NURSING PROCESS

NURSING PROCESSAn overview1Jane Fatima G. VicenteJane Fatima G. VicenteOBJECTIVES FOR THE DAYDefine nursing processExpound on the history of Nursing processIdentify the phases of nursing processEnumerate the steps/tasks to be done in every phase of nursing process2Jane Fatima G. VicenteDEFINITIONis the framework for providing professional, quality nursing caredirects nursing activities for: health promotion, health protection, and Disease preventionused by nurses in every practice setting and specialty3Jane Fatima G. VicenteHISTORY1955 - Lydia Hall first referred to nursing as a process in a journal articleReferring to the nursing process as a series of steps, Johnson (1959), Orlando (1961), and Wiedenbach (1963) further developed this description of nursingnursing process involved only three steps: assessment, planning, and evaluation4Jane Fatima G. Vicente1967 - book The Nursing Process, Yura and Walsh identified four steps in the nursing process:AssessingPlanningImplementingEvaluating5Jane Fatima G. Vicente1973 - The Standards of Practice, American Nurses Association (ANA), included eight standards. standards identified each of the steps, including nursing diagnosis, that are now included in the nursing process.6Jane Fatima G. VicenteFry (1953) first used the term nursing diagnosis1974 - after the first meeting of the group now called the North American Nursing Diagnosis Association (NANDA) - Gebbie and Lavin added nursing diagnosis as a separate and distinct step in the nursing process. 7Jane Fatima G. VicenteFollowing publication of the ANA standards, nurse practice acts of many states were revised to include the steps of the nursing process specifically.ANA made revisions to the standards in 1991 to include outcome identification as a specific part of the planning phase.8Jane Fatima G. VicenteCurrently, the steps in the nursing process are:AssessmentDiagnosisOutcome identification and planningImplementationEvaluation9Jane Fatima G. Vicenteprocess - is a series of steps or acts that lead to accomplishment of some goal or purpose. The purpose of the nursing process is to provide care for clients that is individualized, holistic, effective, and efficient. 10Jane Fatima G. VicenteThe steps of the nursing process build upon each other, but they are not linear. There is overlap of each step with the previous and subsequent steps11Jane Fatima G. Vicente

