Nursing Process

• Nursing process


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

  
• Client


  May be an individual, a family, a community or a group
• Hall originated the term nursing process


  1955
• Johnson, Orlando, and Weidenbach were among the first to use the term nursing process


  1959, 1960, 1963
• The use of nursing process in clinical practice gained additional legitimacy in 1973 when the phases were included in the American Nurses Association (ANA) Standards of Nursing Practice
• Nursing process


  Systematic, rational method of planning and providing individualized nursing care

  
• Nursing process


  • Cyclical; its components follow a logical sequence, but more than one component may be involved at one time

  
• Phases of nursing process

  • Not separate entities but overlapping, continuing sub processes
  • Each phase affects the others; they are closely interrelated
  • Cyclical; at the end of first cycle, care may be terminated if goals are achieved, or the cycle may continue with reassessment, or the plan of care may be modified
• 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

  
• Assessing


  The systematic and continuous collection, organization, validation, and documentation of data (information)
• Assessing is a continuous process carried out during all phases of the nursing process

  
• All phases of nursing process depend on the accurate and complete collection of data

  
• Nursing assessments should include the client's perceived needs, health problems, related experience, health practices, values and lifestyles

  
• Data collected should be relevant to particular health problem; therefore, nurses should think critically about what to assess
• Types of assessment


  • Initial assessment
  • Problem-focused assessment
  • Emergency assessment
  • Time-lapsed reassessment
• Initial assessment


  Performed within specified time after admission to a health care agency to establish a complete database for problem identification, reference, and future comparison
• Problem-focused assessment


  Ongoing process integrated with nursing care to determine the status of specific problem identified in earlier assessment

  
• Emergency assessment


  During any physiological or psychological crisis of the client to identify life-threatening problems and identify new or overlooked problems
• Time-lapsed reassessment


  Several months after initial assessment to compare the client's status to baseline data previously obtained
• To collect data accurately, both the client and nurse must actively participate
• Data base


  Contains all the information about a client; includes nursing history, physical assessment, primary care provider's history and physical examination, results of lab and diagnostic tests and material contributed by other HCP
• Components of nursing health history

  • Biographic data
  • Chief complaint or reason for visit
  • History of present illness
  • Past History
  • Family History of illness
  • Lifestyle
  • Psychological data
  • Social data
  • Patterns of health care

  
• Subjective data


  Apparently only to the person affected, can be described or verified only by the client (e.g. itching, pain, feeling of worry)
• Objective data


  Detectable by an observer or can be measured or tested against an accepted standard, obtained by observation or physical examination (e.g. discoloration of skin, blood pressure reading)
• Other types of data

  • Constant data (information that does not change over time)
  • Variable data (information that change quickly, frequently or rarely)
• Sources of data


  • Primary sources (statements made by the client, objective data directly obtained by the nurse from the client)
  • Secondary sources (support people, client records, health care professionals, literature)
• Observing


  Gather data by using the senses, a conscious, deliberate skill that is developed through effort and with an organized approach
• Aspects of observing


  • Noticing the data
  • Selecting, organizing, and interpreting the data
• Interviewing


  A planned communication or conversation with a purpose, for example, to get or give information, identify problems of mutual concern, evaluate change, teach, provide support, or provide counselling or therapy
• Approaches to interviewing


  • Directive interview (highly structured, elicits specific information)
  • Nondirective interview (rapport building, allows the client to control the purpose, subject matter and pacing)
• Types of interview questions

  • Closed-ended questions (restrictive, require "yes or no" or short factual answers)
  • Open-ended questions (invites clients to discover or explore, elaborate, clarify, or illustrate their thoughts or feelings)
  • Neutral questions (open ended, client can answer without direction or pressure from the nurse)
• Planning the interview and setting

  • Time (when the client is physically comfortable and free of pain, when interruptions are minimal)
  • Place (well lighted, well ventilated room that is relatively free of noise, movements, and distractions)
  • Seating arrangement (nurse can sit at a 45-degree angle to the bed when the client is in bed, seating with no table in between, a few feet apart)
  • Distance (not too small nor too great)
  • Language (use words the client can understand, avoid medical terms, ensure confidentiality)
• Stages of interview


  • Opening (sets the tone, establishes rapport, orients the interviewee)
  • Body (the client communicates what he/she thinks, feels, knows, and perceives in response to questions from the nurse)
  • Closing (the nurse terminates the interview when the needed information has been obtained)
• Examining


  Physical examination or physical assessment is a systematic data collection method that uses observation to detect health problems, conducted using techniques of inspection, auscultation, palpation, and percussion
• The physical examination must be carried out systematically, organized according to the examiner's preference, using a cephalocaudal (head-to-toe) approach or a body systems approach
• When interviewing a client, the nurse must determine

  • The client can read in his or her own native language
• Stages of interview


  1. Opening

  2. Body

  3. Closing
• Opening


  Sets the tone of the interview
• Purpose of opening


  • Establish rapport - creating goodwill and trust
  • Orient the interviewee - explains the purpose and nature of interview
• Body


  The client communicates what he/she thinks, feels, knows, and perceives in response to questions from the nurse