THE NURSING PROCESS

THE NURSING PROCESS “Nursing is the diagnosis and treatment of human response to actual or potential health problems” (ANA, 1980). Thus how the client is responding to a medical problem, treatment plan and changes in activities of daily living. “… to assist the individual sick or well in the performance of those activities contributing to health or its recovery (or to a peaceful death) that he would have perform unaided if he had the necessary strength, will, or knowledge, and to do this in such a way as to help him gain independence as rapidly as possible” (Henderson, 1966) Process……..?

THE NURSING PROCESS Hall (1955) originated the term nursing process. In the 1960s the nursing process emerged and has become widely accepted to describe the series of steps that a nurse takes when caring for his/her patient. Various nurses have described the process of nursing and organized it in various phases and in different ways. The use of the nursing process gained more ground and legitimacy in 1973 when the phases were included in the Standard of Nursing of the American Nurses Association. A model is a simple explanation as to how something works.

THE NURSING PROCESS A systematic and scientifically based model, the nursing process is used to guide nursing practice in providing holistic and individualized care to the client. method used to: identify patient’s health problems, To specify plans to solve them To implement the plans and Evaluate the effectiveness of plans in resolving the problems that were identified (Yura and Walsh, 1978)

THE NURSING PROCESS The nursing process is the basis of all nursing actions. Each step of the nursing process builds on and interacts with the other steps. The nursing process is patient/family centered, problem oriented, goal directed and above all planned with the aim of providing care that is individualized, holistic, effective and efficient.

THE NURSING PROCESS The nursing process runs through five (5) sequential but interrelated steps which are cyclical as follows: Assessment Nursing Diagnosis Planning Implementation Evaluation Each step of the nursing process is dependent upon the accuracy of the preceding step.

THE NURSING PROCESS NURSING DIAGNOSIS ASSESSMENT PLANNING IMPLEMEN-TATION EVALUATION

THE NURSING PROCESS Assessment is the first step of the nursing process. The nurse collects and examine information to get the necessary facts to determine the patient’s health status and describe the strengths and problems. The data collected is on the patient/family, community’s health status. Analysis of this data determines the actual and potential health problems . Assessment progresses in stages: Collection of data Organization of data Validation of data Documenting data

THE NURSING PROCESS The purpose of assessment is to obtain information and to make a decision about a client’s health status. Sensitive and continuous nursing assessment by means of health history and health assessment helps maintain and awareness of the patient’s needs and effectiveness of the nursing care he/she receives. It also helps identify patient’s strength-skills, abilities and behaviours the client has that can be used to promote treatment and recovery. E.g. family support, coping skill, spiritual beliefs etc.

THE NURSING PROCESS Data is collected from a variety of sources: Primary source (client). Secondary source (sources other than the client) e.g. family members, other health care providers, medical records and diagnostic reports, literature review etc. Data collected may subjective or objective. Subjective data refers to symptoms which only the affected person can describe e.g. itching, pain and feelings of worry. It includes the client’s sensation, feelings, values, beliefs, attitudes etc. The best source of subjective data is from the patient.

THE NURSING PROCESS Objective data (signs) are data that can be observed, measured or tested against an accepted standard. This data is collected through observation or physical examination. Sign (objective data) can be seen, heard, felt or smelled. E.g. rashes, sore, hoarseness of voice blood pressure, results of a test etc. The nurse obtains objective data to validate subjective data.

THE NURSING PROCESS Data collection tools/methods Observation-gathering data by using the senses Interviewing e.g. health history taking Physical examination/physical assessment- a systematic data collection method that uses observation. It entails inspection, palpation, auscultation and percussion. Data collected is document.

THE NURSING PROCESS Why nursing assessment? To establish database that identify patient’s health problems, needs and strengths To determine client’s immediate responses to nursing action during the implementation phase To evaluate patient’s progress towards desired outcomes/goals

THE NURSING PROCESS Nursing Diagnosis This is the second phase of the nursing process. It is a clinical judgement about individual, family, or community’s response to actual and potential health problems/life process During this step, one further analyze and synthesize the information and come to some specific conclusion; Identify areas of positive functioning Areas where there may be a risk of problems developing Areas that are problems

The actual or potential health problems to which nurses direct their diagnosis and treatment, then, are the human responses-to the health challenges encountered in birth, illness, growth and development and death

THE NURSING PROCESS The distinguishing feature of any nursing diagnosis is that it describes a health condition primarily resolved by nursing interventions or therapies. Nursing diagnosis provides the basis for selection of nursing interventions for achieve and outcome that the nurse is accountable.