12Jane Fatima G. VicenteCHARACTERISTICSTHE NURSING PROCESS IS:dynamic and requires creativity for its applicationdesigned to be used with clients throughout the life span and in any setting in which a nurse provides care for clients13Jane Fatima G. VicenteASSESSMENTthe first step in the nursing processincludes collection, verification, organization, interpretation, and documentation of data. The completeness and correctness of the information obtained during assessment are directly related to the accuracy of thesteps that follow14Jane Fatima G. VicenteSTEPS:Collecting data from a variety of sourcesValidating the dataOrganizing dataCategorizing or identifying patterns in the dataMaking initial inferences or impressionsRecording or reporting data15Jane Fatima G. VicenteNURSING DIAGNOSISinvolves 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.Formulation of the list of nursing diagnoses is the outcome of this process. 16Jane Fatima G. VicenteNorthAmerican Nursing Diagnosis Association (NANDA)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)17Jane Fatima G. Vicentenursing diagnoses developed during this phase of the nursing process provide the basis for client care delivered through the remaining steps.Client problems are labelled by both medical and nursing diagnoses. Clients receive both medical and nursing diagnoses.18Jane Fatima G. VicenteQUESTIONS TO BE ANSWERED IN THIS STEP:Are there problems here?If so, what are the specific problems?What are some possible causes for the problems?Is there a situation involving risk factors?What are the risk factors?Is there a situation in which a problem can develop if preventive measures are not taken?19Jane Fatima G. VicenteQUESTIONS TO BE ANSWERED IN THIS STEP:Has the client indicated a desire for a higher level of wellness in a particular area of function?What are the clients strengths?What data are available to answer these questions?Are more data needed to answer the question?If so, what are some possible sources of the data that are needed?20Jane Fatima G. VicenteOUTCOME IDENTIFICATION & PLANNINGincludes the formulation of guidelines that establish the proposed course of nursing action in the resolution of nursing diagnoses and the development of the clients plan of care. Once the nursing diagnoses have been developed and client strengths have been identified, planning can begin.21Jane Fatima G. VicenteTASKS:The list of nursing diagnoses is prioritized.Client-centered long- and short-term goals and outcomes are identified and written.Specific interventions are developedThe entire plan of care is recorded in the clients record.22Jane Fatima G. VicenteIMPLEMENTATIONinvolves the execution of the nursing plan of care derived during the planning phase.consists of performing nursing activities that have been planned to meet the goals set with the client. Nurses may delegate some of the nursing interventions to other persons assigned to care for the client23Jane Fatima G. Vicenteinvolves many skills.The nurse must continue to assess the clients condition before, during, and after the nursing intervention. Assessment prior to the intervention provides the nurse with baseline data.Assessment during and after the intervention allows the nurse to detect positive or negative responses the client may have to the intervention. If negative responses occur during the procedure, the nurse must take appropriate action. If positive responses occur, the nurse adds this information to the database for use in evaluating the efficacy of the intervention.24Jane Fatima G. Vicentenurse must also possess psychomotor skills, interpersonal skills, and critical thinking skills to perform the nursing interventions that have been planned.The nurse uses psychomotor skills when performing procedures such as: giving injections, changing dressings, and helping the client perform range-of-motion (ROM) exercises. 25Jane Fatima G. VicenteInterpersonal skills are necessary as: the nurse interacts with the client and the family to collect data, provide information in teaching sessions, and offer support in times of anxiety.Critical thinking skills enable the nurse to: think through the situation, ask the appropriate questions, and make decisions about what needs to be done.26Jane Fatima G. Vicenteinvolves reporting and documentation. Data to be recorded include:the clients condition prior to the intervention, the specific intervention performed, the client response to the intervention,and client outcomes.27Jane Fatima G. VicenteEVALUATIONInvolves determining whether the client goals have been met, partially met, or not met. If the goal has been met the nurse must then decide whether nursing activities will cease or continue in order for status to be maintained.28Jane Fatima G. VicenteIf the goal has been partially met or not been met, the nurse must reassess the situation. Data are collected to determine why the goal has not been achieved and what modifications to the plan of care are necessary.29Jane Fatima G. Vicentepossible reasons that goals are not met or are only partially met:The initial assessment data were incomplete.The goals and expected outcomes were not realistic.The time frame was too optimistic.The goals and/or the nursing interventions planned were not appropriate for the client30Jane Fatima G. Vicentean ongoing process. Nurses continually evaluate data in order to make informed decisions during other phases of the nursing process31Jane Fatima G. VicenteASSESSMENT32Jane Fatima G. VicenteJane Fatima G. VicenteELEMENTS OF ASSESSMENTData collectionData verificationData organizationData interpretationData documentation33Jane Fatima G. VicenteEffective planning of client care depends on a complete database and accurate interpretation of information.Incomplete or inadequate assessment may result in inaccurate conclusions and incorrect nursing interventions.34Jane Fatima G. VicenteProper collection of assessment data directs decision-making activities of professional nurses35Jane Fatima G. VicenteGOAL:the collection and analysis of data that are used in formulating nursing diagnoses, identifying outcomes and planning care, and developing nursing interventions.36Jane Fatima G. VicentePURPOSE:to establish a database concerning a clients:physical, psychosocial, and emotional health in order to identify: health promoting behaviors as well as actual and/or potential health problems.37Jane Fatima G. Vicentedetermines the clients functional abilities and the absence or presence of dysfunction. the clients normal routine for activities of daily living and lifestyle patternsIdentification of the clients strengthsprovides the nurse and other members of the treatment team information about the skills, abilities, and behaviors the client has available to promote the treatment and recovery process38Jane Fatima G. Vicenteoffers an opportunity for the nurse to form a therapeutic interpersonal relationship with the client. the client is provided an opportunity to discuss health care concerns and goals with the nurse39Jane Fatima G. VicenteTYPES OF ASSESSMENTtype and scope of information needed for assessment are usually determined by the health care setting and needs of the clientcomprehensive, focused, and ongoing40Jane Fatima G. VicenteCOMPREHENSIVE ASSESSMENTusually completed upon admission to a health care agencyincludes a complete health history to determine current needs of the client. 41Jane Fatima G. VicenteThis database provides a baseline against which changes in the clients health status can be measuredshould include assessment of:physical and psychosocial aspects of the clients health, the clients perception of health, the presence of health risk factors, and the clients coping patterns

