Nursing Process PDF

 Nursing process Dr/ Amira Sabry Mohamed Lecturer of medical surgical nursing  Nursing process Systemic steps that professional nurses use to apply the best available evidence to deliver nursing care. Purposes of nursing process: 1- Identify client strengths and poten...

 Nursing process Dr/ Amira Sabry Mohamed Lecturer of medical surgical nursing  Nursing process Systemic steps that professional nurses use to apply the best available evidence to deliver nursing care. Purposes of nursing process: 1- Identify client strengths and potential or actual health problems or needs 2- Develop specific nursing interventions to achieve outcomes. 3-Provide individualized, holistic, effective client care efficiently. 4- Providing professional, quality nursing care. 5. Provides the basis for critical thinking in nursing.  Characteristics Systematic: an ordered sequence of activities Cyclical & Dynamic: great interaction and overlapping among the five steps Interpersonal: human being is always at the heart of nursing Outcome oriented: nurses and patients work together to identify outcomes Universally applicable: a framework for all nursing activities Client-centeredness: the nurse organizes the plan of care according to client problems. Focus on problem solving Focus on decision making Interpersonal and collaborative style: Nurses collaborate, as members of the health care team, to provide quality client care. Use of critical thinking 1. Assessment 2. Diagnosis 3. Planning 4. Implementation 5. Evaluation  Steps (Phases) of nursing process 1. Assessment: Is the first step in the nursing process and includes systematic collection of data to determine the patient’s health status and any actual or potential health problems  Dimensions for gathering data Complete health history for patient and family (past, present) Physical examination for all body system Examine patient from head to toes Characteristics of data Purposeful Complete Factual and accurate Relevant Two sources of data collection Patient (Primary source) by using both interview and physical examination. Secondary sources:- Family caregiver, family members Medical records Healthcare professionals Nursing staff Friends  Purpose of assessment: 1. Organize a database regarding a client's health status and needs. 2. Identify actual or potential health problems 3. The nurse can ascertains of the clients about: a. Functional abilities b. Absence or presence of dysfunction c. Normal activities of daily living d. Lifestyle pattern. 4. Provides an opportunity to form therapeutic relationship with clients. Three types of assessment: 1. Comprehensive assessment: 2. Focused assessment: 3. Ongoing assessment:  1. Comprehensive assessment: a. Provide baseline of client data including a complete health history and current needs assessment. b. Usually completed upon admission to health care agency. c. Changes in the clients' health status can be measured against this database.  2. Focused assessment: a. Is limited to potential health care risks, a particular need, or health care problem. b. There are not as a detailed as comprehensive assessment. c. Used in specialty areas such as mental health settings and delivery. d. Used in screening for specific problems  3. Ongoing assessment: a. Follow up, or monitoring of specific problems. b. Determine the client's response to nursing interventions and to identify any other problems. Types of Data collection: A. Subjective data (symptoms) B. Objective data (signs) A. Subjective data (symptoms) -Information that is provided verbally by the patient -Information perceived only by the affected person -For example, pain, dizziness, feeling anxious  B. Objective data (signs): Are observable and measurable data that are obtained through both physical examination and the result of laboratory and diagnostic tests. The primary method of collecting objective information is the physical examination by Inspection, palpation, percussion, and auscultation techniques For example, elevated temperature, skin moisture, and vomiting, flushed face. Methods of Collection 1- Observation 2- Interviewing 3- Examination  Documenting the data: Assessment data must be recorded and reported. The nurse must make a judgment about which data are to be reported immediately as data that reflect a significant deviation from the normal (rapid heart rate with irregular rhythm, severe difficulty in breathing, or high levels of anxiety) should be reported as well as recorded. Examples of data that need only to be recorded at the time include a report that prescribed medication has relieved a headache and a determination that an abdominal dressing is dry and intact.  NOTE: Assessment is dynamic and continues with each nurse-client interaction. 2. Nursing Diagnosis phase: According to the North American Nursing Diagnosis Association (NANDA): Nursing diagnosis: is a clinical judgment about individual, family, or community responses to actual or potential health problems..  A medical diagnosis: Is a clinical judgment by the 3 physician that identifies or determines a specific disease, condition, or pathological state.  Nursing Diagnosis Medical Diagnosis Focuses on clients responses to Focuses on illness, injury, or actual or potential health problems disease process. Changes as the client’s response Remains constant until a cure is and/or the health problem changes. effected or client dies. Recognizes situations that the Recognizes conditions the nurse is licensed and qualified to physician is licensed and qualified intervene. to treat. Example: (Nausea, Acute pain, Example: (Lung cancer, Anxiety, Impaired physical Congestive heart failure, Brain mobility, Ineffective breathing tumor, Exploratory surgery, pattern, Risk for imbalanced fluid Appendectomy, Bronchial volume). asthma).  