THE NURSING PROCESS Types of Nursing Diagnosis Actual diagnosis id a client problem that is present at the time of the nursing assessment Potential/Risk nursing diagnosis is clinical judgement that though a problem does not exist presently, the presence of risk factors indicate that it can develop if certain measures are not put in place. Health promotion diagnosis relates to client’s preparedness to implement behaviours to improve their health condition. E.g. Readiness for enhanced (nutrition)

THE NURSING PROCESS Wellness diagnosis describes human response to levels of wellness in an individual, family or community. E.g. Readiness for enhanced family coping.

THE NURSING PROCESS The Format When communicating nursing diagnosis, it is customary to use a format, that is, the general arrangement or organization. Formats are important because they are used in common by the group adopting them and thus unifying the group’s approach to communication around shared understanding and expectations. The conventional format is the PES format which indicates the direction of the relationship between the health problem (P), its etiologic factors (E), and its defining characteristics/signs and symptoms (S).

THE NURSING PROCESS The Problem is a concise statement of the client’s actual or potential health problem or health state for which nursing therapy is given. It directs the formation of client goals and desired outcomes as well as suggest some of the interventions needed by the client. The problem statement is also called the diagnostic label; it comes from a list of approved nursing diagnosis. E.g. Impaired skin integrity, Activity intolerance. One cannot coin his/ her own diagnostic label! the problem is named using the label that most closely matches it.

THE NURSING PROCESS Diagnostic labels contain qualifiers (deficient, impaired, decreased, inefficient compromised etc.) to give additional meaning to it. Each diagnostic label approved by NANDA carries a definition that clarifies its meaning. Example: Activity intolerance-insufficient physiological or psychological energy to endure or complete required or desired daily activities.

NURSING PROCESS Some Diagnostic Labels Activity intolerance Ineffective airway clearance Anxiety Ineffective thermoregulation Altered urinary elimination Self care deficit Altered nutrition Impaired mobility Knowledge deficit Impaired skin integrity

THE NURSING PROCESS Etiology-the component of the nursing diagnosis that identifies the probable causes of the health problem. Also called the Related Factors or Contributing Factors, it gives direction to the required nursing therapy and enables the nurse to individualize the client’s care. Since the etiology of nursing diagnosis becomes the focus of intervention in the treatment of the overall problem, citing medical condition/diagnosis as etiology inadvisable. Sign and Symptoms-also known as the Defining Characteristics are observed, reported or measured findings that serve as supporting evidence of the diagnosis.

THE NURSING PROCESS The word risk for OR potential for is used to identify the presence of risk factors; thus the actual problem does not yet exist. E.g. Potential for impaired skin integrity related to continuous pressure on skin over bony prominences Or Risk for impaired skin integrity related to continuous pressure on skin over bony prominences.

THE NURSING PROCESS Formulating Diagnostic Statements When communicating the nursing diagnosis, the various parts (PES) are linked with words that indicate the direction of the relationship between the problem, its etiologic factors and the defining characteristics. the problem and the etiologic factors are linked with related to; the defining characteristics are linked with the indicator as evidenced by or as manifested by

THE NURSING PROCESS In the formulation of the nursing diagnosis, one can have; Two part statements- this is composed of the diagnostic label (problem) + contributing factors; e.g. Constipation related to prolonged laxative use. Three part statements-this is composed of the diagnostic label + contributing factors + signs and symptoms e.g. Potential for impaired skin integrity related to continuous pressure on skin over bony Prominences as manifested by discolouration of skin at the buttocks and scapulae.

When writing statements for nursing diagnosis, try to express them in such a way that the second part of the statement (related factors/etiology) directs the interventions. If this is not possible, then be sure the problem directs the intervention.

THE NURSING PROCESS Nursing diagnosis has the following benefits: Assists in organizing, defining and developing nursing knowledge Aids in identifying and describing the domain and scope of nursing practice Focuses nursing care on the client’s response to problems Provides diagnosis-specific nursing interventions that should increase the effectiveness of nursing care. Facilitates the evaluation of nursing practice

THE NURSING PROCESS Provides a framework for testing the validity of nursing interventions Provides a standardized vocabulary to enhance intra- and interprofessional communication Prescribes the content of nursing curricula Provides a framework for developing a system to direct third-party reimbursements for nursing services Indicates specific rationales for (client) care based on nursing assessment Leads to more comprehensive and individualized (client) care.

