Nursing process a simple guide for student nurses
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The document outlines the nursing process, which includes 5 phases - assessment, nursing diagnosis, planning, implementation, and evaluation. The assessment phase involves collecting client data through various methods like observation, interview, and examination. In the nursing diagnosis phase, the nurse analyzes the assessment data to identify client problems/needs and prioritize them. The planning phase involves setting goals to address the problems and selecting nursing interventions. Implementation involves applying the planned care. Finally, in the evaluation phase the nurse determines if the goals were met by collecting additional client data. The nursing process provides a systematic framework to plan and deliver individualized nursing care.
Nursing process a simple guide for student nurses
- 1. H. Deepani RN, BN, Nursing Tutor School of Nursing Colombo Sri Lanka
- 3. Definition The nursing process is a modified form of scientific method used in nursing profession to asses client needs and create a course of action to address and solve patients problems
- 4. The nursing process is a systematic, client centered, goal oriented method of caring that provides a framework for nursing practice It is a systemic, rational method of planning and providing individualized nursing care for individuals, families, groups and communities
- 5. Benefits of Nursing Process Provides an orderly & systematic method for planning & providing care Enhances nursing efficiency by standardizing nursing practice Facilitates documentation of care Provides a unity of language for the nursing profession Is economical Stresses the independent function of nurses Provide continuity of care and prevent duplication
- 6. Characteristics of the Nursing Process Systematic Dynamic Client-centered Goal-directed outcome focused Universally applicable Steps are interrelated and dependant on the accuracy of each step
- 7. Phases/Steps Assesment Nursing diagnosis Planning and goal setting Implementation Evaluation
- 8. Steps of nursing process
- 10. Assesment 1st step Definition -Collecting, organizing, validating and documenting data Gathering information about psychological, physiological, social and spiritual status Data collected through observation, interview, physical examination, health records and family members Focus on patient response to health problems
- 11. Assesment types Initial – after admission. Provide baseline data (vital signs) Problem focused- ongoing process to determine the state of previously identified problem (hourly UOP of ARF pt) Emergency – at life threatening situations (ABC) Time lapsed- after several weeks/ months to determine the progress of disease and treatment (clinic follow up)
- 12. Types of data Subjective (symptoms) information perceived only by affected person Eg: pain, worry, nausea Objective (signs) information perceived by another person that can be verified by others Eg: vital signs, reddened skin
- 13. Sources of data Client Support people Client records and reports Health care professionals Health care literature
- 14. Methods of data collection 1. Observation conscious and deliberate use of the five senses Organized observation (a/c to disease eg. asthma) -clinical signs of patient(SOB) -threats to safety (no side rails) -associated equipment (IV drip not functioning) -immediate environment (slippery floor) -BHT (Dr’s order, Ix reports, charts, drugs)
- 15. 2. Interview planned communication to obtain history 3. Physical assessment examination of the client for objective data Four methods of physical assessment Inspection Palpation Percussion Auscultation 4. Refer client records and reports 5. consultation
- 16. Steps of assessment process Data collection Validation – double checking for accuracy Organizing- head to toe or system wise Documentation – subjective (client’s words) - Objective (medical terms, abbreviations)
- 17. Nursing diagnosis Nursing diagnosis is a clinical judgment about individual, family or community response to actual and potential health problems/life processes 1990 NANDA definition North American Nursing Diagnosis Association
- 18. Nursing diagnosis After gathering information about the client, nurse analyze them and make a decision about the person’s condition, strength, problems or needs It is the judgment that the nurse makes, which forms the link between assessment and nursing care plan
- 19. Components of nursing diagnosis Problem statement (derived from NANDA nursing diagnosis) -self care deficit Etiology/related factor (contributing factor for the problem) -R/T paralysis of lower limbs Defining characteristics (data that signals the existence of the problems) -as evidenced by strong body and urine odor
- 20. Descriptive words Acute Chronic Intermittent Altered Impaired Increased Decreased Deficient Excess Disturbed Ineffective depleted dysfunctional
- 21. Types of nursing diagnosis Actual- current/obvious problem Eg : fluid volume deficit (decreased intake due to nausea and vomiting, dry skin, low UOP, Potential/risk – problems which may occur in the future due to current health status Eg : risk for infection (surgical incision, discharge on dressing)
- 22. Wellness – clinical judgment about the state of wellness Eg: potential for enhanced spiritual wellbeing (practice religious activities, family provides good support in practices )
- 23. Medical vs. nursing diagnosis Medical- identify disease (one) Nursing - identify unhealthy responses associated with a disease (several for signs and symptoms)
- 24. NANDA - nursing diagnoses Standard and approved Keep a copy with you always
- 25. Guidelines to write nursing diagnoses Select problem statement/nursing diagnosis from NANDA list based on pt’s assessment Link the etiology and problem statement with the phrase “related to” Do not write medical diagnosis, signs or symptoms as problem statement
- 26. Use legally advisable terms Be sure the problem statement indicates what is unhealthy Actual diagnoses must have obvious relevant data in the assessment column Use your knowledge, experience and medical literature to develop risk diagnoses Reread and confirm the diagnoses
