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nursing process
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NursingProcessNursingProcess
Objectives:Objectives: IntroducethehistoryofnursingprocessIntroducethehistoryofnursingprocess DiscusspurposeofnursingprocessDiscusspurposeofnursingprocess
IncludingphilosophyIncludingphilosophy DiscussnursingmodelsinrelationtoDiscussnursingmodelsinrelationto
assessmentassessment DiscussdefensibledocumentationDiscussdefensibledocumentation CriticismofprocessCriticismofprocess SummarySummary
NursingProcessNursingProcess
n n AssessmentAssessment
n n PlanningPlanning
n n ImplementationImplementation
n n EvaluationEvaluation
TheNursingProcessTheNursingProcessThetermThetermNursingProcessNursingProcesscametotheUKcametotheUK
inthe1970inthe1970sandcametobeunderstoodsandcametobeunderstoodas:as:
n n AformofdocumentationAformofdocumentationn n Asameansoforganisingwork,thatisAsameansoforganisingwork,thatis
patientallocationorprimarynursingpatientallocationorprimarynursingn n AsaneducationaltooltohelpachieveAsaneducationaltooltohelpachieve
patientcentrednursingpatientcentrednursingn n AsaphilosophytohelpnursingattainAsaphilosophytohelpnursingattain
professionalstatusbyofferinganprofessionalstatusbyofferinganalternativetothemedicalmodel.alternativetothemedicalmodel.
ThenursingprocessisThenursingprocessisAnorganised,Anorganised,systematicanddeliberateapproachsystematicanddeliberateapproachtonursingwiththeaimofimprovingtonursingwiththeaimofimprovingstandardsinnursingcarestandardsinnursingcareRushS,RushS,FergyFergyS&S&WeelsWeelsD(1996)D(1996)
Itusesasystematic,holistic,problemItusesasystematic,holistic,problemsolvingapproachinpartnershipwithsolvingapproachinpartnershipwiththepatientandtheirfamilythepatientandtheirfamily
NursingModelsNursingModelsAllmodelshave4corecomponents,Allmodelshave4corecomponents,n nTheperson,Theperson,n nTheirenvironment,Theirenvironment,n nHealthandHealthandn nNursingNursing(butallhavedifferentemphasis)(butallhavedifferentemphasis)
ThePersonThePersonn nBody(physical/biological)Body(physical/biological)
n nActivitiesofdailylivingActivitiesofdailyliving
n nGeneticmakeGeneticmakeupupgendergender
n nNature/NurtureNature/Nurture
Mind(psychological)Mind(psychological)
n n Healthy,impairedordamagedHealthy,impairedordamagedn n IntellectIntellectn n AttitudesAttitudesn n EffectofillnessEffectofillnessstress,fears,stress,fears,memoriesmemories
n n EmotionalsupportEmotionalsupport
SocialSocialFamilyandfriendsFamilyandfriendsWorkWorkPlayPlayEffectsofillness(e.g.financial)Effectsofillness(e.g.financial)
SpiritSpirit
n n BeliefsystemsaboutthemeaningofBeliefsystemsaboutthemeaningoflife,death,hope,suffering,life,death,hope,suffering,
n n itmayinvolveorganisedreligion,itmayinvolveorganisedreligion,othercustomsorothercustomsorNewageNewagespirituality.spirituality.
EnvironmentEnvironmentHome,neighbours,Home,neighbours,neighbourhood,work,socialneighbourhood,work,socialactivities,town,county,countryactivities,town,county,countryandpoliticalfactorsandpoliticalfactors
HealthHealth
Thecompletestateofphysical,Thecompletestateofphysical,psychologicalandsocialwellpsychologicalandsocialwellbeingbeingWorldWorld
healthorganisation1946healthorganisation1946Healthcarecontinuum(likedtoage)Healthcarecontinuum(likedtoage)OptimumhealthOptimumhealth IllhealthIllhealthIndependenceIndependence DependenceDependenceAdaptationAdaptation MaladaptionMaladaptionSelfSelfcarecare RelianceonothersRelianceonothers
HumanNeedsModel:RoperLoganHumanNeedsModel:RoperLogan&Tierney&TierneysModel(1980)(activitiessModel(1980)(activities
ofdailylivingofdailylivingThisisthemainoneusedinBritainThisisthemainoneusedinBritainandhas5dimensions:andhas5dimensions:
n n Physiological,Physiological,n n psychological,psychological,n n sociosociocultural,cultural,n n politicopoliticoeconomicaleconomicaln n andenvironmental.andenvironmental.
