Nursing Process

Dr M.Pallavi

Introduction

Definition

• Nursing process is a critical thinking process that professional nurses use to apply the best available evidence to care giving and promoting human functions and responses to health and illness
• It is modified form of scientific method used in nursing profession to assess client needs and create a course of action to address and solve patient problems
• It is rational problem solving framework on which professional nursing practice is based.
• It provides an organised, systematic approach to nursing care thereby improving the probability of positive outcomes for individuals and groups.
• It is a systematic method of providing care to clients
• It is a systematic method of planning and providing individualized nursing care

Purposes of nursing process

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• To identify a client’s health status and actual or potential health care problems or needs.
• To establish plans to meet the identified needs.
• To deliver specific nursing interventions to meet those needs.
• Facilitates documentation of care

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Characteristics of nursing process

• Interactive, purposeful and systematic
• Client – centered
• Goal – directed.
• Outcome focused
• Within the legal scope of nursing
• Prioritizing the needs
• The steps are interrelated and dependant on the accuracy of each of the preceding steps
• It is used to identify, diagnose and treat responses to health and illness
• Universal applicability
• Develops critical thinking and clinical reasoning

Assessment

Assessment

• Assessment is the systematic and continuous collection, organization, validation, and documentation of data (information).
• It is the first step of nursing process
• During this process information about a patient’s psychological, physiological, sociological and spiritual status through observation, interviewing, physical examination, health records and family members
• Nursing assessments do not duplicate medical assessments (which target to pathological conditions) but focus on the patient’s responses to health problems or potential health problems

Types of Assessment

• The four different types of assessments are;
• Initial nursing assessment
• Problem-focused assessment
• Emergency assessment
• Time-lapsed reassessment

Types of Assessment

• Initial nursing assessment: Performed within specified time after admission. To establish a complete database for problem identification.
• Eg: Nursing admission assessment
• Problem-focused assessment : To determine the status of a specific problem identified in an earlier assessment.
• Eg: hourly checking of vital signs of fever for a patient

Types of Assessment

• Emergency assessment: During emergency situation to identify any life threatening situation.
• Eg: Rapid assessment of an individual’s airway, breathing status, and circulation during a cardiac arrest.
• Time-lapsed reassessment: Several months after initial assessment. To compare the client’s current health status with the data previously obtained.

Purpose of 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 client’s strengths
• To provide data for the diagnosis phase

Assessment Skills

• Observation
• Interview – a conversation with purpose to get or give information, to teach and provide support
• Physical examination – a systematic data collection method by inspection, palpation, percussion and auscultation
• Intuition (Insight) – use of insight, instinct and clinical experience to make clinical judgements about the client.

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Assessment Activities

• Activities or action performed during assessment are:
• Collect data
• Validate data – double checking the data to confirm accuracy
• Organize data – grouping the data using head to toe model, systemic review etc
• Document data – document subjective data in client own words and objective data using medical terms, key, abbreviations etc

Collection of data

• Data collection is the process of gathering information about a client’s health status. It includes the health history, physical examination, results of laboratory and diagnostic tests, and material contributed by other health personnel.

Types of data

• Two types: subjective data and objective data.
• Subjective data - also referred to as symptoms or covert data, are clear only to the person affected and can be described only by that person.
• Eg - Itching, pain, and feelings of worry are examples of subjective data.
• Objective data - also referred to as signs or overt data, are detectable by an observer or can be measured or tested against an accepted standard. They can be seen, heard, felt, or smelled, and they are obtained by observation or physical examination.
• Eg - discoloration of the skin or a blood pressure reading is objective data.

Sources of data

• Sources of data are primary or secondary
• Primary : It is the direct source of information. The client is the primary source of data.
• Secondary: It is the indirect source of information. All sources other than the client are considered secondary sources. Family members, health professionals, records and reports, laboratory and diagnostic results are secondary sources.

