nursing process Dr. Reem ali

1. nursing processDr. Reem ali Fall Semester 2011-2012

2. Nursing Process • Objectives • Define the Nursing Process • Describe the phases of the nursing process • Identify the characteristics of the nursing process • Identify the purposes of each phase of the nursing process. • Identify activities that occur in each phase of the nursing process.

3. Nursing Process Required Readings Kozier & Erb's Fundamentals of Nursing: Concepts, Process and Practice(2012) (9th ed.) • Chapter Number 11- 14; Assessing; Diagnosing; Planning; Implementing & Evaluation

4. Nursing Process • Nursing process • Is a systematic ,rational method of planning and providing individualized nursing care. • Purpose of the nursing process: • Identify client’s health status • Identify actual or potential health problems or needs • Establish plans to meet the identified needs • Deliver specific nursing interventions to meet those needs.

5. Nursing Process • Consists of 5 phases • Assessment • Diagnosis (outcomes identification & analysis) • Planning • Implementation • Evaluation • The phases of the nursing process are: • Not separate entities but overlapping • Each phase or step affects the others • Closely interrelated for example if the assessment is incomplete the diagnosis, planning will be incomplete

6. Characteristics of Nursing Process • A cycle (regularly repeated event or sequence of events) and dynamic (continuously changing) nature • An adaptation of problem solving and system theory (parallel to but separate from the medical model).

7. Characteristics of Nursing Process • Client-centered (nurse organizes the plan of care according to client problems rather than nursing goals). Incorporate client’s routine into the care plan • Decision making is involved in every phase of the process. • Interpersonal (nurse communicate with client and families) and collaborative (with the health care team) • Universally applicable (it is used as a framework for nursing care in all settings and clients of all age groups) • Nurses must use a variety of critical thinking skills to carry out the process

8. Nursing Process

9. Assessment • Involves • Collecting data (from variety of sources) • Organizing the client data (information) • Validating the client data • Documenting the client data • Purpose Establish information (data base) about person’s response to health concerns and ability to manage health care needs

10. Assessment • Types of assessment: • Initial assessment (e.g nursing admission) • Problem-focused assessment ongoing process integrated with nursing care (Hourly assessment of I &O in ICU) • Emergency assessment. During any physiologic or psychologic crises (emergency assessment of ABC[Airway, Breathing Circulation]) • Time-lapsed reassessment. Several months after initial assessment (reassessment of client’s condition at each shift)

11. Collecting Data • Data collection is a systematic and continuous gathering of information about a client's health status. • Data base contains all the information about a client; it includes nursing health history, physical assessment, primary care provider's history and physical examination, lab and diagnostic test (see Box 11-1). • Types of data • Subjective data • Objective data

12. Collecting Data: Subjective & Objective data • Subjective • symptoms or covert data • Data from the client’s point of view • It include the client’s feelings, perceptions, and concerns • Main way to collect subjective data is the interview • Example: “I feel weak when I try to walk”; pain, feeling of worry, itching

13. Collecting Data: Subjective & Objective data • Objective • Signs or overt data • Observable, testable, & measurable data • Can be seen, heard, felt, or smelled • Main way to collect objective data: • Observation or physical assessment • Lab and diagnostic testing • Example: color of skin, blood pressure

14. Types of Data • Constant data • is the data that doesn’t change over time such as race, blood type. • Variable data • is the data that can change quickly, frequently, or rarely such as blood pressue, age, level of pain

15. Sources of Data • Primary sources (direct) • Client (the best source) • Can be obtained by • Interview • Physical examination • Secondary sources (Indirect) • Family members • Other health care providers • Medical records • Lab and diagnostic analyses • Relevant literature.

16. Assessment • Organizing the Data: Systematic organization of the assessment data using: • Written Format • Computerized Format • Validating the data: The act of “double-checking” or verifying data to confirm that it is accurate and factual. • Not all data require validation such as height, weight, birth date & lab results • Data validated when there is a discrepancies between subjective and objective data

17. Assessment • Documenting the Data: Recording all the collected data about the client • Data should be recorded in factual manner and not interpreted by the nurse. Example the nurse should write the client had breakfast ( 1 egg, 1 slice of toast , juice 120 ml) NOT the client has good appetite • Subjective data should be recorded in the client own words using quotation marks example “ I feel very worried”

18. Diagnosing • Consists of • Analyze data • Indentify health problems, risk and strengths • Formulate diagnostic statements

19. Diagnosing • NANDA (North American Nursing Diagnosis Association) provide a diagnostic labels (names for the diagnosis) • A classification system of nursing diagnoses (ND) • Currently provided more than 200 of nursing diagnostic lables • Example of ND: • Activity intolerance • Anxiety • constipation

20. Diagnosing • Nursing diagnosis is the clinical judgment about client’s response to health problems • Nursing diagnosis provides the bases for the selection of nursing interventions to achieve outcomes • Nursing diagnosis consists of: • diagnostic label + etiology (casual relationship between the problem and its related or risk factors) • Example • Constipation related to long-term laxative use • Constipation related to inactivity & insufficient fluid intake • signs and symptoms

