NURSING PROCESS - systematic, rational method of planning and providing nursing care. -refers to a series of phases describing the practice of nursing. PURPOSES: 1. To identify client’s health status and actual or potential health care problems or needs. 2. To establish plans to meet the identified needs, and to 3. Deliver specific nursing intervention to meet those needs. 5 PHASES/ STEPS OF NURSING PROCESS (ADPIE) 1. A-SSESSMENT 2. D-IAGNOSIS/ ANALYSIS 3. P-LANNING 4. I- MPLEMENTATION/ INTERVENTION/ INTERVENING 5. E-VALUATION CHARACTERISTICS OF NURSING PROCESS A) KOZIER (C2 UFI U) *C-yclic and Dynamic- each phase provide input into the next phase >CYCLIC - regularly repeated events >DYNAMIC - continuously changing *C-lient centered- organize plan of care according to client’s problem *U-niversally Applicable- used as framework for nursing care *F-ocus on problem solving *I- nterpersonal collaborative- communicate in client, families, etc. *U-se of critical thinking- very important in nursing process
B) UDAN (GOSH EE) *G-oal oriented *O-rganized composed of sequential and interrelate steps *S-ystematic *H-umanistic- individualized plan of care EFFICIENT AND EFFECTIVE NURSING CARE
1. ASSESSMENT (COVD) -collection, organization, validation and documentation of data. -is a continuous process carried out during all phases of the nursing process.
* 4 TYPES OF ASSESSMENT (IPET) TYPE TIME I- NITAL ASSESSMENT-after admission
PURPOSE -complete database
EXAMPLE -nursing admission assessment
P-ROBLEM FOCUSED-ongoing process
-determine specific problem status
-hourly I&O in pt in ICU
E-MERGENCY –during physiologic/ psychologic crisis
-identify life threatening problems
-assess ABC -suicidal tendencies
T-IME LAPSED-several months after initial assessment
-compare current status to baseline data
-reassessment
a) C-ollection of Data -gathering info. about a client’s health status *DATABASE- all information about a client includes: -nursing health history (Biographical Data, Present Health/ Illness, Past History, Family History, Psychosocial History, Review of Body Systems) -physical assessment -primary care providers history and physical examination -results of laboratory and diagnostic tests -material contributed by other health personnel *TYPES OF DATA (SOCV) 1. S-UBJECTIVE DATA- also called as Symptoms/ Covert Data -verified only by the patient ex. pain, itching, feelings of worry, sensation, feelings, values, beliefs, attitudes 2. O-BJECTIVE DATA- also called as Signs/ Overt Data -measurable and observable ex. discoloration of the skin, BP 120/80, Temperature 41 degree Celsius 3. C-ONSTANT DATA- does not change over time ex. blood type, race 4. V-ARIABLE DATA- can change quickly ex. vital signs, age, level of pain
*SOURCES OF DATA 1. Primary Source- client best source of data 2. Secondary support people, client records, healthcare professionals, literature
*Support People- useful if pt is too young, too ill, confused *Client Records-medical records, therapy and laboratory records *Healthcare professionals- nurses, social workers, primary health providers W questions Who? What? When? Where? 2. Open Ended Question- invite client to discover, explore, elaborate feelings and thoughts >What? How? 3. Neutral Question-client can answer without direction and pressure; open-ended and non directive >How? Why? 4. Leading Question-client has less opportunity to decide weather the answer is true or not; closed ended/directive >Aren’t you? Won’t you? *PLANNING THE INTERVIEW AND SETTING (TP SA DL) CONSIDER: TIME, PLACE, SEATING ARRANGEMENT, DISTANCE, LANGUAGE