THE NURSING PROCESS Planning The care plan is a blue print for assisting a client to resolve the clients health problem. Constructing a unique plan to guide the delivery of nursing care to every client requires a wide range of knowledge and skills. In developing client care plans, the nurse engages in the following activities: Setting priorities Establishing client goals/desired outcomes Writing individualized nursing interventions on care plans

THE NURSING PROCESS Priority setting is a decision –making process that is used to rank the urgency or relative importance of nursing diagnoses, desired outcomes and nursing implementation. Priorities change as the client’s condition changes. Priority setting is a way of is a way of allocating resources and, if well done, improves the quality and efficiency of nursing care. Maslow’s hierarchy of needs is one framework that used in prioritizing care. The client’s beliefs, values and perception may also influence priority setting as the resources available for patient care.

THE NURSING PROCESS After setting priorities, the nurse and client set goals for each nursing diagnosis formulated. Goals are derived directly fro the problems diagnosed. The goals and desired outcomes(expected outcomes, predicted outcome, outcome criteria or objective) serve as the yardstick in evaluating the nursing interventions implemented. Whiles the goal is a broad statement about the client’s status, the desire outcome the specific observable criteria used to evaluate whether the set goals have been achieved or not. Goals/objectives set must be SMART: Specific Measurable Achievable Realistic and Time bound

THE NURSING PROCESS In stating the objective/outcome criteria, the goal is stated and linked with the outcome criteria with the phrase as evidenced by. E.g. Ineffective airway clearance related to poor cough effort secondary to incision pain. (nursing diagnosis) Patient’s lungs will be clear within 72hours as evidenced by: Clear lung fields on auscultation Good cough effort Absence of skin pallor. The goal/desired outcome statement should have the subject, verb, condition/modifiers and criterion of desired performance.

THE NURSING PROCESS Selecting Nursing Interventions Nursing interventions and activities are the actions that a nurse performs to achieve client goals. The specific interventions chosen should focus on eliminating or reducing the etiologic factors (the problems) of the nursing diagnoses. If it is not possible to eliminate the etiology, then the nurse chooses interventions to treat the signs and symptoms. In the case of risk nursing diagnoses, then the intervention should focus on reducing the client’s risk factors.

THE NURSING PROCESS The interventions may be Dependent Independent Collaborative. After going through the several intervention possible interventions identified for each nursing goal, the nurse must choose and document those that are most likely to achieve the desired client outcomes.

THE NURSING PROCESS Implementation This is the action phase of the nursing process where the care as planned is carried out/performed. It entails performing the actual nursing activities and documenting them. The process of implementation includes Reassessing the client Determining the nurse’s need for assistance Implementing the nursing interventions Supervising delegated care and Documenting nursing activities

THE NURSING PROCESS Evaluating Evaluation is a systematic comparison of a client’s health status to standards/outcome criteria mutually developed by the client and the nurse. It is a planned, ongoing, purposeful activity in which clients and health care professionals determine the effectiveness of the nursing care plan. Evaluation determines whether the nursing interventions should be continued, change or terminated.

NURSING PROCESS During evaluation of nursing care, sharp and objective outcome criteria are important because they establish the kind of evaluative data needed to be collected aside providing the standard or yardstick against which the data collected is judged. The components of evaluations phase are: Collecting data related to desired outcomes Comparing data with desired outcomes Relating nursing activities to outcomes Drawing conclusions about problems status Continuing, modifying or terminating the nursing care plan

NURSING PROCESS Benefits of the Nursing Process Promotes individualized/client centred health care Ensures holistic health care delivery Promotes flexibility and independent thinking Ensures continuity of care Avoid duplication of effort and judicious use of resources.

NURSING PROCESS Nursing Process Medical Process Deals with two types of health problems: Human response problems (problems with human functioning that result from the effect of disease, trauma or changes in life. Problems with structure and function organs or systems requiring physicians’ orders Considers the whole person ; not only the organs and systems functions Deals mostly with problem with structure and function of organs or systems Mainly considers organ and system function

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