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  • 1. Foundations of NursingNursing ProcessPrepared by: Mark Fredderick R. Abejo R.N, M.A.N A. Collecting Data: Data collection is the process of gathering information about a client’s health status. It must be both systematic and continuous to prevent the omission of significant data and reflect a client’s changing health status. FOUNDATIONS OF NURSING  Subjective Data  also referred to as symptoms or covert data Nursing Process  are apparent only to the person affected and Lecturer: Mark Fredderick R. Abejo R.N, M.A.N can be described or verified only by that person. Itching, pain, and feelings of worry NURSING PROCESS are examples of subjective data. It all includes the client’s sensations, feelings, A systematic, rational method of planning values, beliefs, attitudes, and perception ofproviding nursing care. personal health status and life situationGoal:  Objective Data 1. To identify a client’s healthcare status, and  also referred to as signs or overt data, are actual or potential health problems 2. To establish plans to meet the identified needs detectable by an observer or can be 3. To deliver specific nursing interventions to measured or tested against an accepted address those needs standard.  They can be seen, heard, felt, or smelled,I. ASSESSMENT PHASE and they are obtained by observation or physical examination. Primary source is the client Secondary source is family or anyone else that is not the client Methods of Data Collection Observing  To observe is to gather data by using the sense. Observation is a conscious, deliberate skill that is developed through effort and with an organized approach. It has to aspects: (a) noticing the data and (b) selecting, organizing, and interpreting the data.  The nurse carry out a complete & holistic nursing assessment of every patients needs  Utilizes an assessment framework, based on a Interviewing nursing model or Waterlow scoring wherein  An interview is a planned communication or a problems are expressed as either actual or conversation with purpose, for example, to get or potential. give information, identify problems of mutual  Assessing is a systematic and continuous concern, evaluate change, teach, provide support, collection, organization, validation, and or provide counseling or therapy. documentation of data (information)  There are two approaches to interviewing:  Assessing is a continuous process carried out during all phases of the nursing process o Directive interview - Nurse directs  Nursing assessments focus on a client’s interview, client responds to questions and responses to a health problem has limited chances to discuss concerns.  Should include the client’s perceived needs, o Nondirective interview – rapport-building health problems, related experience, health where the client is in control of the practices, values, and lifestyles purpose, subject, and pace.  Questions :Types of Assessment  Initial Assessment  Open-ended – invites client to discover and  Problem-focused Assessment explore, elaborate, clarify, or illustrate their  Emergency Assessment thoughts or feelings. “How have you been  Time-lapsed Reassessment feeling lately?”  Closed-ended – used in directiveThe assessment process involves four closely related interviewing, and are questions that requireactivities: collecting data, organizing data, validating data,and documenting data. a yes or no answer.Foundations of Nursing Abejo
  • 2. Foundations of NursingNursing ProcessPrepared by: Mark Fredderick R. Abejo R.N, M.A.N  Neutral question – a question that the client D. Documenting Data: can answer without direction. “Why do you  To complete the assessment phase, the nurse think you had the operation?” records client data. Accurate documentation is  Leading question – directs the clients essential and should include all data collected answer. “You’re stressed about surgery about the client’s health status. tomorrow, aren’t you?”  Data are recorded in a factual manner and not interpreted by the nurseExamining o The nurse records the client’s breakfast  The physical examination or physical assessment intake (objective) as “coffee 240 mL, 1 is a systematic data-collection method that uses egg, and 1 slice of toast” observation (i.e., the senses of sight, hearing, smell, and touch) to detect health problems. To II. DIAGNOSIS PHASE conduct the examination the nurses uses techniques of inspection, auscultation, palpation, and percussion.B. Organizing Data:  Using a written or computerized format that organizes the assessment data.  Most schools of nursing and health cause agencies have developed their own structured assessment format.  