- 27. Prioritizing nursing diagnoses Ranking of nursing diagnoses in order of importance High priority- if untreated could harm to client eg. Ineffective breathing pattern Medium – non life threatening eg. Risk for impaired skin integrity Low – not directly related to current illness or prognosis Eg. Impaired social interaction
- 28. Guides for prioritizing nursing diagnoses Maslow’s hierarchy Virginia Henderson’s guide for needs Client preference Anticipation of future problems
- 29. Planning In this phase Nurse and client work together to 1. develop client goals if achieved which solve the client problem in nursing diagnosis 2. identify the nursing interventions which are most likely assist the client in achieving those goals
- 30. Types 1- Initial planning: the nurse who performs the admission usually develops the initial comprehensive plan of care. 2- Ongoing planning: - Is done by all nurses who work with the client. 3- Discharge planning: The process of anticipating and planning for needs after discharge. 30
- 31. Planning Process: 1- Setting priorities. 2- Establishing client goals/desired out comes. 3- Selecting nursing strategies./interventions 4- Writing nursing orders. 31
- 32. Planning Process: 1-Setting priorities: As you learned above 32
- 33. Planning Process: Formulating Goal/ objective/ expected outcome * Purpose of Goals: a- provide direction for planning nursing interventions b- Serve as criteria for evaluating client progress. c- Enable the client and the nurse to determine when the problem has been resolved. 33
- 34. Formulating goals - derived from the problem statement of nursing diagnosis -for each diagnosis at least one goal -consider client’s preference -find the descriptive term of the diagnosis -find the opposite term of descriptive term -write the goal as “To +verb stem”
- 35. Example problem statement-impaired skin integrity Descriptive term-Impaired Opposite of impaired- improved Verb stem- improve Goal- To improve skin integrity
- 36. SMART goals S - Specific M - Measurable A - Achievable R - Realistic T - Time bound
- 37. SMART goal example Nursing diagnosis- Fluid volume deficit r/t frequent passage of stools Goal S- Mr. Sirisena M- will drink A- 60ml fluid R-while awake T- every hour
- 38. Types of Goals: a- Short Term Goals: For a client who require health care for a short time. usually achieved in less than one week b- Long Term Goals: Are often used for clients who have a chronic health problem usually takes more than one to two weeks to achieve 38
- 39. Nursing strategies/ interventions Derived from nursing diagnosis Based on causative factors for the problem Identify several options Simple to complex
- 40. Selecting nursing interventions Types of Nursing Intervention: 1- Independent intervention: activities that nurses are licensed to initiate on the basis of their knowledge and skills. 2- Dependent intervention: are activities carried out under the physician orders. 3- Collaborative intervention: are actions the nurse carries out in collaboration with other health team member. 40
- 41. Writing nursing orders Write as orders -provide back care 2hly -change the dressing Clear brief Simple to complex Use abbreviations
- 42. Implementation Putting the planned care into action Prerequisite nursing skills Intellectual Interpersonal technical 42
- 43. Process of implementation Determine the need for assistance (basic human needs) Promote self care, teaching and counseling (active participation of client and family) Assisting to meet health goals (carry out the planned actions) Ongoing data collection Communicating care (documentation –only about carried out actions past tense)
- 44. Evaluation Planned, ongoing, purposeful activity in which clients and health care professionals determine: - The clients progress toward goals an achievement. - The effectiveness of the nursing care plan. 44
- 45. Evaluation Process of evaluating client responses: 1- Identify the desired out comes. 2- Collecting data related to desired out comes. 3- Relate nursing actions to client goals/desired outcomes. 4- Draw conclusions about problem status. 5- Continue to modify or terminate the clients care plan. 45
- 46. Documenting evaluation Goal met Partially met Not met with brief relevant description
- 47. Writing care plans Use institutional format Date/time/assessment/nursing diagnosis/planning/implementation/ evaluation Assessment- include significant data about basic human needs, signs and symptoms, feelings,Ix reports, special medical care, vital signs etc. Avoid too long descriptions
- 48. Nursing diagnoses- use NANDA problem statement +related factor Planning-goals and plans to achieve goal write as orders Implementation- about carried out actions write in past tense Evaluation- mention about goals met or not with brief description. Use accepted abbreviations and symbols of your agency Kardex-mostly used care plan
- 49. Important !important!! Important!!! Every client is unique They have unique problems Develop ability to identify unique problems of each client Unique ,clear assessment helps to provide unique care for each client NEVER COPY AND PASTE from web sources for study purposes
- 50. Questions?
- 51. Thank you!
- 52. Case study 52 years old Mr. Perera is a clerk. He was admitted to your ward with a history of difficulty in breathing, difficulty in swallowing, mild chest pain and hoarseness of voice. He has lost 5kg of weight within last two months. Today is the second day after admission. Still he has all the symptoms he had on admission.
- 53. He looks ill and complains generalized body weakness. he is on liquid diet , but he refuses his meals saying “no appetite”. His urinary and bowel elimination normal. He has not slept last night due to unfamiliar environment. Today he is waiting for his endoscopic biopsy report. He worries about the uncertain results of the report. He wants to know the reason for his physical changes. His last Hb report is 9.2g/dl. His vital signs are normal.
- 54. Underline client’s problems Write those in a separate paper Write possible problems which may occur in the future Select problem statement for each problem from NANDA diagnoses list Select etiology from assessment and literature Write two part nursing diagnosis for each problem. Formulate goals Plan actions to achieve goals