Thereare12activities,someofThereare12activities,someofwhichareessentialsuchasbreathingwhichareessentialsuchasbreathingandothersthatwhichenhancetheandothersthatwhichenhancethequalityoflife.qualityoflife.
Itshouldbecarriedout:Itshouldbecarriedout:n n ByorunderthesupervisionoftheByorunderthesupervisionoftheNamedNurseNamedNurse
n n WiththeagreementandcoWiththeagreementandcooperationofthepatientoperationofthepatient
n n BeevidencebasedandfollowBeevidencebasedandfollowNationalandTrustPolicyandNationalandTrustPolicyandguidelinesguidelines
n n MustusetheMustusetheNMCNMCssStandardsforStandardsforrecordkeepingrecordkeepingandandCodeofCodeofprofessionalconductprofessionalconduct
ThepurposeofcareplanningThepurposeofcareplanningn n ItisalegaldocumentItisalegaldocumentn n ShowsaccountabilityShowsaccountabilityThecareplanThecareplanisadocumentthatidentifiesthecareisadocumentthatidentifiesthecaretobegiven,andarecordthatshowstobegiven,andarecordthatshowswhoplannedandgavethatcarewhoplannedandgavethatcare
n n ItshouldguidetheworkofothersItshouldguidetheworkofothersandbeabasisforcontinuityofcareandbeabasisforcontinuityofcare
n n ShouldshowalogicalandsystematicShouldshowalogicalandsystematicflowofideasthroughfromtheinitialflowofideasthroughfromtheinitialassessmenttothefinalevaluationassessmenttothefinalevaluation
AssessmentAssessmentWhatcomponentsareneededforasuccessfulassessmentWhatcomponentsareneededforasuccessfulassessmentn n GoodcommunicationGoodcommunicationn n AsystematicapproachtodatacollectionAsystematicapproachtodatacollectionn n InterpretationInterpretationbasedonnursingknowledgebasedonnursingknowledgeObjective(scientificQuantitative)Objective(scientificQuantitative)n n EmpiricsEmpiricsmeasurementofknowledgewithmeasurementofknowledgewith
scientificfactscientificfactSubjective(Art,Qualitative)Subjective(Art,Qualitative)n n AestheticsAestheticsgainedthroughempathyandishowagainedthroughempathyandishowa
nursebecomessensitivetoapatientnursebecomessensitivetoapatientspain,spain,worryorjoyworryorjoy
n n EthicsEthicsconcernedwithmotivation,morality,concernedwithmotivation,morality,humanrightsandlawhumanrightsandlaw
n n PersonalknowledgePersonalknowledgeawarenessthatthenurseawarenessthatthenursehasanimpactonpatientcarehasanimpactonpatientcare
SourcesofDataSourcesofData1.1. NonverbalobservationNonverbalobservation
n n SightSightPhysical,psychological(andsocial)Physical,psychological(andsocial)n n TouchTouchSkintemp,hydration,pulse/BPSkintemp,hydration,pulse/BPn n SoundSoundBreathBreathwheeze,wheeze,stridorstridorn n SmellSmellbreathbodyfluidsinfections,gangrenebreathbodyfluidsinfections,gangrene
2.2.VerbalCommunicationVerbalCommunicationn n Patients/clientsPatients/clientsn n Familyandfriends(Meaningfulothers)Familyandfriends(Meaningfulothers)n n NursingcolleaguesNursingcolleaguesn n MedicalcolleaguesMedicalcolleaguesn n OthermembersofmultidisciplinaryteamOthermembersofmultidisciplinaryteam
3.3.WrittenrecordsWrittenrecordsn n G.PLetterG.PLettern n TransferletterTransferlettern n OldnotesOldnotes
CommunicationCommunicationWhyaregoodcommunicationskillsrequired?Whyaregoodcommunicationskillsrequired?n n ToestablishandmaintainarelationshipwithToestablishandmaintainarelationshipwith
patientsandtheirfamiliespatientsandtheirfamiliesn n ToencouragepatientstodescribeallrelevantToencouragepatientstodescribeallrelevant
aspectsoftheirproblemsaspectsoftheirproblemsn n TogetandgiveaccurateinformationTogetandgiveaccurateinformationn n TousetimeandopportunityeffectivelyTousetimeandopportunityeffectivelyn n ToimprovepatientsatisfactionwiththecareToimprovepatientsatisfactionwiththecare
givengivenn n ToimprovethrustandcooperationwiththecareToimprovethrustandcooperationwiththecaren n ToreducenegativeemotionsandfearToreducenegativeemotionsandfear
GuidetoasuccessfulassessmentGuidetoasuccessfulassessmentn n PrepareadequatelyPrepareadequatelyn n IntroduceyourselfIntroduceyourselfpreparepatientpreparepatientn n UsenonUsenonverbalcommunicationverbalcommunicationn n BecourteousBecourteousn n Usesensitivity,compassionandempathyUsesensitivity,compassionandempathyn n Usefocusedquestions(openedandUsefocusedquestions(openedand
closed)closed)n n ListenListenn n ClarifyClarifyn n SummarisewhattheydescribeSummarisewhattheydescriben n MakenotesMakenotesn n reflectreflect
PlanningPlanningEffectiveplanningdependsonthequalityEffectiveplanningdependsonthequality
andcomprehensivenessoftheassessmentandcomprehensivenessoftheassessmentn n DeterminetheproblemsDeterminetheproblemsn n EstablishtherisksandprioritiesEstablishtherisksandprioritiesHowillHowill
arethey?arethey?n n Cantheybreathadequately(safeairway?)Cantheybreathadequately(safeairway?)n n Aretheyinpain?(physical/psychological)Aretheyinpain?(physical/psychological)n n Cantheymaintainasafeenvironment?IfCantheymaintainasafeenvironment?If
notwhynot?(Drugs,drink,mentalornotwhynot?(Drugs,drink,mentalorpsychologicalproblem?)psychologicalproblem?)
