THE NURSING PROCESS  COMPREHENSIVE  GOAL ORIENTED  INTERPERSONAL  SYSTEMATIC  DYNAMIC

NURSING PROCESS (CONT.)  The nursing process is universally applicable. It is equally at home in the surgical or the psychiatric setting or anything in-between.  The nursing process is simply a way of thinking that systemitizes the way nurses give care.  The nursing process gives nurses a structure for helping patients meet their health goals.

The Nursing Process (cont.)  Purpose of the nursing process: To help nurses manage care, scientifically, holisticaly, and creatively. To help nurses manage care, scientifically, holisticaly, and creatively.  PROBLEM SOLVING METHODS: Trial and Error Trial and Error Scientific Method Scientific Method Intuitive Problem Solving Intuitive Problem Solving

The Nursing Process (cont.)  THE 5 STEPS OF THE NURSING PROCESS  1. ASSESSMENT  2. DIAGNOSING  3. PLANNING  4. IMPLEMENTATION  5. EVALUATION THE NURSING PROCESS ALWAYS FOLLOWS THIS CYCLE, ALTHOUGH IT TAKES VARYING AMOUNTS OF TIME TO COMPLETE.

The Nursing Process (cont)  ASSESSMENT is a continuous, systematic collection, validation and communication of client data.  ASSESSMENT IS CONTINUOUSLY UPDATED!!!  Steps in the assessment phase of the nursing process: 1. Establish a data base by 1. Establish a data base by a. Taking the client’s vital signs a. Taking the client’s vital signs b. Performing a head to toe examination b. Performing a head to toe examination c. Taking a complete nursing history c. Taking a complete nursing history d. Reviewing the client’s chart & the literature d. Reviewing the client’s chart & the literature e. Consult with the client, his significant others e. Consult with the client, his significant others

The Nursing Process (cont)  2. Constantly update the data base to reflect client changes  3. Validate all data  4. Communicate the data ASSESSMENT TAKES PLACE IN ALL REALMS: PHYSICAL, MENTAL, EMOTIONAL, CULTURAL, SPIRITUAL AND SOCIO-ENVIRONMENTAL!!!

The Nursing Process(cont.)  DIAGNOSING: USE NANDA (The North American Nursing Diagnosis Association) as listed in your Taylor, Lillis & Lemone text pp and as described in detail in your Sparks & Taylor Nsg. Diagnosis Reference Manual.  The Nursing Diagnosis Describes Only Problems That Can Be Handled By Nurses!!!!!  The nursing diagnosis describes a human response  The nursing diagnosis differs from the medical diagnosis, but should complement it

The Nursing Process (cont.)  STEPS IN MAKING THE NURSING DIAGNOSIS: 1. Interpret and validate client data; analyze all 1. Interpret and validate client data; analyze all data data 2. Identify the client’s problems (and 2. Identify the client’s problems (and strengths) strengths) 3. Formulate and validate the nursing 3. Formulate and validate the nursing diagnoses, both actual & potential diagnoses, both actual & potential 4. Prioritize a list of appropriate nursing 4. Prioritize a list of appropriate nursing diagnoses (No client has only one diagnoses (No client has only one problem in only one realm.) problem in only one realm.)

The Nursing Process (cont.)  WRITING THE NURSING DIAGNOSIS: IN 3 STEPS 1. THE PROBLEM STATEMENT(NANDA) ie: Constipation 1. THE PROBLEM STATEMENT(NANDA) ie: Constipation 2. THE ETIOLOGY (CAUSE OF THE PROBLEM)ie:Related to (R/T) low residue diet and lack of exercise 2. THE ETIOLOGY (CAUSE OF THE PROBLEM)ie:Related to (R/T) low residue diet and lack of exercise 3. THE EVIDENCE FOR THE 3. THE EVIDENCE FOR THE PROBLEM:As evidenced by(AEB)no stool for five days PROBLEM:As evidenced by(AEB)no stool for five days  Putting it all together: Constipation, R/T low residue diet & lack of exercise AEB no stool for five days

The Nursing Process (cont.)  PLANNING (TO END, HEAL OR OVER- COME THE PROBLEMS IN THE PROBLEM STATEMENTS OF THE NURSING DIAGNOSES) 1. Establish priorities (most life threatening or disturbing first) 1. Establish priorities (most life threatening or disturbing first) 2. Select and write down (in cooperation with the client) the goals which are also known as expected outcomes = goals. 2. Select and write down (in cooperation with the client) the goals which are also known as expected outcomes = goals. EXPECTED OUTCOMES (GOALS) MUST ALWAYS BE DATED OR TIMED!!! EXPECTED OUTCOMES (GOALS) MUST ALWAYS BE DATED OR TIMED!!!