Frameworks: o Gordon – 11 functional health patterns o Orem – 8 universal self-care requisites of humans o Roy’s adaptation model o Maslow’s hierarchy of needsC. Validating Data: The term diagnosing refers to the reasoning  The information gathered during the assessment process, whereas the term diagnosis is a statement or phase must be complete, factual, and accurate conclusion regarding the nature of a phenomenon. The because the nursing diagnoses and interventions standardized North American Nursing Diagnosis are based on this information. Validation is the Association (NANDA) names for the diagnoses are called act of “double-checking” or verifying data to diagnostic labels; and the client’s problem statement, confirm that it is accurate and factual. consisting of the diagnostic label plus etiology (causal  Cues vs. Inferences: relationship between a problem and its related o Cues – subjective or objective data that can be directly observed by the nurse, either Types of Nursing Diagnoses what the client says or what the nurse can The five types of nursing diagnoses are actual, see. risk, wellness, possible, and syndrome. o Inferences – nurses interpretations or  An actual diagnosis is a client problem that is conclusions based on the cues. (A nurse present at the time of the nursing assessment. observes the cues that an incision is red, Examples are Ineffective Breathing Pattern and hot, and swollen; the nurse makes the Anxiety. An actual nursing diagnosis is based on inference that the incision is infected.) the presence of associated signs and symptoms. - You don’t have to check all data (like  A risk nursing diagnosis is a clinical judgment birth dates, height, weight and most lab that a problem does not exist, but the presence of studies) risk factors indicates that a problem is likely to  Validating data helps the nurse complete these develop unless nurses intervene. tasks:  A wellness diagnosis “describes human  Ensure that assessment information is responses to levels of wellness in an individual, complete. family or community that have a readiness for  Ensure that objective and related subjective enhancement” data agree.  A possible nursing diagnosis is one in which  Obtain additional information that may have evidence about a health problem is incomplete or been overlooked. unclear. A possible diagnosis requires more data  Differentiate between cues and inferences. either to support or to refute it.  Avoid jumping to conclusions and focusing  Syndrome diagnosis is a diagnosis that is in the wrong direction to identify problems. associated with a cluster of other diagnoses.Foundations of Nursing Abejo
  • 3. Foundations of NursingNursing ProcessPrepared by: Mark Fredderick R. Abejo R.N, M.A.NThe Diagnostic Process  The diagnostic process uses the critical-thinking skills of analysis and synthesis.  Critical thinking is a cognitive process during which a person reviews data and considers explanations before forming an opinion.  Analysis is the separation into components, that is, the breaking down of the whole into its parts  . Synthesis is the opposite, that is, the putting together of parts into the whole. T  he diagnostic has three steps: analyzing data, Basic three-part statements identifying health problems, risks, and strengths, The basic three-part nursing diagnosis statement and formulating diagnostic statements. is called the PES format and includes the following:A. Analyzing Data Problem (P): statement of the client’s response.  In the diagnostic process, analyzing involves the Etiology (E): factors contributing to or probable following steps: cause of the responses. o Compare data against standards (identify Signs and Symptoms (S): defining significant cues). characteristics o Cluster cues (generate tentative hypotheses). manifested by the  Identify gaps and inconsistencies. client.B. Identifying Health Problems, Risks, and Strengths.  After data are analyzed, the nurse and client can together identify strengths and problems. This is primarily a decision-making process.Determining problems and risk  After grouping and clustering the data, the nurse and client together identify problems that support tentative actual, risk, and possible diagnoses.  In addition, the nurse must determine whether the client’s problem is a nursing diagnosis, medical diagnosis, or collaborative problem. • Problem Statement  describes the client’s health problem or response for which nursingDetermining strengths therapy is given  At this stage, the nurse and client also establish • Qualifiers  added words to give additional the client’s strengths, resources, and abilities to meaning to the diagnostic statement cope. • Altered  change from baseline  Most people have a clearer perception of their • Impaired  made worse, weakened, damaged problems or weakness than of their strengths and • Decreased  smaller in size, amount or degree assets, which they often take for granted. • Ineffective  not producing the desired effect  A client’s strengths can be found in the nursing • Acute  severe or of short duration. assessment record (health, home life, education, • Chronic  lasting a long time recreation, exercise, work, family and friends, • Diagnostic Labels religious beliefs, and sense of humor). o Describes the client’s health problem or response for which nursing therapy isC. Formulating Diagnostic Statements given.  Most nursing diagnoses are written as two-part or o Independent function – areas of health care three-part statements, but there are variations of that are unique to nursing and separate and these. distinct from medical management. o Dependent function- Nurses are obligatedBasic two-part statements to carry out physician-prescribed therapies The basic two-part statement includes the and treatments.following: Problem (P): statement of the client’s response. Etiology (E): factors contributing to or probable cause of the responses.Foundations of Nursing Abejo
