage frequent rest periods. Gradually increase activity level as tolerated.  Risk for Imbalanced Nutrition: Less Than Body Requirements: Monitor food and fluid intake. Encourage small, frequent meals. Consult with a dietitian for nutritional counseling. Evaluation: The nurse evaluates the patient's progress towards achieving the established goals. The nurse reassesses the patient's condition and modifies the plan of care as necessary. The nurse documents all assessments, interventions, and evaluations in the patient's medical record.  Reference: Ackley, B. J., Ladwig, G. B., Makic, M. B., Martinez-Kratz, M., & Zanotti, M. (2017). Nursing diagnoses: Definitions and classification 2018-2020. NANDA International. Herdman, T. H., & Kamitsuru, S. (2018). Nursing Diagnoses in Psychiatric Nursing: Definitions and Classifications 2015-2017. NANDA International. Ackley, B. J., Ladwig, G. B., Makic, M. B., Martinez-Kratz, M., & Zanotti, M. (2017). Nursing diagnoses: Definitions and classification 2018-2020. NANDA International. Ackley, B. J., Ladwig, G. B., Makic, M. B., Martinez-Kratz, M., & Zanotti, M. (2017). Nursing diagnoses: Definitions and classification 2018-2020. NANDA International. Ackley, B. J., Ladwig, G. B., Makic, M. B., Martinez-Kratz, M., & Zanotti, M. (2017). Nursing diagnoses: Definitions and classification 2018-2020. NANDA International. American Nurses Association. (2010). Scope and standards of practice. Silver Spring, MD: Author.