1. TIME- when client is physically comfortable and free from pain -minimal interruptions 2. PLACE- well lighted, well ventilated -free of distractions -place where others cannot overhear or see client 3. SEATING ARRANGEMENT- *client in bed- 45 degree angle to bed *initial admission- overbed table between *standing and looking down at a client can be intimidating 4. DISTANCE- neither too small or too far -pts feel uncomfortable when talking to someone who is too close or too far away -2 to 3 feet during interview -also varies in ethnicity 8-12 inches- Arab 24 inches- Britain 18 inches- US 36 inches- Japan 5. LANGUAGE-convert medical terminology into common English usage -interpreters/ translators if nurse don’t speak the same language or dialect *STAGES OF AN INTERVIEW (OB C) 1. Opening-most important part -establish RAPPORT that will create trust and goodwill (greeting, self-introduction) -orient the interviewee (purpose, what info. needed, how long it will take, how info. will be used) 2. Body- client communicates what he/she thinks, feels, knows, perceives -nurse use communication techniques that make both parties feel comfortable 3. Closing-terminates interview when needed information has been obtained -important for maintaining trust/ rapport and for facilitating future interactions TECHNIQUES TO CLOSE THE INTERVIEW 1. Offer to answer questions ( do you have any questions?) 2. Conclude ( Well, that’s all I need to know for now) 3. Thank the client (Thank you for your time and help) 4. Express concern (Take care of yourself) 5. Plan for next meeting (I’ll be here to see you on Monday) 6. Summary/ Summarize (Lets review what we have just covered in this interview…)
3. Examining-systematic data collection method that uses observation to detect health problems -major method used in physical health assessment TECHNIQUES: (IPPA) I-nspection assessing by the use of sense of sight P-alpation examining by sense of touch using fatpads of the finger P-ercussiontapping body part to produce sounds A-uscultation listening to body sounds with the use of stethoscope 3 WAYS OF EXAMINING 1. Cephalocaudal- “head to toe approach” head-neck-thorax-abdomen-extremities-toes 2. Body System- respiratory system, circulatory system, nervous system, etc. 3. Screening examination- “ review of systems” -brief review of essential functioning (nursing admission assessment form)
b) O-rganizing data -nurses use an organized assessment framework. *11 Typology of Functional Health Pattern (Gordon) 1.Health perception/ Health Management-describes the clients perceived pattern of health and well-being and how health is managed. 2.Nutritional/ Metabolic Pattern-describes client’s pattern of food and fluid consumption. 3.Elimination Pattern-describes pattern of excretory function (bowel, bladder and skin). 4.Activity-Exercise Pattern-describes pattern of exercise, activity, leisure and recreation. 5.Sleep-Rest Pattern-describes pattern of sleep, rest and relaxation 6.Cognitive-Perceptual Pattern-describes sensory-perceptual and cognitive patterns. 7.Self Perception/ Self Concept Pattern- describes client’s self concept and perception of self pattern (self-worth, comfort, body image, feeling state). 8.Role-relationship Pattern-describes pattern of participation and relationship. 9.Sexuality-reproductive Pattern-describes client’s pattern of satisfaction and dissatisfaction with sexuality patterns; describes reproductive patterns. 10.Coping/ Stress- tolerance Pattern- describes client’s general coping pattern and effectiveness of pattern in terms of stress tolerance. 11.Values-beliefs Pattern-describes patterns of values, beliefs and goal that guide the client’s
choices or decisions.
*Abraham Maslow’s Hierarchy of Needs
Self-actualization Self esteem
Love and belongingness Safety and Security Physiologic Needs- FONBERS (fluid, oxygen, nutrition, body temperature, elimination, rest & sleep)
c) V-alidating Data- double checking or verifying data to ensure that it is accurate and factual (C2 D2 R) C-ompare- subjective vs. objective C-larify- ambiguous/ vague statement D-ouble check- extremely abnormal data D-etermine factors that may interfere accurate measurement R-eferences- explain phenomena *differentiate CUES from INFERENCES! CUES - are subjective or objective data that can be directly observed by the nurse INFERENCES-are the nurse’s interpretation or conclusion based on the cues
