Transcript Nursing Process

Nursing Process
Back Ground

The nursing process is based on a nursing theory
developed by Ida Jean Orlando. She developed this
theory in the late 1950's as she observed nurses in
action. She saw "good" nursing and "bad" nursing.
 From her observations she learned that 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.
Definition of the Nursing Process:

An organized sequence of problem-solving
steps used to identify and to manage the
health problems of clients

A systematic, rational method of planning
and providing individualized nursing care.
Purposes of Nursing Process
1-
Identify a client health status and actual or
potential health care problems and needs.
2- Establish plans to meet the identifying needs.
3- Deliver specific nursing intervention to meet
needs.
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 client’s 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
Benefits of Nursing Process

Provides an orderly & systematic method for planning &
providing care.

Enhances nursing efficiency by standardizing nursing
practice.

Facilitates documentation of care.

Provides a unity of language for the nursing profession.

Stresses the independent function of nurses.

Increases care quality through the use of deliberate
actions.
5 Steps of the Nursing Process:
1.
Assessment
2.
Diagnosis
3.
Planning
4.
Implementing
5.
Evaluating
Diagnosis
Diagnosis
1st Step of the Nursing Process
ASSESSMENT:

Is a systematic collection of facts or data
Types of Data
1. Objective data-observable and measurable
facts (Signs)
Main way to collect objective data:
Physical assessment
Lab and diagnostic testing
Patient record
Assessment
2. Subjective data-information that only the
client feels and can describe (Symptoms)
 Primary source - the client’s point of view,
Feelings, Perceptions, Concerns
 Usually BEST source
 Main way to collect subjective data:
– Interview with Family & significant others
 When patient is a child or impaired adult
 Spouses
 Consider confidentiality when including friends
Subjective VS. objective

Example:

Patient comes to the ER because he cannot
move his arm, stating, “it happened about an
hour ago when headache got worse. Now I’m
nauseated and dizzy”. (Subjective)

The nurse takes his vital signs: T 37.9, P 100,
BP 170/95, and observes that he cannot move
his left arm and his face is flushed. (objective)
Assessment

Sources of Data
– Primary sources
 Client
 Interview
 Physical examination & vital signs
– Secondary sources
 Family members
 Other health care providers
 Medical records
 test results
Assessment
Step #1
 Involves

– Collecting data (from variety of sources)
– Validating the data
 Organizing the data Grouping of related
information
 Organization of assessment data into small
groups to be analyzed
– Interpreting the data
– Documenting the data
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.
Data Collection
Demographics
 Medical history
 Habits
 Medications, allergies
 Environmental/familial factors
 Potential for injury
 Ability to participate in plan of care

Assessment

Types of Assessment:
1. Comprehensive Assessment
2. Focused Assessment
3. Ongoing Assessment
Types of Assessment
1. Comprehensive assessment “Initial”
– Performed on entry to healthcare facility
– Information you gather on initial contact with
the person to assess all aspects of health
status is the Baseline.
– Often includes:
Health history
Physical exam and
 psychosocial assessment
Types of Assessment
2. Focused Assessment
– The data you gather to determine the status
of a specific condition.
– Occurs after initial assessment and period of
time.
– Limited in scope
– Screening for a specific problem
– Short stay
Types of Assessment
3. Ongoing assessment
– Follow-up
– Monitoring and observation related to specific
problems
ASSESSMENT
Observation
 Interview
 Physical Examination
Is a systematic data collection method that uses the
senses of sight, hearing, smell, and touch to detect
health problems. Four techniques are used:
inspection, palpation, percussion, and auscultation

A physical assessment may be carried out before,
during, or after the health history, depending on a
patient’s physical and emotional status and the
immediate priorities of the situation.
Physical Assessment Techniques
1. Inspection – critical observation “to see”
– Take time to “observe” with eyes, ears, nose
– Use appropriate lighting
– Look at color, shape, symmetry, position
– Odors from skin, breath, wound
– Provide privacy for client
– Expose body areas adequately
– Use instruments when appropriate, i.e. otoscope,
ophthalmoscope, penlight
Inspection is done alone and in combination with
other assessment techniques
Physical Assessment Techniques
2. Palpation - light and deep touch
– Uses the sense of touch
– Back of hand to assess skin temperature
– Fingers to assess texture, moisture, areas of
tenderness
– Assess organ location, size, shape, and consistency
of lesions, swelling, masses, and tenderness.
– Palpation requires a calm, gentle approach and is
used systematically, with light palpation preceding
deep palpation and palpation of tender areas
performed last.
Physical Assessment Techniques
3- Percussion – to tap
Uses short, tapping strokes on
the surface of the skin to
create vibrations of underlying
organs. It is used for assessing
the density of structures or
determining the location and
the size of organs in the body.
Percuss – to tap

