The Nursing process

Shurouq Qadose23/1/2008

The nursing process generally is defined as a systematic problem- solving approach toward giving individualized nursing care.

OR The nursing process is a systematic method that directs the nurse and patient as together they accomplish the following:

(1) Assess the patient to determine the need for nursing care; (2) determine nursing diagnoses for actual and potential health problems; (3) identify expected outcomes and plan care; (4) implement the care; and (5) evaluate the results.

Phases The six phases of the nursing process are assessment,

diagnosis, out come identification, planning, implementation, and evaluation.

Nursing Assessment

The first phase of the nursing process, called assessment, is the collection of data for nursing purposes. Information is collected using the skills of observation, interviewing, physical examination, and intuition and from many sources, including clients, their family members or significant others, health records, other health team members.

Reasons for doing assessment:-

 

- To establish baseline information on the client

- To determine the client’s normal function

- To determine the client’s risk for dysfunction

- To determine the client’s strengths

- To provide data for the diagnosis phase

Preparing for assessmentType Aim Time frame

1- Initial assessment Initial identification of normal function, functional status, and collection of data concerning actual or potential dysfunction.Baseline for reference and future comparison.

Within the specified time frame after admission to a hospital, nursing home, ambulatory healthcare center.

2- Focus assessment Status determination of a specific problem identified during previous assessment.

Ongoing process, integrated with nursing care, a few minutes to a few hours between assessments.

3- Time – lapsed reassessment Comparison of client’s current status to baseline obtained previously, detection of changes in all functional health patterns after an extended period of time has passed

Several months (3,6,9 months or more) between assessment

4- Emergency assessment Identification of life – threatening situation

AT anytime

- Setting and environment

Assessment can take place in any setting where nurses care for clients and their family members: in the client’s home, at a clinic, in a hospital room.

Assessment skills

1- Observation

Comprises more than the nurse’s ability to see the client, nurses also use the senses of smell, hearing, touch, and, rarely, the sense of taste. Observation includes looking, watching, examining. Observation begins the moment the nurse meets the client. It is a conscious, deliberate skill that is developed through efforts and with an organized approach. Observation has two aspects: (a) noticing the data and (b) selecting, organizing, and interpreting the data.

Observation done in the following order:

–Clinical signs of client distress.

–Threats to the client’s safety, real or anticipated.

–The presence and functioning of associated equipment.

–The immediate environment, including the people in it.

2- Interviewing

Is a planned communication or a conversation with a purpose, for example to get or give information, identify problems of mutual concern, evaluate change, teach, provide support. There are two approaches to interviewing, directive and nondirective.

The directive interview is highly structured and elicits specific information. The nurse establishes the purpose of the interview and controls the interview. The client responds to questions but may have limited opportunities to ask questions or discuss concerns. The nondirective interview or rapport-building interview, by contrast the nurse allows the client to control the purpose, subject matter, and pacing.

3- Physical examination techniques

Is a systematic data collection method that uses the senses of sight, hearing, smell, and touch to detect health problems. Four techniques are used: inspection, palpation, percussion, and auscultation

- Inspection

Is visual examination of the client that is done in a methodical and deliberate manner. The client is observed first from a general point of view and then with specific attention to detail. Effective inspection requires adequate lighting and exposure of the body parts being observed.

- Palpation

Uses the sense of touch to assess texture, temperature, moisture, organ location and size, vibrations and pulsations, swelling, masses, and tenderness. Palpation requires a calm, gentle approach and is used systematically, with light palpation preceding deep palpation and palpation of tender areas performed last.

- Percussion

Uses short, tapping strokes on the surface of the skin to create vibrations of underlying organs. It is used for assessing the density of structures or determining the location and the size of organs in the body.

- Auscultation

Involves listening to sounds in the body that are created by movement of air or fluid. Areas most often auscultated include the lungs, heart, abdomen, and blood vessels.

4- Intuition

Use of insight, instinct, and clinical experience to make clinical judgments about the client. Intuition plays a role in the nurse’s ability to analyze cues rapidly, make clinical decisions, and implement nursing actions even though assessment data may be incomplete or ambiguous.