42Jane Fatima G. VicenteFOCUSED ASSESSMENTis limited in scope in order to focus on a particular need or health care problem or potential health care risks.not as detailed as comprehensive assessmentsoften used in health care agencies:in which short stays are anticipatedin specialty areasin mental health settingsor for purposes of screening for specific problems or risk factors43Jane Fatima G. VicenteONGOING ASSESSMENTSystematic follow-up is required when problems are identified during a comprehensive or focused assessment.An ongoing assessment is an assessment that includes systematic monitoring and observation related to specific problems. 44Jane Fatima G. VicenteONGOING ASSESSMENTallows the nurse to broaden the database or to confirm the validity of the data obtained during the initial assessment. particularly important when problems have been identified and a plan of care has been implemented to address these problems.Systematic monitoring and observations45Jane Fatima G. VicenteDATA COLLECTIONnurse must possess strong cognitive, interpersonal, and technical skills in order to elicit appropriate information and make relevant observations during the data collection process. Often begins prior to initial contact between the nurse and the client, primarily through the nurses review of biographical data and medical records46Jane Fatima G. VicenteTYPES OF DATASubjective dataare data from the clients point of view and include feelings, perceptions, and concerns. also referred to as symptomsobtained through interviews with the client. rely on the feelings or opinions of the person experiencing them and cannot be readily observed by another.47Jane Fatima G. VicenteObjective dataare observable and measurable (quantitative)obtained through observation, standard assessment techniques performed during the physical examination, and laboratory and diagnostic testing.also called signscan be seen, heard, or felt by someone other than the person experiencing them.Assessments that are comprehensive and accurate include both subjective and objective data.48Jane Fatima G. VicenteSOURCESA comprehensive database should include data from every possible sourceprimary source of data - client (the major provider of information about self)As much information as possible should be gathered from the client, using both interview techniques and physical exam examination skills49Jane Fatima G. Vicentesecondary sources - Sources of data other than the client, includes family members, other health care providers, and medical records50Jane Fatima G. VicenteMETHODS OF DATA COLLECTIONobservation, interview, health history, Symptom analysis, physical examination, and laboratory and diagnostic data51Jane Fatima G. VicenteOBSERVATIONnurse uses the skill of observation to carefully and attentively note the general appearance and behavior of the client. occur whenever there is contact with the clientinclude factors such as: client mood, interactions with others, physical and emotionalresponses, and any safety considerations.52Jane Fatima G. Vicentehelps the nurse determine the clients status, both physical and mentalnurse can detect nonverbal cues that indicate a variety of feelings, including presence of pain, anxiety, and angeressential in detecting the early warning signs of physical changes53Jane Fatima G. VicenteINTERVIEWa therapeutic interaction that has a specific purpose purpose of the assessment interview - to collect information about the clients health history and current status in order to make determinations about the clients health needs

54Jane Fatima G. VicenteINTERVIEWEffective interviewing depends on the nurses knowledge and ability to skillfully elicit information from the client using appropriate techniques of communication. Observation of nonverbal behavior during the interview is also essential to effective data collection.55Jane Fatima G. VicenteInterview Preparationincludes review of the clients medical records, conversations with other health care team members and research of the presenting medical diagnosis.can be useful in obtaining the clients relevant history and formulating a current needs assessment56Jane Fatima G. Vicenteassessment interview often occurs at the beginning of a nurse-client relationship, it is helpful to begin the process with an orientation phase. During this period introductions are made, rapport is established, and roles are defined57Jane Fatima G. VicenteInterview StagesIntroductionWorkingClosure58Jane Fatima G. VicenteIntroduction Interview establishes the goals for the interaction. Primary goal of the assessment interview - the collection of data about the client.The purpose and use of the data collection should be discussed.59Jane Fatima G. VicenteAdequate time and privacy should be allowed for the interview so that the client feels free to share any information that may be relevant. inform the client about the approximate duration of the interview.60Jane Fatima G. Vicenteclient is more likely to respond freely if: the interview environment provides comfort and privacy and if rapport exists between the client and the nurse61Jane Fatima G. Vicentenurse should sit (if possible), establish eye contact with the clientlisten attentively.nurses responsibility to note nonverbal messages that can indicate that the client is uncomfortable, tired, or preoccupied with other matters. If this situation occurs, it might be necessary to complete the interview at a later time62Jane Fatima G. VicenteWorkingFocuses on the details of data collection.The scope of the assessment interview depends on the type of assessment to be conductedmay be structured and formal (used in situations when a large amount of information needs to be obtained) or unstructured and informal (used in interactions that focus on a specific area of concern to the client). 63Jane Fatima G. VicenteThe nurse should be familiar with the specific assessment format used by the health care agency so that attention can be focused toward the client rather than the form itself.64Jane Fatima G. Vicentegenerally begins with questions about biographical and other nonthreatening informationThe clients reason for seeking health care is also addressed early in the working phase65Jane Fatima G. VicenteInformation is usually gathered from the general to the specific, with details about intimate or potentially embarrassing topics reserved until later66Jane Fatima G. VicenteTypes of questionsA comprehensive interview that seeks to identify problems and concerns is facilitated by open-ended questions,while an interview that focuses on specific details about a presenting problem will be facilitated by direct, closed questions.

