The Nursing Process

The Nursing Process
An organizational framework for the practice of nursing
Orderly, systematic
Central to all nursing care
Encompasses all steps taken by the nurse in caring for a patient

Definition of the Nursing Process
An organized sequence of problem-solving steps used to identify and to manage the health problems of clients

The Nursing Process
Assessment
Planning
Implementation
Evaluation

Characteristics of the Nursing Process
Within the legal scope of nursing
Based on knowledge-requiring critical thinking
Planned-organized and systematic
Client-centered
Goal-directed
Prioritized
Dynamic

What Are the nurses’ Responsibilities?
Recognize health problems.
Anticipate complications.
Initiate actions to ensure appropriate and timely treatment.
Begin to think CRITICALLY !!!!!!

Assessment of Well-Being
According to the World Health Organization well-being includes the following:
Emotional
Physical
Social
Spiritual

Lets Get Started :
Nurse collects background info from previous charts
Ensure environment is conducive
Arrange seating
Allow adequate time
Nurse introduces self
Identifies purpose of interview
Ensure confidentiality of information
Provide for patient needs before starting

ASSESSMENT
Observation
Interview
Types of questions
Environment
Examination

Types of Data To Collect:
Objective data-observable and measurable facts (Signs)
Subjective data-information that only the client feels and can describe (Symptoms)

CULTURAL DIVERSITY
Respect INDIVIDUAL’S DIFFERENCES, What is the significance of the problem or illness to the client?
What does it mean in the family/community?

Resources
Client
Other individuals
Previous records
Consultations
Diagnostics studies
Relevant literature

Assessment
Data base assessment – comprehensive information you gather on initial contact with the person to assess all aspects of health status.

Sources of Data
Primary source: Client
Secondary source: Client’s family, reports, test results, information in current and past medical records, and discussions with other health care workers

Disease Prevention
Primary prevention – protection from a disease while still in a healthy state.
Secondary prevention – early detection and treatment of disease.
Tertiary prevention – prevent complications and to maintain health once the disease process has occurred.

Planning
Establish the goals, interventions and outcomes

General Guidelines for Setting Priorities
Take care of immediate life-threatening issues.
Safety issues.
Patient-identified issues.
Nurse-identified priorities based on the overall picture, the patient as a whole person, and availability of time and resources.

Nursing Interventions
Outlining the best ways to provide nursing care.
Evidence based nursing.
Monitor health status.
Minimize risks.
Resolve or control a problem.
Assist with ADLs.
Promote optimum health and independence.

Interventions
Direct interventions: actions performed through interaction with clients.
Indirect interventions: actions performed away from the client, on behalf of a client or group of clients.

Documenting the Plan of Care
To ensure continuity of care, the plan must be written and shared with all health care personnel caring for the client.
Consists of:
Prioritized nursing diagnostic statements.
Outcomes.
Interventions.

Documentation
Clear and concise
Appropriate terminology
Usually on a designated form
Physical assessment
Usually by Review of Systems
Overview of symptoms
Diet

Documentation
Use patient’s own words in subjective data – enclose in “ ___” (quotation marks)
Avoid generalizations – be specific

Evaluation
Determining outcome achievement
Identifying the variables affecting outcome achievement
Deciding whether to continue, modify, or terminate the plan

Determining Outcome Achievement
Must be aware of outcomes set for the client.
Is patient able to meet outcome criteria?
Is it:
Completely met?
Partially met?
Not met at all?
Record in progress in notes.
Update care plan.

Maintain individuality of care plan:
1. Is the plan realistic for the client?
2. Is the plan appropriate at the time for this particular client?
3. Were changes made in the plan when needed?
4. How does the client feel about the plan?

Planning
The process of prioritizing nursing diagnoses and collaborative problems, identifying measurable goals or outcomes, selecting appropriate interventions, and documenting the plan of care.
The nurse consults with the client while developing and revising the plan.

Setting Priorities
Determine problems that require immediate action
Maslow’s Hierarchy of Human Needs

Short-Term Goals
Outcomes achievable in a few days or 1 week
Developed form the problem portion of the diagnostic statement
Client-centered
Measurable
Realistic
Accompanied by a target date

Long-Term Goals
Desirable outcomes that take weeks or months to accomplish for client’s with chronic health problems

The Nursing Process
Planning
Identification of goals and outcome criteria
Prioritization
Time frame

Communicating The Plan
The nurse shares the plan of care with nursing team members, the client, and client’s family.
The plan is a permanent part of the record.

Evaluation
The way nurses determine whether a client has reached a goal.
It is the analysis of the client’s response, evaluation helps to determine the effectiveness of nursing care.

The Nursing Process
Evaluation
Ongoing part of the nursing process
Determining the status of the goals and
outcomes of care
Monitoring the patient’s response to drug therapy