Nursing Process 2024-2025 Lecture PDF

Nursing Process Prof: Hanan Ramzy Ataaallah Professor of Medical Surgical Nursing  Outline:  Definition of nursing process  Characteristics of nursing process  Steps of nursing process  Components of a NANDA nursing diagnosis  Comparison of nursing and medical...

Nursing Process Prof: Hanan Ramzy Ataaallah Professor of Medical Surgical Nursing  Outline:  Definition of nursing process  Characteristics of nursing process  Steps of nursing process  Components of a NANDA nursing diagnosis  Comparison of nursing and medical diagnosis  Application of nursing process  The nursing process is a systematic, rational method of planning and providing nursing care.  Its purpose is to identify a client's health care 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. Phases of nursing process  The 5 phases of nursing process are assessment, nursing diagnosis, planning, implementation and evaluation. Each phase of nursing process affects the others; they are closely interrelated.  Characteristics of nursing process:  nursing process is cyclic and dynamic.  It is client centered.  It is an adaptation of problem solving.  Decision making is involved in every phase of the nursing process.  It is interpersonal and collaborative.  Use critical thinking skills  I-Assessment:  It is the systematic and continuous collection, organization, validation and documentation of data. Types of assessment: there four types of assessment as follow:  1-Initial assessment: performed after admission to a health care agency to establish a complete data base for problem identification, reference and future comparison, e.g. nursing admission assessment  CONT’ Types of assessment  2-Problem- focused assessment: It is ongoing process integrated with nursing care. It is used to determine the status of a specific problem identified in an earlier assessment, e.g. Hourly assessment of client’s fluid intake and urinary output in an Intensive Care Unit.  3-Emergency assessment: it is used during any physiologic or psychological crisis of the client to identify life threaten problems, e.g. Rapid assessment of an individual’s airway, breathing status, and circulation during a cardiac arrest or suicidal attitude of patient.   4-Time- lapsed assessment: it occurs several months after initial assessment to compare the current status to base line data previously obtained, e.g. Reassessment of a client’s functional health patterns in a home care or outpatient setting or, in a hospital, at shift change The assessment process involves four related activities  Collecting data: is the process of gathering information about a client health status to prevent the omission of significant data and reflect a client changing health status.  Data base: is all information about a client; it includes the nursing health history, physical assessment, primary care provider’s history and physical examination, results of laboratory and diagnostic tests.  Types of data:  1-Subjective data (symptoms) or covert data can be described or verified only by affected person. It includes sensations, feelings, values, beliefs, attitudes and perception of personal health status. Itching, pain, and feeling of worry are examples of subjective data.  2-Objective data (signs) or overt data, are detectable by an observer or can be measured or tested against an accepted standard. They can be seen, heard, felt or smelled and they are obtained by observation or physical examination as discoloration of the skin or blood pressure reading. Source of data:  Are primary or secondary.  The client is the primary source.  Family members or other support persons, other health professionals, records and reports, laboratory and diagnostic analyses are secondary or indirect sources.  Methods of data collection:  The methods used to collect data are observation, interview, and examination, diagnostic procedure and lab investigation.  Observation: It is gathering data by using the senses. Vision, Smell and Hearing are used.  Interview: An interview is a planned communication or a conversation with a purpose. Physical Examination  A complete examination includes a patient’s height, weight, vital signs, and a head-to-toe examination of all body systems. Techniques of physical examination: there are 4 technique of physical examination: inspection, palpation, percussion and auscaltation  Inspection  Carefully look, listen, and smell to distinguish normal from abnormal findings, watching for nonverbal expressions of emotional and Physical movements.  Palpation  Palpation involves using the sense of touch to gather information.  Percussion  Percussion: tapping the skin with the fingertips to vibrate underlying tissues and organs.  Auscultation  Auscultation involves listening to sounds the body makes to detect variations from normal. Diagnostic and Laboratory Data  Organizing the data The nurse uses a written (or computerized) format that organizes the assessment systematically.  Validating the data the act of double checking or verifying data to confirm that it is accurate and complete.  Documenting data. To complete assessment phase, the nurse records all data collected about the client’s health status. II-Nursing diagnosis  North American Nursing Diagnosis Association (NANDA) adopt an official working definition of nursing diagnosis: “… a clinical judgment about individual, family or community responses to actual and potential health problems/ life processes. Types of nursing diagnosis  An actual diagnosis is a client problem that is present at the time of the nursing assessment. An actual nursing diagnosis is based on the presence of associated signs and symptoms.  