Methods of data collection

• The methods used to collect data are observation, interview and examination
• Observation : It is gathering data by using the senses. Vision, Smell and Hearing are used.
• Interview : An interview is a planned communication or a conversation with a purpose.
• There are two approaches to interviewing: directive and nondirective.
• The directive interview is highly structured and directly ask the questions. And the nurse controls the interview.
• A nondirective interview, or rapport building interview and the nurse allows the client to control the interview.

• Examination : The physical examination is a systematic data collection method to detect health problems. To conduct the examination, the nurse uses techniques of inspection, palpation, percussion and auscultation.
• Organization of data - The nurse uses a format that organizes the assessment data systematically. This is often referred to as nursing health history or nursing assessment form.
• Validation of data - The information gathered during the assessment is “double-checked” or verified to confirm that it is accurate and complete.
• Documentation of 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.

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Diagnosis

Nursing Diagnosis

• Diagnosis is the second phase of the nursing process. In this phase, nurses use critical thinking skills to interpret assessment data to identify client problems.
• North American Nursing Diagnosis Association (NANDA) define or refine nursing diagnosis.
• “a clinical judgment concerning a human response to health conditions / life processes, or a vulnerability for that response, by an individual, family, group, or community.”

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• Benefits of Nursing Diagnosis
• Gives nurse a common language
• Promotes identification of appropriate goals or correct choice
• Can create a standard for nursing practice
• Provides a quality improvement base

Status of Nursing Diagnosis

• The status of nursing diagnosis are actual, health promotion and risk.
• An actual diagnosis is a client problem that is present at the time of the nursing assessment.
• A health promotion diagnosis relates to clients’ preparedness to improve their health condition.
• A risk nursing diagnosis is a clinical judgement that a problem does not exist, but the presence of risk factors indicates that a problem may develop if adequate care is not given.

Components of Nursing Diagnosis

• A nursing diagnosis has three components:
• The problem and its definition - describes the client’s health problem.
• The etiology - component of a nursing diagnosis identifies causes of the health problem.
• The defining characteristics - are the cluster of signs and symptoms that indicate the presence of health problem.

Formulating Diagnostic Statements

• The basic three-part nursing diagnosis statement is called the PES format and includes the following:
• Problem (P): statement of the client’s health problem (NANDA label)
• Etiology (E): causes of the health problem
• Signs and symptoms (S): defining characteristics manifested by the client.

Formulating Diagnostic Statements

• Acute pain related to abdominal surgery as evidenced by patient discomfort and pain scale.

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Planning

Planning

• Planning involves decision making and problem solving.
• It is the process of formulating client goals and designing the nursing interventions required to prevent, reduce, or eliminate the client’s health problems.

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• Types of Planning:
• Initial Planning – done after the initial assessment.
• Ongoing Planning - It is a continuous planning.
• Discharge Planning - Planning for needs after discharge

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Elements of Planning

• Prioritizing the problems / nursing diagnosis
• Formulate goals / desired outcomes
• Short term (to resolve in few hours or days)
• Long term (to resolve over weeks or months)
• Select nursing interventions
• Write nursing interventions

Nursing interventions

• A nursing intervention is any treatment, that a nurse performs to improve patient’s health.

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• Types of Nursing Interventions:
• Independent interventions are those activities that nurses are licensed to initiate on the basis of their knowledge and skills.
• Dependent interventions are activities carried out under the orders or supervision of a licensed physician.
• Collaborative interventions are actions the nurse carries out in collaboration with other health team members

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Implementation

• Implementation consists of doing and documenting the activities.
• The process of implementation includes;
• Implementing the nursing interventions
• Documenting nursing activities
• Nursing skills during implementation
• Cognitive skills – problem solving and decision making
• Interpersonal skills – include verbal and non verbal response, communication
• Technical skills – includes hand on skills need to perform procedures such as administration of inj, drugs, lifting and moving of the patient

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Evaluation

• It is the last phase of nursing process
• Evaluation is a planned, ongoing, purposeful activity in which the nurse determines.
• It is required to know
• The client’s progress toward achievement of goals/outcomes and
• The effectiveness of the nursing care plan
• The evaluation includes;
• Comparing the data with desired outcomes
• Continuing, modifying, or terminating the nursing care plan.

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