Assessment Activities

The activities that make up the assessment are the following:

1 -Collect data

Data collection, the process of compiling information about the client, begins with the first client contact. Nurses use observation, interviewing, and physical examination.

Types of data:

-Subjective data also known as symptoms or covert cues include the client's feeling and statement about his or her health problems and are best recorded as direct quotations from the client, such as

''Every time I move, I feel nauseated''.

- Objective data also known as signs or overt cues, are observable and measurable (quantitative) data that are obtained through observation, standard assessment techniques performed during the physical examination, and laboratory and diagnostic testing.

Sources of data

It can be primary or secondary. The client is the primary source of data. Family members or other support persons, other health professionals, records and reports, laboratory and diagnostic analyses, and relevant literatures are secondary or indirect sources.

2 -Validate data

Validation, commonly referred to as double – checking the information at hand, is the process of confirming the accuracy of assessment data collected. Validation assists in verifying and clarifying cues and inference.

Examples of cues and inferencesExample 1Group of cues client has

-Blurry vision or visual defect -Headache

-Tingling and numbness in extremities -Dizziness

Possible inferences -Client has a brain tumor

-Client is having warning signals of a stroke -Client may be diabetic

- Client is anxious

3 -Organize dataAfter data collection is completed and

information is validated, the nurse organizes, or clusters, the information together in order to identify areas of strengths and weaknesses. This process is known as data clustering. How data are organized depends on the assessment model used. One of these model is Head – to – Toe model.

4- Documenting Data

To complete the assessment phase, the nurse records client data. Accurate documentation is essential and should include all data collected about the client’s health status. To increase accuracy, the nurse records subjective data in the client’s own words to avoid the chance of changing the original meaning.

Nursing Diagnosis

The second step in the nursing process involves further analysis (breaking the whole down into parts that can be examined) and synthesis (putting data together in a new way) of the data that have been collected.

According to the North American Nursing Diagnosis Association (NANDA) a nursing diagnosis is a clinical judgment about individual, family, or community responses to actual or potential health problems/life processes. Nursing diagnoses provide the basis for selection of nursing interventions to achieve outcomes for which the nurse is accountable. (Carroll-Johnson, 1990, p. 50).

Purposes of nursing diagnosis - Nursing diagnosis is unique in that it focuses

on a client’s response to a health problem, rather than on the problem itself, and it provides the structure through which nursing care can be delivered.

- Nursing diagnosis also provides a means for effective communication.

- Holistic client, family, and community-focused care are facilitated with the use of nursing diagnosis.

- Nursing diagnosis has an important impact on the health care delivery system

 

Components of a nursing diagnosis:-

 The Two-Part Statement

The components of a nursing diagnosis typically consist of two parts. The first component is a problem statement or diagnostic label. The diagnostic label is the name of the nursing diagnosis as listed in the NANDA. Some examples include stress urinary incontinence, Anxiety.

The second component of a two-part nursing diagnosis is the etiology. The etiology is the related cause or contributor to the problem. The diagnostic label and etiology are linked by the term related to (RT). Examples of nursing diagnoses are Disturbed Body Image RT loss of left lower extremity and Activity Intolerance RT decreased oxygen-carrying capacity of cells.

Descriptive words or terms may be added to clarify specific nursing diagnoses. These descriptive words are called qualifiers and include Acute, Chronic, Decreased, Deficient, Depleted, Disturbed, Dysfunctional, Enhanced, Excessive, Impaired, Increased, Ineffective, Intermittent, Potential for, and Risk. These terms specify a degree of qualification for the identified nursing diagnosis and are placed (used) before the problem statement.

The Three-Part Statement

The nursing diagnosis can also be expressed as a three part statement. As in the two-part statement, the first two components are the diagnostic label and the etiology. The third component consists of defining characteristics (collected data that are also known as signs and symptoms, subjective and objective data, or clinical manifestations).

In the three-part nursing diagnosis format, the third part is joined to the first two components with the connecting phrase “as evidenced by” (AEB).

Differentiating Nursing Diagnosis versus Medical Diagnosis

 Nursing Diagnosis Medical Diagnosis

- focus on unhealthy responses to health and illness.

- identify diseases

- describe problems treated by nurses within the scope of

independent nursing practice.