n n NonNoncompliancewithmedicaladvicecompliancewithmedicaladvice
Writingacareplan(s)Writingacareplan(s)ThinkaboutThinkaboutn n Whoisitfor?(ThepatientandothermembersofWhoisitfor?(Thepatientandothermembersof
nursingteam)nursingteam)n n WhataretheshortWhataretheshorttermandlongtermgoals?termandlongtermgoals?n n HowcanyoudeterminethatyouhavereachedHowcanyoudeterminethatyouhavereached
thegoals?(measurable)thegoals?(measurable)n n Howwillthepatientknowhe/shehasachievedHowwillthepatientknowhe/shehasachieved
thegoals?(realistic)thegoals?(realistic)n n Whoisinvolvedinthedeliveryofthecare?(TheWhoisinvolvedinthedeliveryofthecare?(The
patient(andfamily),yourself,thenursingteam,patient(andfamily),yourself,thenursingteam,medicalstaff,multidisciplinaryteam,labs,medicalstaff,multidisciplinaryteam,labs,investigations,proceduresetc)investigations,proceduresetc)
n n HowquicklyistheproblemlikelytochangeHowquicklyistheproblemlikelytochangeHowHowsoonwillyouneedtoresoonwillyouneedtoreevaluatetheplan?evaluatetheplan?
n n HowmanyproblemsarethereHowmanyproblemsarethereWhichorderofpriority?Whichorderofpriority?
n n HowcanyouprovethattheyareHowcanyouprovethattheyareevidencebased(whatresourcesdoevidencebased(whatresourcesdoyouneed?)(corecareplansVsyouneed?)(corecareplansVsindividualisedones)individualisedones)
ImplementingImplementinga)a) Atthestartoftheshift,duringhandoverandAtthestartoftheshift,duringhandoverand
whenyoufirstmeetthem,thinkaboutwhetherwhenyoufirstmeetthem,thinkaboutwhethertheoralreportmatchesthepatientsactualtheoralreportmatchesthepatientsactualconditioncondition
b)b) ComparethistowhatyoualreadyknowoftheComparethistowhatyoualreadyknowofthepatientandtotheexistingcareplanspatientandtotheexistingcareplans
c)c) HasanythingchangedforbetterorworseHasanythingchangedforbetterorworsed)d) Decide:Decide:WhataretheprioritiesforlookingafterthisWhataretheprioritiesforlookingafterthis
patient?patient? Istheirconditionstable?WhatobservationsIstheirconditionstable?Whatobservations
needdoingneeddoinghowoftenhowoften Aretheygoingoffthewardtests/investigations/Aretheygoingoffthewardtests/investigations/
operationsoperations Aretheybeingdischarged?WhenaretheyAretheybeingdischarged?Whenarethey
going?Iseverythingready?going?Iseverythingready?