d) D-ocumenting Data -data are recorded in a factual manner and not interpreted by the nurse. -for example, the nurse must record the client’s intake as “coffee 240 ml, juice 120 ml, 1 egg and 1 slice of toast” rather than as “appetite good” or “normal appetite” a judgment . F-actual A-ctual T-imely
2. DIAGNOSIS/ DIAGNOSING - statement or conclusion regarding the nature of phenomena. - provides basis for the selection of nursing intervention. NANDA (North American Nursing Diagnosis Association) -define, refine and promote a taxonomy of nursing diagnostic terminology of general use to professional nurses. A taxonomy is a classification system or set of categories arranged based on a single principle or set of principles. *DIAGNOSTIC LABELS -standardized NANDA names for diagnoses *DIAGNOSING -reasoning process *NURSING DIAGNOSIS- diagnostic label + etiology ***TYPES OF NURSING DIAGNOSIS (WARPS) TYPE W-ellness Dx
A-ctual Dx R-isk Dx
P-ossible Dx S-yndrome Dx
DESCRIPTION -describes human responses to level of wellness in an individual, family or community that have a readiness for enhancement -problem is present (+) signs/ symptoms -problem does not exist, but the present of risk factors indicates a problem is likely to develop unless nurses intervene -health problem is incomplete or unclear -associated with a cluster of other diagnosis
EXAMPLE -Readiness for Enhanced Spriritual Well-being -Enhanced Family Coping
-Ineffective Breathing Pattern -Anxiety -Risk for infection
-Possible Social Isolation r/t unknown etiology -Impaired Physical Mobility -Risk for Disuse Syndrome -Risk for Impaired Tissue Integrity
***COMPONENTS OF NURSING DIAGNOSIS (PED)
P-roblem (diagnostic label) - describes client’s health problem or response for nursing theraphy given. PURPOSE : to direct the formation of client’s goals and desired outcomes. Qualifiers- word that have been added to NANDA labels to give additional meaning. (DIDIC) D-eficient (inadequate in amount, quality or degree; not sufficient; incomplete) I- mpaired (made worse, weakened, damaged, reduced, deteriorated) D- ecreased ( lesser in size, amount, degree) I- neffective ( not producing the desired effect) C- ompromised ( to make vulnerable to threat) E-tiology (related factors/ risk factors) -identifies one or more probable causes of health problem, gives direction to the required nursing theraphy and enables the nurse to individualized nursing care. D-efining Characteristics -cluster of signs and symptoms that indicate the presence of a particular diagnostic label ***DIAGNOSTIC PROCESS -uses critical thinking skills of analysis and synthesis *Critical Thinking- cognitive process during which a person reviews data and considers explanation before forming an opinion. *Analysis- separation into components; breaking down of the whole into its parts ( deductive reasoning) *Synthesis- putting together parts into whole (inductive reasoning) 3 STEPS OF DIAGNOSTIC PROCESS ( AIF) 1. A-nalyze Data 2. I-dentifying health problems, risk, strengths 3. F-ormulating Diagnostic Statements 1. A-nalyzing Data A) Compare data against standards B) Cluster Cues C) Identify gaps and inconsistencies
A) Compare data against standard and norms TYPE OF CUE Deviation from population norms Dysfunctional behavior
Developmental Delay
Changes in usual health status Changes in usual behavior
CLIENT CUES F- 5’2 in height, 240 lbs
STANDARD/NORM F- 5’2 in height -108-121 lbs (ideal weight) Adolescents usually liked to be with their peers
Teen (16 y/o) not left the room for 2 days as verbalized by the mother Child 17 months old, still Children usually speak their cannot speak as verbalized first word by 10-12 months by the parent States “I’m not hungry these Client usually eats three days” balanced meals per day Reports that his husband Husband usually relaxed and angers easily easygoing
