NURSING PROCESSNURSING PROCESS

INTRODUCTIONThe nursing process provides a useful description of how nursing should be performed. Practice of nursing is caring which is directed by the way the nurses view the client, the client’s environment, health and the purpose of nursing.

HISTORY• First described by Hall in 1955 as a

three step process.• In 1967, Yura and Walsh added

assessment to the three steps.• In the mid-1970s an addition of

diagnostic phase resulted into a five step process.

CONCEPT OF NURSING PROCESSThe basic concepts were:

• Nursing, • Person, • Environment • Health

DEFINITION• Nursing Process (NP) is defined as

a systematic, continuous and dynamic method of providing care to clients. It comprises series of sequential phases built upon the preceding step. Each phase logically leads to the next.

PHASES• Assessment• Nursing Diagnosis• Planning• Implementation• Evaluation

Assessment – The nurse gathers subjective & objective information from the client & other sources in order to understand the client’s situation.

2. Nursing Diagnosis –Organizes (in collaboration with the client), interprets the data and makes nursing diagnosis/diagnoses, which is nursing’s perspective on the appropriate focus for client nursing care.

3.Planning- Sets, in collaboration with client, mutually agreed upon goals of care, desired outcomes strategies to achieve goals of care & the identification & prioritization of appropriate nursing actions.

4.Intervention- Perform the nursing actions identified in planning.5.Evaluation- Determine if the goals are met and outcomes achieved.

PURPOSES/USES• It makes client and family feel

important and participative• It is a time saving device • It avoids unnecessary nursing

actions.

Benefits of Nursing Process

• Provides an orderly & systematic method for planning & providing care

• Enhances nursing efficiency by standardizing nursing practice

• Facilitates documentation of care

• Provides a unity of language for the nursing profession

• Is economical• Stresses the independent

function of nurses• Increases care quality through

the use of deliberate actions

CHARACTERISTICS• Dynamic and Cyclic• Client-centered• Planned and Goal-directed• Universally Applicable• Problem-oriented• Cognitive Process

• Dynamic and CyclicThe dynamic nature involves continuous assessment and evaluation of changing client’s responses to nursing interventions so as to achieve the outcomes.

• Client-centeredThe plan of care is organized in terms of client problems rather than nursing goals. The nurse-client relationship is shaped around the needs of the client.

• Planned and Goal-directedInterventions are considered according to the nursing diagnoses and are based on scientific principles rather than tradition.

• Universally ApplicableNursing process can be used with clients of any age, with any medical diagnosis, and at any point on the wellness-illness continuum.

• Problem-orientedCare plans are organized according to client’s problems. Interventions are carried out to eliminate the problems related to any aspect of an individual.

• Cognitive ProcessNursing process involves the use of intellectual skills in making judgments, decisions and eliminating client’s problems.

FACTORS AFFECTING NURISNG PROCESS

• Knowledge• Skill • Beliefs

Knowledge:Nursing process is the application of the nurses’ knowledge. As part of her/his academic preparation nurse learns basic concepts of biochemistry, biophysics, microbiology, anatomy, physiology, psychology, sociology, and nutrition. The knowledge of these sciences enables the nurse to recognize the problem more clearly and also determine how the client’s health is getting disturbed.

• Skills:Nurse uses technical and interpersonal skills to collect information about the client. The effectiveness of the nursing process depends on the intellectual (cognitive) skills of the nurse that she uses in creative and critical thinking, and decision making.

• Beliefs:The nurse’s personal belief about nursing, health, the client as an individual, as a health care consumer forms the basis of nursing practice.The nurse is also faced with a moral and ethical dilemma of providing care to such a client and his family members.

Components of Nursing Process

1. Assessment2. Nursing Diagnosis3. Planning4. Implementation5. Evaluation

Assessment

Assessment is the deliberate and systemic collection of data to determine client current and past health status and copping pattern

Components of Assessment:

1. Collection of data2. Verification of data3. Organization of data4. Recording of data

Types of Data

1.Subjective Data:These are client’s perception about their health problem. e.g. pain

2.Objective Data:These data are observable and measurable by data collector e.g. Vital signs

Sources of data:1.Primary Sources:

Client2. Secondary sources:

– Family & significant others– Health care team members– Medical records– Other records– Literature review– Nurses experience

Method of data collection1. Observation2. Interview technique

It is a organized conversation with the client or family members to obtain the current health information regarding patient.

3. Physical examination4. Laboratory tests5. Review of the records, books & related

literature

Interview techniqueIt is a organized conversation with the client or family members to obtain the current health information regarding patient.

Phases of Interview:1. Orientation phase2. Working phase3. Termination phase

1. Orientation phaseIt begins with the nurse’s introduction with client which includes the nurse’s name, position and explanation of purpose of the interview. The nurse client relationship is enhanced by the professionalism and competence conveyed by the nurse’s attitude, manner & appearance

2.Working phaseDuring the working phase of the interview the nurse gather information about the client’s health status. Nurse use variety of communication strategies such as listening, paraphrasing, focusing, summarizing & clarifying to facilitate communication and ensure that nurse & client clearly understood each other.

