Nursing process - documentation

• The Nursing Process was legitimized in 1973 when the phases were included in the American Nurses Association (ANA) Standards of Nursing Practice
• The Nursing Process was originated by Hall in 1955
• Program and activity for the continuing professional education shall be submitted to and approved by the Board
• THE NURSING PROCESS

  1. Assessment

  2. Diagnosis

  3. Planning

  4. Implementation

  5. Evaluation
• Phases of the Nursing Process (National Licensure Examination for Registered Nurses - NCLEX)

  • Assessment
  • Diagnosing
  • Planning
  • Implementation
  • Evaluation
• Nursing Process Purposes: To identify 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
• Clients of the Nursing Process

  • Individual
  • Family
  • Community
  • Group
• Nursing Process

  A systemic, rational method of planning and providing individualized nursing care
• Examples of a care plan: rationale tal
• Johnson, Orlando, and Weidenbach were among the first to use the Nursing Process to refer to a series of phases describing the practice of nursing
• Phases of the Nursing Process (ANA, 2010)

  • Assessment
  • Diagnosis
  • Outcomes Identification
  • Planning
  • Implementation
  • Evaluation
• National Licensure Examination for Registered Nurses (NCLEX) - 5 phases

  • Assessment
  • Diagnosing
  • Planning
  • Implementation
  • Evaluation
• Problem-solving

  A mental act where a problem is identified that represents an unsteady state. Requires obtaining information to clarify the nature of the problem and suggest possible solutions
• Data collected should be relevant to a particular health problem
• NURSING PROCESS: ASSESSMENT

  The first phase of the nursing process, systematic and continuous collection, organization, validation, and documentation of data
• If at the end of evaluation the patient has no changes

  Identify another diagnosis and check if interventions are already effective
• Medical Diagnosis

  • Refer to disease process, specific pathophysiologic responses that are fairly uniform
  • Remain the same as long as the disease process is present
• Types of Assessment

  • Initial Nursing Assessment
• Care plan

  • Rationale talks about the scientific basis of each intervention that was applied in the care plan
• Directed towards client’s responses

  Interventions focus on solving the problem
• Nursing Process

  1. Outcomes Identification

  2. Planning

  3. Implementation

  4. Evaluation
• Nursing Diagnosis

  • Describe the human response (physical, sociocultural, psychological, and spiritual response) to an illness
  • Change as the client’s response changes
• Characteristics of Nursing Process

  • Cyclic and dynamic
  • Client-centeredness
  • Focus on problem-solving and decision-making
  • Interpersonal and collaborative style
  • Universal Applicability
  • Use of critical thinking and clinical reasoning
• Focus on a client's responses to a health problem
• Each client should have an initial nursing assessment consisting of a history and physical examination performed and documented within 24 hours of admission
• LPN may gather data, RN responsible for care and must assess the data determining the needs of the client
• Nursing diagnosis

  A clinical judgment concerning human response to health conditions/life processes or a vulnerability for that response, by an individual, family, group, or community (NANDA)
• Database

  • Contains all information about the client
  • Includes Nursing health history, Physical assessment, Primary care provider’s history and physical information, Results of laboratory and diagnostic tests, Material contributed by other health personnel
• Documenting Data

  Recording of client’s data, Should include all data collected about the client’s health status, Should be factual rather than interpreted by the nurse
• Organizing Data

  All assessment data should be organized systematically, E.g. Gordon’s Functional Health Patterns
• Sources of data

  • Client (primary)
  • Support People
  • Client Records
  • Health care professionals
  • Literature
• Assessment - Data Collection

  1. Process of gathering information about client’s health status

  2. Should be systematic and continuous
• Nursing Process: Diagnosing

  1. Second phase of the nursing process

  2. Analyzing the data

  3. Identifying health problems, risks, and strengths

  4. Formulate diagnostic statements
• Types of Data

  • Subjective data: Symptoms or covert data that only the affected person can describe and verify
  • Objective data: Signs or overt data detectable by an observer, Can be seen, heard, felt, or smelled and obtained by observation or physical examination
• Data collection Methods

  1. Observation: Gather data using the senses, Must be organized so nothing is missed

  2. Interview: Planned communication or a conversation with a purpose

  3. Examining: A systematic collection of data collection method that uses observation to detect health problems, Uses the technique of inspection, auscultation, palpation, and percussion
• Validating Data

  Act of double-checking or verifying data to confirm that it is accurate and factual, Nurse’s assumptions are validated or further questioning may be prompted
• Ensuring Confidentiality of Computer Records

  A personal password is required to enter and sign off computer files; after logging on, never leave a computer terminal unattended. Do not leave client information displayed on the monitor where others may see it. Shred all unneeded computer-generated worksheets. Know the facility’s policy and procedure for correcting an entry error
• Nurse modifying care plan

  1. After drawing conclusions, the nurse modifies the care plan, as indicated

  2. Assessing → if incomplete, reassess client and record new data

  3. Diagnosing → new diagnostic statements may be required; check if the identified nursing problem is also correct (if incorrect, revise the nursing diagnosis)

  4. Planning → desired outcome. If nursing diagnosis is incorrect, goals are also incorrect. Goals should be realistic and attainable. Check also prioritization of nursing problems

  5. Implementing → manner of implementation should be checked. Check whether they are carried out. After making the necessary modifications, the modified plan should be implemented
• Discussion is an informal oral consideration of the subject by two or more healthcare personnel to identify a problem or establish strategies to resolve a problem
• Report is oral, written or computer-based communication intended to convey information to others