B) Cluster Cues - combining data from different assessment areas to form a pattern and organizing subjective and objective data into appropriate categories - nurse interprets meaning of cues, label the cue clusters with tentative diagnostic hypothesis C) Identifying Gaps and Inconsistencies in Data - Final check to ensure that data are complete and correct. Possible sources: measurement error, expectations, and inconsistent or unreliable reports. E.g. Nursing history - not seen doctor in 15 years, stated my doctor takes my BP every year 2. I-dentifying Health Problems, Risk and Strengths *Determining Health Problem and Risk - after grouping and clustering data, nurse- client together identify problem Ex. 1. Decreased urinary frequency and amount for two days possible urinary problem 2. Deficient Fluid Volume (urinary problem- eliminated) *Determining Strengths -when problem is already identified, taking inventory of strengths promotes self-concept and self-image. -this strengths aid in mobilizing health and regenerative process Ex. normal weight/ height, absence of allergies, being a non-smoker
3. F-ormulating Diagnostic Statements a) One- part statement (Problem) -consist of NANDA label only -Wellness diagnosis, Syndrome diagnosis e.g. Rape-Trauma Syndrome, Readiness for Enhanced Spiritual Well Being
b) Two- part statement (Problem + Etiology) -are joined by the words Related to e.g. Constipation related to prolonged laxative use, Severe anxiety related to threat to physiologic integrity; possible cancer c) Three- part statement (Problem + Etiology + Signs/ Symptoms) -are joined by the word related to; and manifested by for the signs/ symptoms e.g. Non Compliance ( Diabetic Diet) related to unresolved anger about diagnosis as manifested by: S- “ I forget to take my pills” “ I can’t live without sugar in my food” O- Weight 98 kg (215 lbs) BP- 190/ 100 VARIATIONS OF BASIC FORMAT 1. Unknown Etiology- does not know the cause e.g. Noncompliance (Medication Regimen) related to unknown etiology 2. Complex Factors- too many etiologic factors e.g. Chronic Low Self- Esteem related to complex factors 3. Possible- nurse believes more data are needed about clients problem/ needs e.g. Possible Low Self-Esteem related to loss of job and rejection by family 4. Secondary to-divide etiology in 2 parts; more descriptive, useful; often pathophysiologic or disease process or medical diagnosis e.g. Risk for Impaired skin integrity related to decreased peripheral circulation secondary to diabetes 3. PLANNING - A deliberative, systematic phase of nursing process that involves decision making and problem solving. NURSE refers client’s assessment data and diagnostic statements formulating client’s goals designing interventions prevent, reduce or eliminate the client’s health problem
-product NCP “blueprint of nursing process ***TYPES OF PLANNING (IOD) I- NITIAL PLANNING - admission assessment -initial comprehensive plan of care O-NGOING PLANNING - done by all nurses who work with the client, occurs at the beginning of the shift as the nurse plans the care to be given that day. PURPOSES: 1. To determine whether the client’s health status has changed 2. To set priorities for the client’s care during the shift 3. To decide which problems to focus on during the shift 4. To coordinate the nurse’s activities so that more than one problem can be addressed at each client contact D-ISCHARGE PLANNING - the process of anticipating and planning for the needs after discharge THE PLANNING PROCESS (SESI) 1. S-etting Priorities 2. E-stablishing Client’s Goal 3. S-electing Nursing Intervention 4. I-ndividualized Nursing Care Plan Writing 1. S-etting priorities -a process of establishing a preferential sequence for addressing nursing diagnosis and intervention. *High Priority- life- threatening *Medium Priority- delayed development or causes physical and emotional changes *Low Priority-arises from normal developmental needs or that requires minimal nursing support Ex. Loss of cardiac function, Loss of respiratory function Acute illness, Decreased coping ability
Often use HIERARCHY OF NEEDS of Abraham Maslow
FACTORS TO CONSIDER: 1. Client’s Values and Beliefs- values concerning health may be more important to the nurse than to the client. 2. Client’s Priorities- involving client in prioritizing and care planning enhances cooperation.