- describe problems for which the physician directs the primary

treatment .

- may change from day to day as the patient’s responses change

- remains the same for as long as the disease is present

Myocardial infarction (heart attack) is a medical diagnosis.

Examples of nursing diagnoses for a person with myocardial infarction include Fear, Altered Health Maintenance, Knowledge Deficit, Pain, and Altered Tissue Perfusion.

Nursing Diagnosis versus Collaborative Problems

If such problems require physician – prescribed and nurse – prescribed action, however, they are collaborative health problems. Collaborative problems refer to actual or potential physiologic complications that can result from disease, trauma, treatment, or diagnostic studies for which nurses intervene in collaboration with personnel of other disciplines.

Example 1

56-year-old mother of seven; 167 lb; “Whenever I sneeze lately, I dribble urine. This is embarrassing.”

 Diagnostic statement

Stress Urinary Incontinence related to degenerative changes in pelvic muscles and structural supports associated with advanced age, obesity, gravid uterus

Select nursing responses

Teach Kegel exercises to increase muscle tone; explore patient’s willingness and motivation to pursue weight reduction and exercise program; evaluate need for bladder-training program.

Example 2

42-year-old woman; 1 hour after delivery; spinal anesthesia; 1500 mL fluid infused in past 4 hours without patient voiding; unable to void.

 

Diagnostic statement

Potential complication: Urinary Retention related to fluid overload and effects of anesthesia.

Select nursing responses

Monitor for signs of increasing urine retention; offer bedpan, and encourage voiding with running water, warm water dripped over perineum, and so forth; if no result, administer physician-prescribed medication; if no result, perform physician-prescribed catheterization.

Example 3

“Whenever I have to urinate it burns terribly. I also feel like I have to go all the time—real bad.” Small, frequent voidings, cloudy urine; T—100.8°F

Diagnostic statement

Cystitis

 Select nursing responses

Report signs and symptoms to physician; obtain urine culture; report results to physician; administer appropriate physician-prescribed antibiotic.

Types of Nursing Diagnoses

1- Actual Nursing Diagnoses

Describe a human response to a health problem that is being manifested. They are written as three- part statements: diagnostic label, related factors, defining characteristics.

Example – Acute pain related to surgical trauma and inflammation, as evidenced by grimacing and verbal reports of pain.

Q- Which One is accurate nursing diagnosis?

1- Impaired physical mobility related to pain

2- Ineffective movement related to arthritis

2- Risk nursing diagnosis As defined by NANDA, ’’describes human

responses to health conditions that may develop in a vulnerable individual, family, or community. It is supported by risk factors that contribute to increased vulnerability’’.

Risk nursing diagnoses are two – part statements because they do not include defining characteristics (diagnostic label, risk factors).

 

Example - Risk for infection related to surgery and immunosuppression.

Risk for aspiration related to reduced level of consciousness

Risk for Impaired Skin Integrity related to inability to turn self from side to side in bed.

3- Wellness nursing diagnosis

Is a diagnostic statement that describe the human response to levels of wellness in an individual, family, or community that have a potential for enhancement to a higher state (NANDA, 2005).

 

Wellness nursing diagnosis are one part statement includes diagnostic label.

 Example

– Readiness for enhanced spiritual well being

- Readiness for Enhanced Self-Esteem.

 

 Q- Which One is accurate nursing diagnosis?

1- Readiness for Enhanced Family Coping

2- Family coping potential due to desire for better health

4- Possible Nursing Diagnoses

Is made when not enough evidence supports the presence of the problem but the nurse thinks that is highly probable and wants to collect more information.

Possible Nursing Diagnoses are two part statement includes diagnostic label, related factors (unknown).

 Example- Possible self – esteem disturbance related to unknown etiology

 Q- Which One is accurate nursing diagnosis?

Adjustment impaired, possibly due to recent car accident that resulted in quadriplegia

Possible impaired adjustment related to unknown etiology

Validate Diagnosis

For each diagnosis, the nurse should discuss with the client the significance of the problem, determine the client’s perception of the reason for the problem, and ask whether the client desires help to resolve or to diminish the problem.