67Jane Fatima G. VicenteOpen-ended questions are questions that encourage the client to elaborate about a particular concern or problem.Closed questions are questions that can be answered briefly or with one-word responses.

68Jane Fatima G. VicenteClosureis established in the introduction phase when approximate time parameters are set. As the interview session is concluding, the nurse should indicate this fact by stating that almost all the information needed has been obtained or that the time for the interview is almost over. This action allows the client an opportunity to present any other relevant information and it avoids surprises when the interview terminates.69Jane Fatima G. Vicentethe nurse summarizes what was covered or accomplished during the interviewrequests validation of perceptions with the client. If the nurse or the client feels that additional time is needed for further exploration of specific points discussed during this session, plans can be made for future interviews.

70Jane Fatima G. VicenteHEALTH HISTORYprimary focus of the data collection interviewhealth history is a review of the clients functional health patterns prior to the current contact with a health care agencymedical history concentrates on symptoms and the progression of disease71Jane Fatima G. Vicentefocuses on the clients functional health patterns, responses to changes in health status, and alterations in lifestyle. also used in developing the plan of care and formulating nursing interventions.72Jane Fatima G. VicentePHYSICAL EXAMINATIONpurpose of the physical examination is to: make direct observations of any deviations from normal and To validate subjective data gathered through the interviewBaseline measurements are obtained, and physical examination techniques are used to gather objective data73Jane Fatima G. VicenteLABORATORY AND DIAGNOSTIC DATAResults can be useful objective datathese values often serve as defining characteristics for various altered health statesthese can also be helpful in ruling out certain suspected problems.74Jane Fatima G. VicenteLABORATORY AND DIAGNOSTIC DATAResults can be useful objective dataThe pattern of these types of variations is useful in determining a plan of care. In addition, the effectiveness of nursing and medical interventions and progress toward health restoration are often monitored through laboratory and diagnostic test data.75Jane Fatima G. VicenteDATA VERIFICATIONthe process through which data are validated as being complete and accurate. Once the nurse completes the initial data collection, the data are reviewed for inconsistencies or omissions.particularly important if data sources are considered unreliable.76Jane Fatima G. Vicentedone by examining the congruence between subjective and objective data.The nurse would need to consider possible reasons for this discrepancy in findings and collect more information before formulating conclusions or planning care. 77Jane Fatima G. VicenteFindings should also be compared with norms. Any grossly abnormal findings should be rechecked and confirmed78Jane Fatima G. VicenteDATA ORGANIZATIONDATA CLUSTERING - the nurse organizes, or clusters, the information together in order to identify areas of strengths and weaknessesHow data are organized depends on the assessment model used79Jane Fatima G. VicenteNURSING MODELSFunctional Health Patterns (Marjory Gordon) 11 Functional Health PatternsHuman Response Pattern (NANDA) 9 human response patternTheory of Self-Care (Orem) - Roy Adaptation Model adaptive behaviors80Jane Fatima G. VicenteNONNURSING MODELSBody systems models organ and tissue functionHierarchy of needs 5 basic needs

81Jane Fatima G. VicenteDATA INTERPRETATIONData clustering facilitates recognition of patterns, and determination of further data that are needed. Data interpretation is necessary for identification of nursing diagnoses82Jane Fatima G. VicenteDATA DOCUMENTATIONAccurate and complete recording of assessment data are essential for communicating information to other health care team members. documentation is the basis for determining quality of care and should include appropriate data to support identified problems.83Jane Fatima G. Vicente