21. Components of Nursing Diagnosis • Problem statement from NANDA label • Related factors (Etiology) • Defining characteristics (Signs and Symptoms) • Example : Noncompliance (Diabetic diet) related to unresolved anger about the diagnosis as manifested OR evidenced by patient’s verbalization “ I forget to take my bills ; weight gain of 4.5 kg; blood pressure 190/100 • Nursing Diagnosis vs. Medical Diagnosis • Medical diagnosis (Amputation) • Nursing diagnosis (Body image disturbance)

22. Types of Nursing Diagnosis • Actual diagnosis – problem is present • Problem present at the time of nursing assessment • e.g. (Ineffective breathing pattern ; anxiety) • Risk nursing diagnosis • does not exist but there are risk factors • e.g. (Risk for infection) • Health promotion diagnosis • Client’s preparedness to implement behaviors to improve health • e.g. (Readiness for Enhanced Nutrition) • Wellness diagnosis • Describe human response to levels of wellness • e.g. (Readiness for enhanced family coping)

23. Planning • Consists of • The process of prioritizing nursing diagnoses • Formulate goals/desired outcomes • Selecting appropriate interventions • Write nursing interventions . • The nurse consults with the client while developing and revising the plan.

24. Types of Planning • Initial planning Done immediately after the initial assessment • Ongoing planning Done by all nurses who work with the patient as well as at the beginning of a shift • Discharge planning The process of anticipating and planning for needs after discharge

25. The Planning Process • Establishes Priorities • Establish client goals/desired outcomes • Goals • An aim, intent or end. • Short term goals • Hours to days (less than a week) • e.g. reduce temperature • Long term goals • Weeks to months • weight gain

26. The Planning Process • Selects Nursing Interventions • Independent nursing interventions • No order needed (elevate edematous legs) • Collaborative nursing interventions • In conjunction with an interdisciplinary team member • (assist client with physical therapy exercises) • Dependent nursing interventions • Require physician order or supervision • (Administering of medications) • Writing individualized nursing intervention on care plan

27. Implementation • The action phase that consists of : • Reassessing the client (Continue to collect data) • Determining the nurse’s need for assistance (Assist person to meet goals; facilitate coping) • Implementing the nursing interventions (Carry out the plan) • Supervising the delegated care • Documenting nursing activities

28. Implementation • Implementation skills • Cognitive (intellectual skills) e.g. problem solving, decision making • Interpersonal: important for all nursing activities • Technical: purposeful “hands- on” skills e.g. giving injection, moving, bandaging. (psychomotor skills)

29. Evaluation • Collecting data related to desired outcome • Comparing data with desired outcomes • Relating nursing activities to outcomes • Drawing conclusions about problem status • Continuing, modifying, or terminating the nursing care plan

30. Evaluation • Determining whether the clients goals have been met, partially met or not met • Should care continue • Modify plan if necessary • The evaluation incorporates all input from the entire health care team, including the patient.

31. Quiz • This stage involves delivering the plan of care using evidence-based nursing interventions to achieve the goals. What stages of the nursing process is this? • Nursing diagnosis • Implementation • Assessment • Evaluation • Planning

32. Quiz • This stage involves delivering the plan of care using evidence-based nursing interventions to achieve the goals. What stages of the nursing process is this? • Nursing diagnosis • Implementation • Assessment • Evaluation • Planning

33. Quiz • This stage involves identifying the patient’s nursing problems/needs, both actual and potential, which will require nursing interventions. What stage of the nursing process is this? • Nursing diagnosis • Implementation • Assessment • Evaluation • Planning

34. Quiz • This stage involves identifying the patient’s nursing problems/needs, both actual and potential, which will require nursing interventions. What stage of the nursing process is this? • Nursing diagnosis • Implementation • Assessment • Evaluation • Planning

35. Quiz • This stage is when the nurse reviews the care plan to see whether the goals have been met or partially met and whether the care that was planned was appropriate & effective. If the goal has not been fully or partially achieved re-assessment may be necessary and the nursing process begins again. What stage of the nursing process is this? • Nursing diagnosis • Implementation • Assessment • Evaluation • Planning

36. Quiz • This stage is when the nurse reviews the care plan to see whether the goals have been met or partially met and whether the care that was planned was appropriate & effective. If the goal has not been fully or partially achieved re-assessment may be necessary and the nursing process begins again. What stage of the nursing process is this? • Nursing diagnosis • Implementation • Assessment • Evaluation • Planning

37. Quiz • This stage involves the setting of appropriate goals and the nursing care required to meet the goal. A goal should be specific, measurable, achievable & realistic and time-oriented. Goals can be short term of long terms so there must be an indication of when the goal should be achieved. What stage of the nursing process is this? • Nursing diagnosis • Implementation • Assessment • Evaluation • Planning

38. Quiz • This stage involves the setting of appropriate goals and the nursing care required to meet the goal. A goal should be specific, measurable, achievable & realistic and time-oriented. Goals can be short term of long terms so there must be an indication of when the goal should be achieved. What stage of the nursing process is this? • Nursing diagnosis • Implementation • Assessment • Evaluation • Planning

39. Quiz • This stage is crucial to the whole nursing process and involves collection of data from a variety of sources and is structured according to the nursing model being used. What stage of the nursing process is this? • Nursing diagnosis • Implementation • Assessment • Evaluation • Planning

40. Quiz • This stage is crucial to the whole nursing process and involves collection of data from a variety of sources and is structured according to the nursing model being used. What stage of the nursing process is this? • Nursing diagnosis • Implementation • Assessment • Evaluation • Planning