Nursing Planning

 The third step of the nursing process includes the formulation of guidelines that establish the proposed course of nursing action in the resolution of nursing diagnoses and the development of the client’s plan of care.

 The planning of nursing care occurs in three phases: initial, ongoing, and discharge. Each type of planning contributes to the coordination of the client’s comprehensive plan of care.

- Initial planning involves development of beginning of care by the nurse who performs the admission assessment and gathers the comprehensive admission assessment data. Initial planning is important in addressing each prioritized problem, identifying appropriate client goals, and correlating nursing care to hasten resolution of the client’s problems.

- Ongoing planning entails continuous updating of the client’s plan of care. Every nurse who cares for the client is involved in ongoing planning.

 

- Discharge planning involves critical anticipation and planning for the client’s needs after discharge.

The four critical elements of planning include:

 

• Establishing priorities

• Setting goals and developing expected outcomes (outcome identification)

• Planning nursing interventions (with collaboration and consultation as needed)

• Documenting

1- Establishing Priorities

The establishment of priorities is the first element of planning. In establishing priorities, the nurse examines the client’s nursing diagnoses and ranks them in order of physiological or psychological importance.

Various guidelines are used in the establishment of priorities for determining which nursing diagnosis will be addressed initially.

The client’s basic needs, safety, and desires, as well as anticipation of future diagnoses must be considered. One of the most common methods of selecting priorities is the consideration of Maslow’s hierarchy of needs, which requires that a life-threatening diagnosis be given more urgency than a non life threatening diagnosis.

The client must participate in the identification of priorities so that the nature of the problem, as well as the client’s values, are reflected in the selected course of action.

2- Establishing Goals and Expected Outcomes

The purposes of setting goals and expected outcomes are to provide guidelines for individualized nursing interventions and to establish evaluation criteria to measure the effectiveness of the nursing care plan. A goal is an aim, an intent, or an end.

A goal is a broad or globally written statement describing the intended or desired change in the client’s behavior, response, or outcome. An expected outcome is a detailed, specific statement that describes the methods through which the goal will be achieved.

Goals should be established to meet the immediate, as well as long-term prevention and rehabilitation, needs of the client.

A short-term goal is a statement written in objective format demonstrating an expectation to be achieved in resolution of the nursing diagnosis in a short period of time, usually in a few hours or days.

A long-term goal is a statement written in objective format demonstrating an expectation to be achieved in resolution of the nursing diagnosis over a longer period of time, usually over weeks or months.

Guidelines for Writing OutcomesWritten outcomes can be evaluated by seeing if

they conform to the following criteria:

• Each set of outcomes is derived from only one nursing diagnosis.

• At least one of the outcomes shows a direct resolution of the problem statement in the nursing diagnosis.

• Both long-term and short-term outcomes are identified as necessary.

• Cognitive, psychomotor, and affective outcomes appropriately signal the type of change needed by the patient.

• The patient and family value the outcomes.

• Each outcome is brief and specific (clearly describes one observable, measurable patient behavior/manifestation), is phrased positively, and specifies a time line.

• The outcomes are supportive of the total treatment plan

Example

 

NURSING DIAGNOSIS: Disturbed Sleep Pattern

Goal: Client will sleep uninterrupted for 6 hours.

EXPECTED OUTCOMES

• Client will request back massage for relaxation.

• Client will set limits to family and significant other visits.

 

NURSING DIAGNOSIS: Ineffective Tissue Perfusion: Peripheral

Goal: Client will have palpable peripheral pulses in 1 week.

EXPECTED OUTCOMES

• Client will identify three factors to improve peripheral circulation.

• Client’s feet will be warm to touch.

3- Planning Nursing Interventions

Once the goals have been mutually agreed on by the nurse and client, the nurse should use a decision-making process to select appropriate nursing interventions.

Nursing interventions are treatment, based upon clinical judgment and knowledge that a nurse performs to enhance patient / client outcomes.

Writing a client plan of care

Two important concepts guide a client plan of care:

 1- The plan of care is client centered.

 2- The plan of care is a step – by step process.

•  Sufficient data are collected to substantiate nursing diagnoses.