  • 4. Foundations of NursingNursing ProcessPrepared by: Mark Fredderick R. Abejo R.N, M.A.NDifferentiating Nursing Diagnoses from Collaborative A Nursing DiagnosisProblems Is Is not o Collaborative – monitoring the client’s condition and preventing development of  A statement of a the potential complication and using patient problem  A medical  Actual or potential diagnosis physician-prescribed interventions.  Within the scope  A nursing action o Nursing Diagnoses – involve the human of nursing practice  A physician order response, which vary from one person to  Directive of  A therapeutic the next. nursing treatment interventionCOMMON ERRORS IN FORMULATING NURSINGDIAGNOSES 1. Using medical diagnosis III. PLANNING PHASE – INCORRECT: Self-care deficit related to stroke – CORRECT: Self-care deficit related to neuromuscular impairment 2. Relating the problem to an unchangeable situation 3. Confusing the etiology or signs/symptoms for the problem – INCORRECT: Post-operative lung congestion related to bed rest – CORRECT: Ineffective airway clearance related to general weakness and immobility 4. Use of a procedure instead of a human response – INCORRECT: Catheterization related to urinary retention – CORRECT: Urinary retention related to perineal swelling  The third phase of the nursing process, in which 5. Lack of specificity the nurse and client develop client goals/desired – INCORRECT: Constipation related to outcomes and nursing interventions to prevent, nutritional intake reduce, or alleviate the client’s health problems. – CORRECT: Constipation related to  Planning is a deliberative, systematic phase of the nursing process that involves decision inadequate dietary bulk and fluid intake making and problem solving. In planning, the 6. Combining two nursing diagnosis nurse refers to the client’s assessment data and – INCORRECT: Anxiety and fear related to diagnostic statements for direction in separation from parents formulating client’s goals and designing the – CORRECT: Anxiety related to change in nursing interventions required to prevent, reduce, environment and unmet needs or eliminate the client’s health problems.  A nursing intervention is “any treatment, based 7. Relating one nursing diagnosis to another upon clinical judgment and knowledge that a – INCORRECT: Coping, individual ineffective nurse performs to enhance patient/client related to anxiety outcomes” – CORRECT: Anxiety, severe related to change in role functioning and socio-economic Types of Planning status Planning begins with the first client contact and 8. Use of judgmental/value-laden language continues until the nurse-client relationship ends, usually when the client is discharges from the health care agency. Ineffective airway clearance related to bad habit 9. Making assumptions Initial Planning – INCORRECT: Risk for altered parenting  The nurse perform the admission assessment related to inexperience usually develops the initial comprehensive plan – CORRECT: Deficient knowledge regarding of care. child care issues related to lack of previous  This nurse has the benefit of the client’s body experience, unfamiliarity with resources language as well as some intuitive kinds of information that are not available solely from the 10. Writing a Legally Inadvisable Statement written database. – INCORRECT: Skin integrity related to not  Planning should be initiated as soon as possible being turned every 2 hours after the initial assessment, especially because of – CORRECT: Impaired skin integrity related to the trend toward shorter hospital stays. pressure and altered circulationFoundations of Nursing Abejo
  • 5. Foundations of NursingNursing ProcessPrepared by: Mark Fredderick R. Abejo R.N, M.A.NOngoing Planning  Tailor plan to the client: Ask when the best time  Is done by all nurses who work with the client. is for the client to do interventions  As nurses obtain new information evaluate the  Ensure that the plan incorporates preventive and client’s responses to care, they can individualize health maintenance aspects as well as restorative the initial care plan further.  Ongoing planning also occurs at the beginning of ones. a shift as the nurse plans the care to be given that  Ensure that the plan contains interventions for day. ongoing assessment of the client.  Include collaborative and coordination activitiesDischarge Planning in the plan  The process of anticipating and planning for  Include plans for the client’s discharge and home needs after discharge, is a crucial part of care need comprehensive health care and should be addressed in each client’s care plan. The Planning ProcessNURSING CARE PLAN In the process of developing client care, the nurse engages in the following activities:Types of NCP Priority Setting  Informal Nursing Care Plan  Is the process of establishing a preferential o Strategy for action that exists in the nurse’s sequence for addressing nursing diagnoses and mind. interventions.  