The Nursing Process (cont.) GOALS MUST BE REALISTIC (in terms of the client’s potential for achieving them & the nurse’s ability to help the client achieve them.) GOALS SERVE AS GUIDES IN SELECTING NURSING INTERVENTIONS. GOALS ARE ALWAYS STATED BEGINNING WITH “CLIENT WILL” GOALS ARE ALWAYS STATED BEGINNING WITH “CLIENT WILL” ie: By Sept. 17, client will state what high fiber foods he prefers ie: By Sept. 17, client will state what high fiber foods he prefers By Sept. 18, client will eat one high fiber food with each meal By Sept. 18, client will eat one high fiber food with each meal By Sept. 17, client will walk length of hall tid with assistance By Sept. 17, client will walk length of hall tid with assistance

The Nursing Process (cont)  NURSING INTERVENTIONS (ALSO CALLED IMPLEMENTATIONS)  NURSING INTERVENTIONS MAKE THE CLIENT GOALS COME TRUE!!  NURSING INTERVENTIONS ALWAYS ARE STATED “NURSE WILL”!!  ie: Nurse will consult with the client, dietician, and physician regarding upgrading client’s diet to a high fiber diet.  Nurse will walk with client, assisting and supporting him, the length of the hall tid.  IMPLEMENTATION IS THE ACTION PHASE OF THE NURSING PROCESS (when the nurse does something with, to, or for the client)

The Nursing Process (cont.) .All actions (interventions) planned for the client must be based on scientific principles and rationale.  Interventions are based on the least amount of discomfort, invasion and risk for the client.  The nurse never does for the client what he can safely and capably do for himself. (We’re not taking them to raise; we’re usually trying to return them to their life.)  THE LAST STEP IN INTERVENTION IS TO ACCURATELY DOCUMENT IT!!!

The Nursing Process (cont.)  Nursing interventions require intellectual, interpersonal and technical skills.  Intellectual skills required of the nurse include: problem identification, and problem solving, critical thinking, and the ability to make sound judgments. A strong theoretical background is necessary for these intellectual skills! A strong theoretical background is necessary for these intellectual skills!

The Nursing Process (cont.)  Interpersonal skills used during nursing intervention include: communicating, listening, conveying interest, compassion, empathy, and TLC. These skills are invaluable in establishing rapport and building a therapeutic relationship. TLC. These skills are invaluable in establishing rapport and building a therapeutic relationship.  Technical skills refer to the performance of procedures and the use of equipment and materials competently and proficiently. (Practice makes perfect!) (Practice makes perfect!)

The Nursing Process (cont.)  Nursing interventions can be: 1. DEPENDENT ie: giving the patient a medication (the nurse is dependent on the physician to write the medication order.) 1. DEPENDENT ie: giving the patient a medication (the nurse is dependent on the physician to write the medication order.) 2. COLLABORATIVE ie: consulting with a colleague such as a dietician, physical therapist or another nurse before taking action. 2. COLLABORATIVE ie: consulting with a colleague such as a dietician, physical therapist or another nurse before taking action. 3. INDEPENDENT ie: when the nurse takes action alone, such as starting oxygen on a client who has become cyanotic or beginning one man rescue CPR. 3. INDEPENDENT ie: when the nurse takes action alone, such as starting oxygen on a client who has become cyanotic or beginning one man rescue CPR.

The Nursing Process (cont.)  The last phase of the nursing process is EVALUATION. Our patient goals and nursing actions are useless if we are not constantly evaluating whether or not they are making any headway in returning the client to health and functioning.  EVALUATION MEASURES THE DEGREE TO WHICH THE NURSING PROCESS HAS BEEN SUCCESSFUL.  EVALUATION MEANS WE REASSESS AT EACH STEP TO ASSURE EFFECTIVENESS AND ACCURACY.

The Nursing Process (cont.)  Common evaluation outcomes: 1. Client responded as expected, problem is solved, goals effective 1. Client responded as expected, problem is solved, goals effective 2. Client’s problem has not been resolved, even though expected outcomes were accomplished. Re-evaluate, make new problem solving goals. 2. Client’s problem has not been resolved, even though expected outcomes were accomplished. Re-evaluate, make new problem solving goals. 3.Client’s problem has not been resolved and has,in fact, worsened. Replanning is urgently needed. 3.Client’s problem has not been resolved and has,in fact, worsened. Replanning is urgently needed. 4. Client has manifested a new problem; nursing process begins all over again. 4. Client has manifested a new problem; nursing process begins all over again.