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Nursing Process

• Indiana Gabbidon RN.,MSN

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Back Ground

• The patient must be the central character.
• Nursing care needs to be directed at improving
  outcomes for the patient, and not about nursing
  goals.
• The nursing process is an essential part of the
  nursing care plan.

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The Nursing Process is

• A systematic, rational method of planning and
  providing individualized nursing care.

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Holistic

• Physical-
• Emotional-
• Psychosocial-
• Developmental-
• Spiritual Being

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5 components of the Nursing Process

• Assessment
• Diagnosis
• Planning
• Implementing
• Evaluating

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We will only focus on 4 components of the Nursing
Process

• Assessment
• Diagnosis
• Planning
• Implementing
• Evaluating

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1st Component of the Nursing Process- ASSESSMENT

• Data Collection
• Assessment involves taking vital signs (TPR BP
  Pain assessment.
• Performing a head to toe assessment
• Listening to the patient's comments and questions
  about his health status
• Observing his reactions and interactions with
  others. It involves asking pertinent questions
  about his signs (observable) and symptoms
  (Non-observable), and listening carefully to the
  answers.

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During Assessment, the care provider

• Establishes A Data Base
• Continuously Updates The Data Base
• Validates Data
• D. Communicates Data

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2nd component of the Nursing Process- Planning

• The establishment of client goals/outcomes
• Working with the client, to prevent, reduce, or
  resolve problems
• To determine related nursing interventions
  (actions) that are most likely to assist client
  in achieving goals
• This is about improving the quality of life for
  your patient.
• This is about what your patient needs to do to
  improve his health status or better cope with his
  illness.

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During Planning, the provider

• A. Establishes Priorities
• B. Writes Client Goals/Outcomes And Develops An
  Evaluative Strategy
• C. Selects Nursing Interventions
• D. Communicates The Plan

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Establishing Priorities

• Helps nurses to anticipate and sequence nursing
  interventions
• Classification of priorities
• High
• Intermediate
• Low

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Time Factor in Setting Priorities

• The planning of nursing care occurs in three
  phases
• Initial
• Ongoing
• Discharge planning

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Critical Thinking in Establishing Goals and
Expected Outcomes

• Goal
• A broad statement that describes the desired
  change in a clients condition or behavior
• An aim, intent, or end
• Expected outcome
• Measurable criteria to evaluate goal achievement

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Goals of Care

• Client-centered goal
• A specific and measurable behavior or response
• Short-term goal
• An objective behavior or response expected within
  hours to a week
• Long-term goal
• An objective behavior or response expected within
  days, weeks, or months

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Expected Outcomes

• A specific, measurable change in a clients
  status
• Provide focus or direction
• Determine when a specific, client-centered goal
  has been met

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Guidelines for Writing Goals
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Types of Interventions

• Nurse initiated
• Independent
• Physician initiated
• Dependent
• Collaborative
• Interdependent

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Selection of Interventions

• Six factors to include
• Characteristics of nursing diagnosis
• Goals and expected outcomes
• Evidence base for interventions
• Feasibility of the intervention
• Acceptability to the client
• Nurses competency

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3rd Component of the Nursing Process-
Implementing

• The provider carries out the plan of care

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During Implementing, the care provider

• Carries Out The Plan Of Nursing Care or Setting
  your plans in motion and delegating
  responsibilities for each step.
• Continues Data Collection And Modifies The Plan
  Of Care As Needed
• Documents Care

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Critical Thinking in Implementation

• Review the set of all possible nursing
  interventions.
• Review all possible consequences associated with
  each possible nursing action.
• Determine the probability of all possible
  consequences.
• Make a judgment of the value of that consequence
  to the client.

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Standard Nursing Interventions

• Clinical practice guidelines and protocols
• Standing orders
• NIC interventions

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Implementation Process
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Implementation Skills

• Cognitive skills
• Interpersonal skills
• Psychomotor skills

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Direct Care
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Indirect Care

• Communicating nursing interventions
• Written or oral
• Delegating, supervising, and evaluating the work
  of other health care team members

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Achieving Client Goals

• Nurses implement care to meet client goals.
• At times, multiple interventions may be needed.
• Priorities help nurses to anticipate and sequence
  nursing interventions.

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4th Component of the Nursing Process- Evaluating

• The measuring of the extent to which client goals
  have been met
• Evaluation involves not only analyzing the
  success of the goals and interventions, but
  examining the need for adjustments and changes as
  well.
• The evaluation incorporates all input from the
  entire health care team, including the patient.

