NURSING PROCESS - FUNDA LEC

• Nursing process


  The cornerstone of the nursing profession, essential for the clinical application of knowledge and theory in nursing practice
• Evolution of the nursing process

  1. 3-step process

  2. 4-step process (APIE)

  3. 5-step process (ADPIE)

  4. 6-step process (ADOPIE) - assessment, Diagnosis, Outcome Identification, Planning, Implementation and Evaluation
• Nursing process


  Synonymous with the problem-solving approach for discovering the healthcare and nursing care needs of clients, enabled nursing to build its own scientific body of knowledge and elevated nursing from a vocation into a profession
• Lydia Hall originated the term Nursing Process in 1955, introduced three steps: note observation, ministration of care, validation
• Dorothy Johnson introduced three steps of nursing process: assessment, decision, nursing action (1959)
• Ida Jean Orlando identified three steps of nursing process: client's behavior, nurse's reaction, nurse's actions (1961)
• Yura and Walsh suggested the four components of nursing process: assessing, planning, implementing and evaluating (1967)
• Knowles described nursing process as discover, delve, decide, do, discriminate (1967)
• American Nurses Association introduced innovations in the nursing process: Diagnosis distinguished as separate step (1973), Diagnosis of actual and potential health problems delineated as integral part of nursing practice (1980), Outcome identification differentiated as a distinct step (1991)
• Nursing process


  • Logical, systematic scientific problem solving process utilized by nurses to deliver total quality health care services to patients
• Nursing process


  • Organized
  • Systematic
  • Efficient
  • Goal-Oriented
  • Effective
  • Humanistic Care
• Nursing process


  • Composed of 6 sequential and interrelated steps
  • Developed and implemented with great consideration to the unique needs and concerns of the individual client
  • Individualized
  • Involves aspect of human dignity
  • Relevant to the needs of the client
  • Promotes client satisfaction and progress
  • Utilizes resources wisely in terms of human, time, cost resources
• Characteristics of nursing process

  • Problem oriented
  • Goal oriented
  • Systematic
  • Dynamic
  • Interpersonal
  • Creative
  • Cyclical
  • Universal
• Benefits of the nursing process for the patients

  • Quality patient care
  • Continuity of care
  • Respect for human dignity
• Benefits of the nursing process for the nurse

  • Consistent and systematic nursing education
  • Job Satisfaction
  • Professional Growth
  • Avoidance of legal action
  • Meeting professional nursing standards
  • Meeting standards of accredited hospitals
• The heart of the nursing process

  • Knowledge - broad, varied
  • Skills - manual, intellectual, interpersonal
  • Caring - willingness
• Knowledge


  Broad, varied
• Skills


  • Manual
  • Intellectual
  • Interpersonal
• Manual skills


  Technical skills
• Intellectual skills


  Critical thinking - careful, deliberate, goal directed to solve problems, make decisions, good habits of inquiry, check for evidence, keeping an open mind, avoid jumping into conclusions
• Interpersonal skills


  To establish positive relationships with clients and coworkers, requires communication skills
• Caring


  Willingness and ability to care, being able to understand ourselves to be more able to understand others, being more objective/non-judgmental, requires ability to listen empathetically, entering into another's way of thinking and viewing the world, connecting with another's feelings and perceptions, identifying with another's struggles, frustrations and desires, then being able to detach from feelings and returning to our own frame of reference
• Willingness to care


  • Keep the focus on what is best for the patient
  • Respect the beliefs/values of others
  • Stay involved
  • Maintain a healthy lifestyle
• Caring behaviors


  • Inspiring someone/instilling hope and faith
  • Demonstrating patience, compassion and willingness to persevere
  • Offering companionship
  • Helping someone stay in touch with positive aspect of his life
  • Demonstrating thoughtfulness
  • Bending the rules when it really counts, doing the "little things"
  • Keeping someone informed
  • Showing your human side by sharing "stories"
• The nursing process (ADPIE)

  1. Assessment - collecting, validating, organizing and recording data about the client's health status

  2. Diagnosis - analyzing assessment information and deriving meaning to identify the client's health care needs and prepare diagnostic statements

  3. Outcome Identification - determining the client's goals and expected outcomes

  4. Planning - determining the strategies or course of actions to be taken before implementation of nursing care

  5. Implementation - carrying out the planned nursing interventions

  6. Evaluation - determining the extent to which the client's goals and expected outcomes have been met
• Assessment


  Collecting, validating, organizing and recording data about the client's health status, to establish a data base
• Activities during assessment


  • Collection of data - gathering information about the client, considering the physical, psychological, emotional, socio-cultural, and spiritual factors that may affect his/her health status
  • Verifying/Validating data - making sure information is accurate
  • Organizing data - clustering facts into groups of information
• Types of data


  • Subjective data (symptoms) - those that can be described only by the person experiencing it
  • Objective data (signs) - those that can be observed and measured
• Methods of data collection

  • Interview - planned purposeful conversation
  • Observation - use of senses, use of units of measure, physical examination techniques, interpretation of laboratory results
• Sources of data


  • Primary: Patient/Client
  • Secondary: Family members, Significant Others, Patient's Record/Chart, Health Team Members, Related Literature
• Nursing diagnosis


  A statement of client's potential or actual alteration of health status, using the critical-thinking skills of analysis and synthesis, in PRS/PES format
• Types of nursing diagnoses

  • Problem-focused
  • Risk
  • Health Promotion
• Critical thinking and the nursing diagnostic process

  1. Organize, Cluster or Group Data

  2. Compare data against standards

  3. Analyze data after comparing with standards

  4. Identify gaps and inconsistencies in data

  5. Determine the client's health problems, health risk and strengths

  6. Formulate Nursing Diagnoses statements
• Planning


  Determining beforehand the strategies or course of actions to be taken before implementation of nursing care, requires communicating with the patient, their families and the health care team and ongoing consultation with team members
• Purposes of planning


  • To identify the client's goals and appropriate nursing interventions
  • To direct patient care activities
  • To promote continuity of care
  • To focus charting requirements
  • To allow for delegation of specific activities
• Activities during planning


  1. Establishing priorities

  2. Setting goals and expected outcomes

  3. Planning nursing interventions appropriate for each diagnosis

  4. Writing a nursing care plan
• Establishing priorities


  A decision-making process that ranks the order of nursing diagnoses in terms of importance to the client, considering factors such as life-threatening situations, Maslow's hierarchy of needs, client's unstable condition, amount of time/resources required, actual vs potential problems, attending to the client before equipment
• Levels of priority


  • High-priority - potentially life-threatening, require immediate action
  • Medium-priority - could result in unhealthy consequences but not life-threatening
  • Low-priority - problems that can be resolved easily with minimal interventions
• Setting goals and expected outcomes

  Client goals are educated guesses about the client's state after nursing intervention, written as behavioral goals with an action verb and a qualifier indicating the level of performance to be achieved, can be short-term or long-term
• Client goal


  An educated guess, made as a broad statement, about what the client's state will be after the nursing intervention is carried out