Purpose of diagnosing step: Identify how an individual, group, or community responds to actual or potential health and life processes. Identify factors that contribute to, or cause, health problems (etiologies). Identify resources or strengths upon which the individual, group, or community can draw to prevent or resolve problems provides the basis for selection of nursing interventions to achieve outcomes for which the nurse is accountable Types of Nursing Diagnoses/ Problem Statements 1. An actual nursing diagnosis 2. A potential nursing diagnosis 3. A risk nursing diagnosis 4. A wellness nursing diagnosis 1. An actual nursing diagnosis: client problem that is already present at the time of the nursing assessment 2. A potential nursing diagnosis: is one in which evidence about a health problem is incomplete or unclear. A potential diagnosis requires more data either to support or to refute it. 3. A risk nursing diagnosis: is a clinical judgment that a problem does not yet exist, but the presence of risk factors indicates that a problem is likely to develop unless the nurse intervenes. For example, all people admitted to a hospital have some possibility of acquiring an infection 4. A wellness nursing diagnosis: Sometimes is referred to as health promotion diagnosis, which relates to clients’ preparedness to implement behaviors to improve their health condition  Components of a NANDA Nursing Diagnosis Problem: Activity Intolerance Etiology “related to” Related to Bed rest Defining Characteristics / signs & symptoms “ as evidenced by” As evidenced by Verbal report of fatigue  Example ND: Acute pain r/t myocardial ischemia as evidenced by C/O of radiating chest pain to neck and left jaw  3. Planning: Development of goals and outcomes, as well as a plan of care designed to assist the patient in resolving the diagnosed problems and achieving the identified goals and desired outcomes  The Planning Process 1- Setting priorities based on Maslow's Hierarchy of Human Needs 2- Establishing client goals/desired outcomes 3- Writing individualized nursing interventions on care plans 1- Setting priorities based on Maslow's Hierarchy of Human Needs  Steps to Setting Priorities 1- Assign high priority to first-level priority problems (immediate priorities): Remember the “ABCs plus V”: Airway problems Breathing problems Cardiac/circulation problems Vital sign concerns (e.g., high fever) Exception: With cardiopulmonary resuscitation (CPR) for cardiac arrest, begin chest compressions immediately. 2. Second-level priority problems: Mental status change (confusion, decreased alertness) Untreated medical problems requiring immediate attention (a person with diabetes who has not had insulin) Acute pain Acute urinary elimination problems Abnormal laboratory values Risks of infection, safety, or security 3. Third-level priority problems (later priorities): Health problems that do not fit into the previous categories (e.g., problems with lack of knowledge, activity, rest, family coping)  2- Establishing client goals/ desired outcomes After establishing priorities, the nurse and client set goals for each Nursing diagnosis Goal (broad): Improved nutritional status. Desired outcome (specific): Gain 5 KG by April 25. Expected Outcomes must be (SMART) S Specific M Measurable A Attainable \ achievable R Realistic T Timed Purpose of Goals/Desired Outcomes Provide direction for planning nursing interventions Serve as criteria for evaluating client progress. Help motivate the client and nurse by providing a sense of achievement  Types of goals Short-term goals -Outcomes achievable in a few days or 1 week Long-term goals Desirable outcomes that take weeks or months to accomplish for client’s with chronic health problems 3-Writing individualized nursing interventions on care plans Type of nursing care plan 1- Initial 2-Ongoing 3-Discharge (on admission)  4. Implementation phase: It performing nursing activities that have been planned to meet the goals. It is the action phase in which the nurse performs the nursing interventions. It consists of doing and documenting the activities after carrying out the nursing activities. Types of Nursing Interventions Nurse-initiated Independent actions Physician-initiated Dependent actions Collaborative  Nurse-initiated—actions performed by a nurse without a physician’s order Independent actions Those activities that nurse are licensed to initiate on the basis of their knowledge and skills. They include physical care, ongoing assessment, emotional support and comfort, teaching, counseling, environmental management, and making referrals to other health care professionals.  Physician-initiated—actions initiated by a physician in response to a medical diagnosis but carried out by a nurse under doctor’s orders Dependent actions Activities carried out under the orders or supervision physician or other health care provider authorized to write orders to nurses Nurse is depending on Dr. (to write order for medication) for intervention  Collaborative Actions the nurse carries out in collaboration with other health team members, such as physical therapists, social workers, dietitians, and primary care providers. Working with other members of team for intervention  EX: Nurse Initiated Interventions Monitor health status. Reduce risks. If patient drowsy, put side rails up and monitor near patient If patient is in respiratory difficulty; put patient in higher position and put oxygen Facilitate independence or assist with ADLs (activities of daily living).  5. Evaluation phase: Determination of the patient’s responses to the nursing interventions and the extent to which the outcomes have been achieved. Determining whether the goals have been met, partially met, or not met. 1. If the goal has been met, the nurse must then decide whether nursing activities will stop or continue in order for status to be maintained. 2. If the goal has been partially met or not been met, the nurse must reassess the situation and change the plan of care accordingly. There are a number of possible reasons that goals are not met or are only partially met, including: a. The initial assessment data were incomplete. b. The goals and expected outcomes were not realistic. c. The time frame was too optimistic. d. The nursing interventions planned were not appropriate for the client. 54