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Critical Thinking and Evaluation

• Evaluation is an ongoing process.
• If outcomes are met, client goals are met.
• Positive evaluations occur when nurses meet
  desired outcomes.
• Positive evaluations lead nurses to conclude that
  interventions were successful.

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The Evaluation Process

• Includes five elements
• Identify evaluative criteria and standards.
• Collect data.
• Interpret and summarize findings.
• Document findings and clinical judgments.
• Terminate, continue, or revise the care plan.

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During Evaluating, the care provider

• Measures The Clients Achievement Of Desired
  Goals/Outcomes
• Identifies Factors That Contribute To The
  Clients Success Or Failure
• Modifies The Plan Of Care, If Indicated

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Characteristics

• a. Systematic
• The nursing process has an ordered sequence of
  activities and each activity depends on the
  accuracy of the activity that precedes it and
  influences the activity following it.
• b. Dynamic
• The nursing process has great interaction and
  overlapping among the activities and each
  activity is fluid and flows into the next
  activity
• c. Interpersonal
• The nursing process ensures that nurses are
  client-centered rather than task-centered and
  encourages them to work to enhance clients
  strengths and meet human needs
• d. Goal-directed
• The nursing process is a means for nurses and
  clients to work together to identify specific
  goals (wellness promotion, disease and illness
  prevention, health restoration, coping and
  altered functioning) that are most important to
  the client, and to match them with the
  appropriate nursing actions
• e. Universally applicable
• The nursing process allows nurses to practice
  nursing with well or ill people, young or old, in
  any type of practice setting

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Purpose of the nursing process

• To Achieve Scientifically- Based, Holistic,
  Individualized Care For The Client
• To Achieve The Opportunity To Work
  Collaboratively With Clients, Others
• To Achieve Continuity Of Care

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The Whole Patient

• The nursing process involves looking at the whole
  patient at all times. It personalizes the
  patient. He is not "the CVA in 214B."
• It also forces the health care team to observe
  and interact with the patient, and not just the
  task they are performing such as a dressing
  change, or a bed bath. The process provides a
  roadmap that ensures good nursing care and
  improves patient outcomes.

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Nursing Diagnosis

• A nursing diagnosis is a clinical diagnosis made
  by a registered nurse which, unlike a MD's
  diagnosis, does not cover the patient's medical
  condition, but the patient's response to the
  medical condition.

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Critical Thinking and the Nursing Diagnostic
Process

• Diagnostic reasoning
• A process of using assessment data to create a
  nursing diagnosis
• Defining characteristics
• Clinical criteria or assessment findings
• Clinical criteria
• Objective or subjective signs and symptoms

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Actual Diagnosis

• An actual diagnosis is a statement about a health
  problem that the client has, and could benefit
  from nursing care. An example of an actual
  nursing diagnosis is Ineffective airway
  clearance related to decreased energy and
  manifested by an ineffective cough.

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Risk Diagnosis

• A risk diagnosis is a statement about a health
  problem that the client doesn't have yet, but is
  at a higher than normal risk of developing in the
  near future. An example of a risk diagnosis is
• ---Risk for injury related to altered mobility
  and disorientation.

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• A possible diagnosis is a statement about a
  health problem that the client might have now,
  but the nurse doesn't yet have enough information
  to make an actual diagnosis. An example of a
  possible diagnosis is
• ----Possible fluid volume deficit related to
  frequent vomiting for three days and manifested
  by increased pulse rate.

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• A syndrome diagnosis is used when a cluster of
  nursing diagnoses are often seen together. An
  example of a syndrome diagnosis is
• ----Rape-trauma syndrome related to anxiety about
  potential health problems and as manifested by
  anger, genitourinary discomfort, and sleep
  pattern disturbance.

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• A wellness diagnosis is used to describe an
  aspect of the client which is at a high level of
  wellness. An example of a wellness diagnosis is
• ---Potential for enhanced organized infant
  behavior, related to prematurity and as
  manifested by response to visual and auditory
  stimuli

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Nursing Diagnosis contd

• Patients generally have multiple nursing
  diagnoses covering everything from their physical
  well-being through their psychosocial well-being
  to the well-being of their family and caregivers.
• These diagnoses must cover problems that the
  nurse can treat independently of the MD.

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How to write a Nursing Dx

• A complete nursing diagnosis is written in the
  format problem related to cause of problem as
  evidenced by symptoms of problem
• An example of such a nursing diagnosis would be
  Impaired gas exchange related to excessive
  secretions as evidenced by O2 saturation of 86.