Percussion Sounds - elicits 4 percussion notes
on selected body surfaces
–
–
–
–
Flatness (thigh muscle) elicit and describe sound
Dullness (liver) elicit and describe sound
Resonance (normal lung) elicit and describe sound.
Tympani (gastric air bubble) elicit and describe
sound
Physical Assessment Techniques
4- Auscultation - listening to sounds produced by
the body that are created by movement of air or
fluid.
 Direct auscultation – sounds are audible
without stethoscope
 Indirect auscultation – uses stethoscope
Assessment techniques - Cont.
Auscultation

Instrument: stethoscope (to
skin)
 Diaphragm –high pitched
sounds
– Heart
– Lungs
– Abdomen
 Bell – low pitched sounds
- Blood vessels
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Nursing Diagnosis

Step 2 in the nursing process

The purpose of this stage is to identify the
patient's nursing problem

Nursing diagnosis: actual or potential
health problems that can be managed by
independent nursing interventions .
It contains three parts:

Problem: Name of the health-related issue or problem

Etiology: (its cause)

Sign and symptom

It called PES system.

The name of the nursing diagnosis is linked to the
etiology with the phrase “related to,” and the signs
and symptoms are identified with the phrase “as
manifested (or evidenced) by”
Writing Diagnostic Statements
Problem
Diagnostic
Label
Etiology
Related
To
Contributin
g Factors
As
Signs &
manifested
Symptoms
By
Nursing Diagnosis
Prioritize the problems
Not a medical diagnosis
Medical vs. Nursing diagnosis
Medical diagnosis
physician "clinical
judgment of the
disease- i.e.
diabetes mellitus.
Nursing diagnosis
statement used to describe the
client's actual or potential
response to a health problem
that a nurse is licensed and
competent to treat i.e.Impaired skin integrity, Risk for
Infection, etc.
Focuses on illness, Focuses on the clients
injury or disease
responses to actual or
processes
potential health / life problems
Medical vs. Nursing diagnosis
Medical diagnosis
Nursing diagnosis
Remains constant Changes as the clients
until a cure is
response and/or the health
effected
problem changes
i.e. Breast cancer
i.e. Knowledge deficit
Powerlessness
Grieving, anticipatory
Body image disturbance
Individual coping, ineffective
Examples of Diagnosis
Nursing diagnosis
Medical diagnosis
Breathing patterns,
ineffective
Chronic obstructive
pulmonary disease
Activity intolerance
Cerebrovascular accident
Pain
Appendectomy
Body image disturbance
Amputation
Self-care deficit: bathing,
related to joint stiffness
Rheumatoid Arthritis
Planning & Outcome identification

Step 3
– Types of planning
 Initial planning
 Ongoing planning
 Discharge planning
Planning

The process of prioritizing nursing diagnoses and
collaborative problems, identifying measurable
goals
or
outcomes,
selecting
appropriate
interventions, and documenting the plan of care.

The
nurse
consults
with
the
client
while
developing and revising the plan.

Determine problems that require immediate
action
Short-Term Goals






Outcomes achievable in a few days or 1 week
Developed from the problem portion of the
diagnostic statement
Client-centered
Measurable
Realistic
Accompanied by a target date
Long-Term Goals

Desirable outcomes that take weeks or months
to accomplish for client’s with chronic health
problems
Formula for Writing Goals/Outcomes:
Goal statement (long or short term) = patient
behavior + criteria + time + conditions (if
needed)
 1. Subject -patient
 2. Verb -action/behavior which pt performs
 3. Criteria -acceptable performance
 4. Within specified time period
 5. Condition (if needed) circumstances under
which behavior performed
Example:
 The patient (1) will walk (2) the length of the
hall (3) with a walker (5) by the end of the shift
(4).

Prioritizing the nursing diagnosis
– Maslow’s hierarchy of needs
Priorities are classified:

High: nursing diagnosis that if untreated,
could result in harm to the client or others
have the highest priority

Intermediate: nursing diagnosis involves
the non-emergency, non-life threatening
needs of the clients

Low: nursing diagnosis are client’s needs
that may not be directly to a specific
illness or prognosis
Implementation
 4th
step of Nursing Process:
– Put the plan of nursing care into action
–DO IT
–DO IT RIGHT
–DO IT RIGHT NOW!
Nursing Implementation

Direct interventions:
Actions performed through interaction with
clients.

Indirect interventions:
Actions performed away from the client, on
behalf of a client or group of clients.
Evaluation

5th and final step
– It is the analysis of
the client’s response,
evaluation helps to
determine the
effectiveness of
nursing care.
– Determining whether
the clients goals have
been met, partially
met or not met.
Example:
NURSING DIAGNOSIS: Disturbed Sleep
Pattern
Goal: Client will sleep uninterrupted for 6
hours.
EXPECTED OUTCOMES
• Client will request back massage for
relaxation.
• Client will set limits to family and
significant other visits.