Ex; ineffective breathing pattern and anxiety.  A risk nursing diagnosis / potential is a clinical judgment that a problem doesn’t exist, but the presence of risk factors indicates that a problem is likely to develop unless nurses intervene.  Ex; all people admitted to a hospital have higher risk for infection. Cont’  A health promotion diagnosis relates to clients’ preparedness to implement behaviors to improve their health condition. These diagnosis labels begin with the phrase Readiness for Enhanced, as in Readiness for Enhanced Nutrition. Components of a NANDA nursing diagnosis: it has 3 components and is written in a format called (PES):  Problem (diagnostic label) and definition: the problem statement describes the client’s health problem or response for which nursing therapy is given, for example, Deficient Knowledge (Medications) or deficient Knowledge (Diet).  2-Etiology (related factors and risk factors): it identifies one or more probable causes of the health problems, gives direction to the required nursing therapy and enables the nurse to individualize the client’s care.  3- Defining characteristics (Signs and symptoms): are the cluster of signs and symptoms that indicate the presence of a particular diagnostic label.  For actual nursing diagnosis, the defining characteristics are the client’s signs and symptoms.  For risk nursing diagnoses, no signs are present. Thus, the factors that causes the client to be more vulnerable to the problem from the etiology of a risk nursing diagnosis. N.B: Actual nursing diagnosis must contain 3 parts:  (1) Diagnostic label (problem)  (2) Related to (contributing factors or etiology)  (3) As evidenced by (signs & symptoms =defining characteristics  ∎ Example: Noncompliance related to knowledge deficit of the need for weekly blood pressure measurements, as evidenced by “I don’t keep my BP appointments if I am busy.”  Basic two-part statements  Problem (P): statement of the client’s response (NANDA label)  Etiology (E): factors contributing to or probable causes of the responses  N.B:The two parts are joined by the words related to rather than due to. Usually used for potential (risk) problems  Example: Risk for impaired skin integrity related to immobility  Nursing diagnosis Medical diagnosis A nursing diagnosis is a statement of A medical diagnosis is made by a nursing judgment that made by nurse, physician by their education, experience, and expertise, are licensed to treat Nursing diagnoses describe the human Medical diagnoses refer to disease response to an illness or a health processes problem Nursing diagnoses may change as the A client’s medical diagnosis remains client’s responses change the same for as long as the disease is present Examples Ineffective breathing pattern Asthma Activity intolerance Cerebrovascular accident Acute pain Appendicitis Formulating diagnostic statements  Basic three-part statement includes the following I. Problem (P) II. Etiology (E) III. Signs and symptoms (S) : defining characteristics Example: Noncompliance (Diabetic Diet) related to unresolved anger about diagnosis as manifested by S- I can’t live without sugar in my food. O- Weight 98 kg (gain of 4.5 kg) and blood pressure 190/ 100 mm hg. Impaired Physical Mobility related to decreased muscle control as evidenced by inability to control lower extremities. Acute Pain related to tissue ischemia as evidenced by statement of “I feel severe pain on my chest!”  PLANNING:  Planning involves decision making and problem solving.  It is the process of formulating client goals and designing the nursing interventions required to prevent, reduce, or eliminate the client’s health problems TYPES OF PLANNING  1. Initial Planning: Planning which is done after the initial assessment.  2. Ongoing Planning: It is a continuous planning.  3. Discharge Planning: Planning for needs after discharge Guidelines for writing nursing care plans:  Date and sign the plan.  Use standardized medical or English symbols and key words  Be specific about expected timing of an intervention.  Refer to the procedure books or other sources of information CONT’ Ensure that  the plan containing intervention for ongoing assessment of the client.  Include collaborative and coordination activities in the plan.  Include plans for the client's discharge and home care needs. Nursing interventions  A nursing intervention is any treatment, that a nurse performs to improve patient’s health.  IMPLEMENTATION  Implementation consists of doing and documenting the activities. The process of implementation includes: Implementing the nursing interventions Documenting nursing activities  EVALUATION  Evaluation is a planned, ongoing, purposeful activity in which the nurse determines THE FOLLOWING:  (a)the client’s progress toward achievement of goals/outcomes and  (b)the effectiveness of the nursing care plan. The evaluation includes:  Identifying criteria and standards  Collecting evaluation data  Interpreting and summarizing finding  Documenting finding  Care plan revision What the nurse can do after evaluation?:  Terminate plan of care or  Modify plan of care or  Continue plan of care