• At least one goal must be stated for each nursing diagnosis

• Outcome criteria must be identified for each goal

• Nursing interventions must be specifically designed to meet the identified goal.

• Each intervention should be supported by a scientific rationale.

• Evaluation must address whether each goal was completely met, partially met, or completely unmet.

ImplementingConsists of doing and documenting the activities

that are the specific nursing actions needed to carry out the interventions or nursing orders. The first three nursing process phases-assessing, diagnosing, and planning-provide the basis for the nursing actions performed during the implementing step. In turn, the implementing phase, provide the actual nursing activities and client responses that are examined in the final phase, the evaluating phase.

While implementing nursing orders, the nurse continues to reassess the client at every contact, gathering data about the client’s responses to nursing activities and about any new problems that may develop. To implement the care plan successfully, nurses need cognitive, interpersonal, and technical skills. These skills are distinct from one another. The cognitive skills (intellectual skills) include problem solving, decision making, critical thinking, and creativity.

Interpersonal skills are all of the activities, verbal and nonverbal, people use when interacting directly with one another, this depends on the ability of the nurse to communicate effectively with others. It is necessary for all nursing activities, caring, comforting, advocating, referring, counseling, and supporting others. Technical skills are hands-on skills such as manipulating equipments, giving injections and bandaging, moving lifting, and repositioning clients. These are called procedures, tasks, or psychomotor skills.

Process of Implementing

• Reassessing the client

• Determining the nurse’s need for assistance

• Implementing the nursing interventions

• Supervising the delegated care

• Documenting nursing activities

Reassess the Client, to make sure the intervention is still needed. Even though an order is written on the care plan, the client’s condition may have changed. The nurse also provides supportive communication to help alleviate the client’s stress.

Determining the Nurse’s Need for Assistance, for one of the following reasons:

• The nurse is unable to implement the nursing activities safely alone

• Assistance would reduce stress on the client

• The nurse lacks the knowledge or skills to implement a particular nursing activities

Implementing the nursing Interventions, it is important to explain to the client what interventions will be done, what sensations to expect, what the client is expected to do, and what the outcome is. Ensure client privacy, coordinate client care, and involve scheduling client contacts with other departments.

When implementing interventions, nurses should follow these guidelines:

• Base nursing interventions on scientific knowledge, nursing research, and professional standards of care whenever possible.

• Clearly understand the order to be implemented and question any that are not understood.

• Adapt activities to the individual client, a client’s beliefs, values; age, health status, and environment are factors that can affect the success of a nursing action.

• Implement safe care

• Provide teaching, support and comfort to enhance the effectiveness of nursing care plans.

• Be holistic; view the client as a whole.

• Respect the dignity of the client and enhance the client’s self- esteem

• Encourage client to participate actively in implementing the nursing interventions.

Supervising Delegating Care, if care has been delegated to other health care personnel, the nurse responsible for all the client’s care must ensure that the activities have been implemented according to the care plan.

Documenting Nursing Activities, the nurse complete the implementing phase by recording the interventions and client responses in the nursing process notes. The nurse may record routine or recurring activities such as mouth care in the client record at the end of shift, while some actions recorded in special worksheets according to agency policy. Immediate recording helps safeguard the client to prevent double actions.

Evaluation

 

The last phase of the nursing process, follows implementation of the plan of care, it’s the judgment of the effectiveness of nursing care to meet client goals based on the client’s behavioral responses.

Process of Evaluating Client Responses

Collecting data related to the desired outcomes

Comparing the data with outcomes

Relating nursing activities to outcomes

Drawing conclusions about problem status

Continuing, modifying, or terminating the nursing care plan.

When determining whether a goal has been achieved, the nurse can draw one of the three possible conclusions:

– The goal was met, that is the client response is the same as the desired outcomes.

–The goal was partially met, that is either a short term goal was achieved but the long term was not, or the desired outcome was only partially attained.

–The goal was not met.

Relationship of Evaluation to Nursing Process

 

“When goals have been partially met or when goals have not been met, two conclusions may be drawn:

• The care plan may need to be revised, since the problem is only partially resolved

OR

• The care plan does not need revision, because the client merely needs more time to achieve the previously established goals. So the nurse must reassess why the goals are not being partially achieved.