3. Termination phase• This phase also require skill on the part of

the interview . The client should be given a clue that the interview is coming to an end.e.g. There are just two more questions orWe will be finished within 5 to 6 minutes

• This approach also gives the client an opportunity to ask questions.

• The interview terminated in a friendly manner

Elements for effective interview:

• Clear goal• Aware about background of the client• Self introduction• Choose strategy• Maintain rapport• Confidentiality• Recovery• Closure

Types of Interview Technique:

1.Open ended questions:It prompts clients to describe a situation in more that one or two words. This questions give chance to client to speak freely.e.g. What do you know about your

condition?How do you feel in hospital?

2. Close ended questions:

It prompts client to give answer in only one or more wordse.g. Do you have pain?

How many time you go for toilet?

Validation of Data

• Data validation to be done to ensure its accuracy

• Validation of collected data involves comparing the data with other sources

Organization of data

• Clustering of data & arrangement in a systematic and logical order which gives clue for nursing diagnosis

e.g. Anger is a cue for the diagnosis for anxiety, fear

Recording of data

• Documentation should be concise, thorough and accurate

• Documentation depends upon the institutional policy

• It is descriptive in nature

INTRODUCTION:

Nursing Process Nursing Diagnosis

INTRODUCTIONFrom Assessment to Diagnosis

1.Gathering Data 2.Validating Data3.Organizing Data4.Identify Data5.Reporting & Recording Data

ANALYSIS AND SYNTHESIS OF DATA

DIAGNOSIS

Nurses are Responsible

“Nurse are responsible and accountable for diagnosing actual and potential health problem and initiating action to ensure appropriate and finely

treatment”

What Is Nursing Diagnosis (Dx)?Has two related meanings:

• Nursing diagnosis is an action: the process of analyzing assessment data to arrive at a….nursing diagnosis!

• Nursing diagnosis is a label that describes the patient’s response to an actual or potential health problem

Medical Diagnosis Nursing Diagnosis• Describes a disease or pathology• Conditions MD treats• MD cares for a pt with Congestive Heart Failure

(CHF) – treats pathology with meds, oxygen, diet & fluid restriction

• Describes pt’s response to a health problem

• Situations RNs can treat• Nursing dx describe pt’s response to CHF: such as: Anxiety Activity Intolerance, Impaired Peripheral Tissue Perfusion, Powerlessness

Nursing Diagnosis: The Action• RN reviews assessment data to

identify patterns• Subjective & objective “cues” are

organized into groups that seem to fit together & indicate actual or potential client problems (nursing dx)

• RN makes an educated hunch about which nursing diagnoses might fit the cue cluster

• Review the selected nursing diagnoses to decide which is most accurate

Nursing Diagnosis: The Label

• North American Nursing Diagnosis Association (NANDA): official organization responsible for developing system of naming & classifying nursing diagnoses

• Diagnostic label is often called a “NANDA”

• Each NANDA describes the essence of the problem in as few words as possible.

NANDA DefinitionsEach NANDA-approved nursing diagnosis isaccompanied by a definition that describes itscharacteristics:– NANDA: Impaired Physical Mobility– NANDA Definition: state in which a personexperiences or is at risk of experiencinglimitation of physical movement but is notimmobile

Types of Nursing Diagnoses

• Actual nursing diagnoses: patient has problem

• Risk diagnoses: patient is at risk for developingthe problem (Either begins with “Risk for” orthe definition will include “is at risk for”)

• Wellness diagnoses: patient functioning effectively but desires higher level of wellness

• Others that you do not need to know: – Possible diagnoses – Syndrome diagnoses – Collaborative problems:

Parts of a Nursing Diagnosis: Defining Characteristics• These are the signs & symptoms that validate

that an actual nursing diagnosis is present. Major: at least one must be present to use the

nursing diagnosis Minor: may not be present, but if it is, helps to

validate selecting the nursing diagnosis• Defining characteristics are not present in

‘Risk’dx because signs & symptoms don’t exist if the problem hasn’t happened

.

Parts of a Nursing Diagnosis:Related Factors or Risk Factors

• Related Factors: factors that contributed to the development of

patient’s problem (nursing dx)• Risk Factors: factors that increase the possibility

of the patient developing a problem• Is a relationship rather than direct cause & effect

(is ‘related to’ rather than ‘caused by’)• Only one of these factors (risk or related) needs

to be present to justify use of the nursing dx

Nursing Diagnosis Action Revisited

• Make a hunch about which diagnosis might fit• Read the diagnosis definition to see if it fits• Check out the defining characteristics •Major: one must be present •Minor: if present may help confirm hunch• Rule out any diagnosis for which your patient does not meeting the defining characteristics

Formulating the Diagnostic Statement

• After identifying the best NANDA to describe your patient’s problem...• You need to formulate a “diagnostic statement” – An actual diagnosis has a three-part

statement – A risk diagnosis has a two part statement – A wellness diagnosis has a one part

statement

Actual Diagnostic Statement Three-Part Format

Three parts: 1 NANDA label 2 Related factors (follows NANDA & linked by the words “related to”) 3 Defining characteristics (follows related factors & linked by the words “as

manifested by”)