RepeatthisRepeatthisprocessforalltheprocessforallthepatientsyouarelookingafter.patientsyouarelookingafter.
f)f) WhatroutineworkmustbedoneandWhatroutineworkmustbedoneandwhenshouldthisbedonewhenshouldthisbedone
g)g) WhoisgoingtodothisworkWhoisgoingtodothisworkareyouonareyouonyourownordoyouhaveaClinicalyourownordoyouhaveaClinicalsupportworkerwithyou?Howwilltheysupportworkerwithyou?Howwilltheygiveyoufeedback?giveyoufeedback?
h)h) WhoisavailabletogiveyouhelporWhoisavailabletogiveyouhelporadviceifneeded?(seniornurseadviceifneeded?(seniornursemedicalmedicalteam)team)
i)i) HowareyougoingtoorganisetheworkHowareyougoingtoorganisetheworkTIMEMANAGEMENTTIMEMANAGEMENT
j)j) Whatresourcesdoyouneed?Whatresourcesdoyouneed?
Evaluation.Evaluation.n n MENTALMENTALOngoingthroughoutOngoingthroughout
implementationimplementation
n n WRITTEN(thisshouldpreferablybedoneWRITTEN(thisshouldpreferablybedonewiththepatientpresentinordertogetwiththepatientpresentinordertogetaccuratefeedback)accuratefeedback)
n n Mustbecarriedoutatleasttwicein24hoursMustbecarriedoutatleasttwicein24hoursn n Andwheneveranyincidentoccurs.(date,timeAndwheneveranyincidentoccurs.(date,timesignature)signature)
n n WriteageneralstatementaboutpatientWriteageneralstatementaboutpatientsconditionscondition(better,same,worse)(better,same,worse)
n n EvaluateeachcareplaninturnandbynumberEvaluateeachcareplaninturnandbynumber
n n PersonalisePersonaliseusepatientusepatientsownwordssownwordsappropriateappropriate
n n StatewhatcareyouhavegivenStatewhatcareyouhavegivenCareofCareofplannedplannedoranyvariation/commente.g.oranyvariation/commente.g.pressureareacaregivenskinslightlyredpressureareacaregivenskinslightlyredononsacrumsacrum
n n AmendthecareplanifcircumstancesAmendthecareplanifcircumstanceshavechangedhavechanged
n n DiscontinuecareplansiftheDiscontinuecareplansifthegoal(sgoal(s)have)havebeenreachedbeenreached
n n LegallyLegallyifthecaregivenhasnotbeenifthecaregivenhasnotbeenrecordedthanithasnrecordedthanithasntoccurred!toccurred!
Criticismsofthenursingprocess&Criticismsofthenursingprocess&RoperLogan&TierneyRoperLogan&TierneysModelsModel
AssessmentAssessmentn n ItisonlyaItisonlyasnapshotsnapshotandisoftennotreferredandisoftennotreferred
toaftertheinitialassessmentorupdatedtoaftertheinitialassessmentorupdatedn n ThereisthedangerofaThereisthedangerofareductionistreductionistapproachapproach
inwhichpatientsaremadetoinwhichpatientsaremadetofitfitintotheboxesintotheboxesratherthanallowingflexibilityratherthanallowingflexibility
n n ItisonlyoneamongseveralnursingassessmentItisonlyoneamongseveralnursingassessmenttools(tools(waterlowwaterlow,moving&handling,nutrition,,moving&handling,nutrition,painetc)inadditiontoothermedical.painetc)inadditiontoothermedical.ParamedicalrecordsParamedicalrecords
n n PatientsmaylieorconcealPatientsmaylieorconcealincriminatingincriminatingororembarrassinginformationembarrassinginformation
n n Psychological,sexual,spiritualorissuesPsychological,sexual,spiritualorissuessurroundingdeathmaynotbementionedsurroundingdeathmaynotbementioned
PlanningandGivingCarePlanningandGivingCaren n ThepatientThepatientsmaynotbeconsulted,smaynotbeconsulted,
empoweredtocooperate,orempoweredtocooperate,orcomplientcomplientinintheircaretheircare
n n WithincreasingskillmixWithincreasingskillmixCSWCSWssnownowprovidemostofthephysicalcare,Buttheprovidemostofthephysicalcare,Buttheoftenhavenotbeentaught(orexpected)oftenhavenotbeentaught(orexpected)toreadcareplans,maynotreportbacktoreadcareplans,maynotreportback(orrealisethesignificanceof)changesto(orrealisethesignificanceof)changestotheRNwhoiswritingtheevaluationandtheRNwhoiswritingtheevaluationandmayormaynotdocumentthecaretheymayormaynotdocumentthecaretheyhavegivenhavegiven