3. Resources Available 4. Urgency of Health problem 2. E-stablishing Client’s Goal GOAL (broad) DESIRED OUTCOME (specific)
Improve nutritional status Gain 5 lbs by Dec. 15, 2009
GOAL (broad) DESIRED OUTCOME (specific)
Improve knowledge regarding disease (Hypertension) Be able to discuss the factors that affect the disease (Hypertension)
2 TYPES OF GOALS 1. SHORT TERM GOAL- can achieve in a short period of time (days/ less than a week) (useful: pts that require healthcare for short time,pts frustrated with long term goals) 2. LONG TERM GOAL- can achieve for weeks or months (useful: who lives at home, with chronic problems, pts in nursing extended care facilities, rehabilitation centers) COMPONENTS OF GOAL/ DESIRED OUTCOME STATEMENT 1. Subject- a noun ( client, any part of client) 2. Verb- specifies an action the client is to perform 3. Conditions/ Modifiers- added to verb to explain –what, where, when, how? 4. Criterion of Desired Outcome- level at which client will perform specified behavior (time, speed, accuracy, distance, quality)
Client walks the length of the hall without cane by date of discharge. (December 1, 2009) Client performs leg ROM exercises as taught every 8 hours 3. S-electing Nursing Intervention -nurse perform to achieve client’s goals ***3 TYPES OF NURSING INTERVENTIONS 1. Independent Interventions- nurses licensed to initiate e.g. physical care, ongoing assessment, emotional support and comfort, teaching, counseling, environmental management, making referrals to other health care professionals 2. Dependent Interventions- activities carried out under physician’s order/ supervision e.g. medications. IV therapy, diagnostic tests, treatments, diet and activity
3. Collaborative Interventions- nurse carries with collaboration with other health team members
CRITERIA FOR CHOOSING NURSING INTERVENTIONS I- ndividual’s age, health, condition T- herapies S- afe Intervention S- how respect (values/ beliefs) A- chievable with resources available F- irm adherance E- evidenced based 4. Individualized NCP Writing 4. IMPLEMENTATION -is putting the nursing care plan into action. -an action phase in which nurse performs nursing intervention. Purpose: To carry out planned nursing interventions to help the client attain goals and achieve optimal level of health. ***Implementing Skills 1. Cognitive- include intellectual skills like problem solving, decision-making, critical thinking and creativity. Crucial to safe, intelligent nursing care 2. Interpersonal- nurse ability to communicate with others. caring, comforting, advocacy, referring, counseling/ supporting 3. Technical skills- hands on skills, tasks, procedures, and psychomotor skills. manipulating equipment, giving injections, bandaging, moving, lifting 4. Therapeutic use of self – is being willing and being able to care. PROCESS IN IMPLEMENTING (RIDDS) R - eassessing client I- mplementing nursing intervention D- etermine nurse’s need for assistance D- ocumenting nursing activities S- upervising nursing activities 1. Reassessing the client - to ensure prompt attention to emerging problems. >just before implementing an intervention, nurse must reassess the client to make sure the
intervention is still needed. Ex. Diagnosis ( Disturbed Sleep Pattern r/t Anxiety) during rounds you see that the pt is sleeping (X) relaxation strategy 2. Implementing nursing intervention- it is important to explain the client the ff: What interventions will be done? • What sensation to expect? • What the expected outcome is? • ***Always ensure patient’s privacy!!!
>>>When implementing nursing intervention, nurses should follow these guidelines. (ABC RE HIP). A- dapt activities to the individual client - client’s beliefs, values, age, health status and environment that can affect the success of a nursing action. B- ased on scientific knowledge, research and professional standard of care -rationale, possible side effects or complications C- learly understand interventions to be implemented -intelligent implementation of medical and nursing plan R - espect dignity of client and enhance client’s self- esteem -providing pricay and encouraging clients to make their own decision E- ncourage patient to participate actively -enhances client sense of independence and control but it varies (because some patient may want total or little involvement. ***Amount of desired involvement may be related to: Severity of illness • Client’s culture • Client’s fears • Client’s understanding of the illness/ intervention • H- olistic -nurse must view client as a whole and consider client’s responses in that context I- mplement safe care P-rovide teaching, support and comfort -should explain purpose of intervention, what client will experience, how the client can participate increase responsibility for self-care 3. Determining nurse’s need for assistance - when implementing nursing intervention, nurse may need assistance for one or more of the following reasons: Unable to implement NURSE: Assistance decreases stress of clients Lacks knowledge/ skills
4. Documenting nursing activities- part of the agency’s permanent record for the client -after carrying out DOCUMENT! *not done before implementation 5. Supervising nursing activities- if care is delegated to other healthcare personnel, the nurse is responsible for client’s overall care and must ensure that activities have been implemented according to the care plan. COMMUNICATE- documenting the client’s record - reporting verbally - filling out a written form 5. EVALUATION -assessing client’s response to nursing progress toward healthcare and effectiveness of nursing care plan. TYPES OF EVALUATION 1. Ongoing Evaluation - continous 2. Initial Evaluation - specific intervals 3. Terminal Evaluation - evaluation at discharge TYPES OF OUTCOMES • • •
The goal was completely met. The goal was partially met. The goal was completely unmet.