Actual Diagnostic Statement Example

1 Impaired Physical Mobility 2 related to (r/t) decreased motor ability and muscle weakness 3 as manifested by limited ROM

“Impaired Physical Mobility r/t muscle weakness AMB limited ROM”

Risk Diagnostic Statement Two-Part Format

Two parts:• 1 NANDA label• 2 Risk factors (follows NANDA label

and is linked by the words related to)

Risk Diagnostic Statement Example

1 Risk for Impaired Physical Mobility2 related to (r/t) full leg cast

“Risk for Impaired Physical Mobilityr/t full leg cast”

Clarifying the Related FactorsPart of the Diagnostic Statement

• You will often need to add words to the ‘related

to’ portion of an actual or a risk diagnostic statement to clarify the origin of the problem• These words always follow the ‘related to’ and are linked with the words ‘secondary to’ (2°)• NOTE: This is the only way a medical

diagnosis can ever be inserted into a nursing dx

statement

Examples: Adding a Secondary Factor to the ‘related to’ part of a Diagnostic Statement for Clarity

• Impaired Physical Mobility r/t muscle rigidity and tremors secondary to (2°) Parkinson’s Disease AMB limited ROM and compromised ability to move purposefully

• Risk for Impaired Skin Integrity r/t immobility 2° fractured hip

Wellness Diagnostic Statement

• Used when pt doesn’t have a health problem but can attain higher level of health• Is a one part statement consisting only of the

NANDA: – Readiness for Enhanced Parenting – Readiness for Enhanced Family Processes – Readiness for Enhanced Spiritual Well- Being

MCQs – 7/09/20151. The nursing process was first

described by ……………… in 1955.a. yurab. Walshc. Hall d. Florence

2. Following are the basic concept of nursing process except :

a. healthb. illnessc. nursed. patient

3. Nursing Process (NP) is defined as a ……………, continuous and dynamic method of providing care to clients.

a. systemicb. rhythmicc. cumulatived. judgement

4. Nursing process having mainly ……… components/phases. a. 2

b. 3c. 4d. 5

5. After the analysis of data next phase of nursing process is ………… .

a. planningb. formulate nursing diagnosisc. implementingd. evaluation

Answers

1. - c2. – b 3. – a4. - d5. - b

MCQs – /09/20151. Nursing process is ……………

centered.a. nurseb. doctorc. familyd. patient

2. In ………… phase of nursing process, nurse has to set outcomes strategies to achieve goals of care.

a. assessmentb. planningc. implementationd. evaluation

3. Nursing process is the application of the nurses’ ………… .

a. judgmentb. knowledgec. beliefd. skill

4. …………… data are observable and measurable by nurse.

a. subjective b. pastc. objectived. present

5. Primary data is directly collected from …………… .

a. medical recordsb. family membersc. nurse’s experiencesd. client/ patient

• Nursing assessment includes two steps:

1. Collection of information from a primary source (the patient) and secondary sources (e.g., family members, health professionals, and medical record)

2. The interpretation and validation of data to ensure a complete database

PROBLEMAND

ASSOCIATEDFACTORS

QUESTIONS PHYSICALASSESSMENT

Nature of pain Describe your pain for me.Place your hand over thearea that hurts or isuncomfortable.

Observe nonverbal cues.Observe where patientpoints to pain; note if itradiates or is localized.

Precipitatingfactors

Do you notice if painworsens during anyactivities or specifictime of day?Is pain associated withmovement?

Observe if patientdemonstratesnonverbal signs of painduring movement,positioning,swallowing.

Severity Rate your pain on a scaleof 0 to 10.

Inspect area ofdiscomfort; palpate fortenderness.

1. The nurse asks a patient, “Describe for me your typical diet over a 24-hour day. What foods do you prefer? Have you noticed a change in your weight recently?” This series of questions would likely occur during which phase of a patient centered interview?

a. Setting the stageb. Gathering information about the patient’s

chief concernsc. Collecting the assessmentd. Termination

2. During the review of systems in a nursing history, a nurse learns that the patient has been coughing mucus. Which of the following nursing assessments would be best for the nurse to use to confirm a lung problem? a. Family reportb. Chest x-ray filmc. Physical examination with auscultation of the lungsd. Medical record summary of x-ray film findings

3. What type of interview techniques does the nurse use when asking these questions, “Do you have pain or cramping?” “Does the pain get worse when you walk?” (Select all that apply.)a.Active listeningb.Open-ended questioningc. Closed-ended questioningd.Problem-oriented questioning

4. What technique(s) best encourage(s) a patient to tell his or her full story except one : 1.Active listening2.Back channeling3.Validating4.Use of open-ended questions

5. A 58-year-old patient with nerve deafness has come to his doctor’s office for a routine examination. The patient wears two hearing aids. The advanced practice nurse who is conducting the assessment uses which of the following approaches while conducting the interview with this patient? (Select all that apply.)•Maintain a neutral facial expression•Lean forward when interacting with the patient•Acknowledge the patient’s answers through head nodding•Limit direct eye contact

1 - c2 – c,d3 - c4 - c5 – b,c