n n PatientcareisfragmentedPatientcareisfragmentedtasknursingtasknursingratherthanholisticnursingratherthanholisticnursing
EvaluationEvaluationn n ThereisnotenoughtimeThereisnotenoughtimen n ItisjustpaperworkthattakesnursesItisjustpaperworkthattakesnurses
awayfromhandsawayfromhandsononcarecaren n Wearebadatreading:socareplansareWearebadatreading:socareplansare
notconsultednotconsultednursesrelyonverbalnursesrelyonverbalhandoversandtheirnotes.(Butthesearehandoversandtheirnotes.(Buttheseareonlyasgoodastheindividualsmemoryonlyasgoodastheindividualsmemoryandcontinuityofcareandcontinuityofcare
n n EvaluationtendstoconcentrateonEvaluationtendstoconcentrateonobjectivemeasurableactivityobjectivemeasurableactivityitmaynotitmaynotbeappropriatetodescribebeappropriatetodescribetherapeutictherapeuticcareinterventionsorsetmeasurablegoalscareinterventionsorsetmeasurablegoals
OtherModelsOtherModelsTheseincludeTheseincluden n Nightingale(1859)Nightingale(1859)n n MedicalmodelMedicalmodeln n Henderson(1966)Henderson(1966)n n Systemsmodel:usedinUSASystemsmodel:usedinUSAn n DevelopmentmodelsDevelopmentmodelsn n MaslowMaslow(1970)(1970)HierarchyofneedsHierarchyofneedsn n BurfordBurfordNursingDevelopmentUnitNursingDevelopmentUnit
? ? Any Any
Questions Questions
FurtherReading:FurtherReading:BowmanG.S,ThompsonD&BowmanG.S,ThompsonD&SuttinSuttinT(1983)T(1983)NursesattitudesNursesattitudes
towardsthenursingprocesstowardsthenursingprocessJournalofAdvancedNursingJournalofAdvancedNursing8(2)p.1258(2)p.125129129
BradenS(1998)BradenS(1998)Evaluatingnursinginterventions:AtheoryEvaluatingnursinginterventions:AtheorydrivenapproachdrivenapproachSagepublicationsLondonSagepublicationsLondon
CohenE,CohenE,GestaGestaT(2001)T(2001)NursingcasemanagementfromNursingcasemanagementfromessentialtoadvancedpracticeapplicationessentialtoadvancedpracticeapplication3rdedition3rdeditionMosbyMosbyUSAUSA
FaulknerA(2000)FaulknerA(2000)Nursing:ThereflectiveapproachtoadultNursing:Thereflectiveapproachtoadultpracticepractice2ndEdition2ndEditionBailliereBailliereTindallTindallCheltenhamCheltenham
HincliffHincliffS,NormanS,S,NormanS,SchoberSchoberJ(1998)J(1998)NursingpracticeandNursingpracticeandhealthcare:Afoundationtexthealthcare:Afoundationtext 3rdeditionArnoldOxford3rdeditionArnoldOxford
n n KowalakKowalakJ&HughesAetal(2002)J&HughesAetal(2002)BestpracticesBestpracticesaguidetoexcellenceinnursingcareaguidetoexcellenceinnursingcareLippincottLippincottWilliams&Williams&WlikinsWlikins
n n LeahyJ,LeahyJ,KizilayKizilayP(1998)P(1998)FoundtionsFoundtionsofnursingofnursingpractice:Anursingprocessapproachpractice:AnursingprocessapproachSaundersSaundersPhiladelphiaPhiladelphia
n n LittlejohnC,(2002)LittlejohnC,(2002)ArenursingmodelstoblameArenursingmodelstoblameforlowmorale?forlowmorale?NursingStandardNursingStandardVolVol16(17)16(17)p.39p.394141
n n MasonC(1999)MasonC(1999)GuidetopracticeorGuidetopracticeorloadofloadofrubbishrubbish?Theinfluenceofcareplansonnursing?TheinfluenceofcareplansonnursingpracticeinfiveclinicalareasinNorthernIrelandpracticeinfiveclinicalareasinNorthernIrelandJournalofAdvancedNursingJournalofAdvancedNursingVolVol29(2)P.38029(2)P.380387387
RoperW,LoganW,&TierneyA(1990)RoperW,LoganW,&TierneyA(1990)TheelementsofnursingbasedonaTheelementsofnursingbasedonamodeloflivingmodelofliving3rdeditionChurchill,3rdeditionChurchill,LivingstonLondonLivingstonLondon
SwashM(2002)SwashM(2002)HutchinsonHutchinsonsclinicalsclinicalmethodsmethods21steditionSaunders21steditionSaundersEdiburghEdiburgh
WalshM(2001)WalshM(2001)ModelsandcriticalModelsandcriticalpathwaysinclinicalnursingpathwaysinclinicalnursingBailliereBailliereTindallTindallCheltenhamCheltenham