Formal Nursing Care Plan  The nurse and client begin planning by deciding o Written or computerized guide for which nursing diagnosis requires attention first, organizing information which second, and so on. Instead of rank- ordering diagnoses, nurses can group them as  Standardized Nursing Care Plan having high, medium, or low priority. o Formal plan that specifies the nursing care  Life-threatening problems such as loss of for groups of clients with common needs. respiratory or cardiac function are designated as o Not for individuals high priority. o Preprinted guides for the nursing care of a  The nurse must consider a variety of factors client who has a need that arises frequently when assigning priorities, including the following: in the agency.  Client’s health values and beliefs o Problem -> Goals/desired outcomes ->  Client’s priorities Nursing interventions -> Evaluation  Resources available to the nurse and client  Individualized Nursing Care Plan  Urgency of the health problem o Is tailored to meet the unique needs of a  Medical treatment plan specific client. - When nurses use the client’s nursing Establishing Client Goals/Desired Outcomes  After establishing priorities, the nurse and client diagnoses to develop goals and set goals for each nursing diagnosis. nursing interventions, the result is a  On a care plan the goals/desired outcome holistic, individualized plan of case describe, in terms of observable client responses, that will meet the client’s unique what the nurse hopes to achieve by needs. implementing the nursing interventions. - During planning phase, the nurse must  The term goal and desired outcome are used decide which of the client’s problems interchangeably in this text, except when discussing and using standardized language. need individualized plans and which problems can be addressed by Selecting Nursing Interventions and Activities standardized plans and routine care,  Nursing interventions and activities are the and write unique desired outcomes actions that a nurse performs to achieve client and nursing interventions for client goals. problems that require nursing  The specific interventions chosen should focus on eliminating or reducing the etiology of the attention beyond preplanned, routine nursing diagnosis, which is the second clause of care. the diagnostic statement.Guidelines for writing a Nursing Care Plan Types of Nursing Interventions  Date and sign the plan  Use category headings “Nursing Diagnoses” Independent interventions “Goals/Desired Outcomes”  Are those activities that nurses are licensed to initiate on the basis of their knowledge and  Use standardized medical or English symbols skills. and key words rather that complete sentences to  They include physical care, ongoing assessment, communicate your ideas. emotional support and comfort, teaching,  Be specific counseling, environmental management, and  Refer to procedure books or other sources of info making referrals to other health care rather than including all steps on something professionals.Foundations of Nursing Abejo
  • 6. Foundations of NursingNursing ProcessPrepared by: Mark Fredderick R. Abejo R.N, M.A.NDependent interventions interventions that were developed in the planning  Are activities carried out under the physician’s step and then concludes the implementing step orders or supervision, or according to specified by recording nursing activities and the resulting routines. client responses.Collaborative interventions Implementing Skills  Are actions the nurse carries out in collaboration  To implement the care plan successfully, nurses with other health team members, such as need cognitive, interpersonal, and technical physical therapist, social workers, dietitians, and skills. physicians.  These skills are distinct from one another; in practice, however, nurses use them in variousCriteria for Choosing Nursing Interventions combinations and with different emphasis,The following criteria can help the nurse to choose the depending on the nursing interventions. The plan must be:  Having these skills contributes to the greater  Safe and appropriate for the individual’s age, improvement of the nurses delivery of health health, and condition. care to the patient, including the patients level of  Achievable with the resources available. health, or health status.  Congruent with the client’s values, beliefs, and culture. Cognitive or Intellectual Skills  Congruent with other therapies.  Such as analyzing the problem, problem solving,  Based on nursing knowledge and experience or - critical thinking and making judgments knowledge from relevant sciences. regarding the patients needs.  Within established standards of care as  Included in these skills are the ability to identify, determined by state laws, professional differentiate actual and potential health problems associations, and the policies of the institution. through observation and decision making by synthesizing nursing knowledge previouslyWriting Nursing Order acquired.  After choosing the appropriate nursing interventions, the nurse writes them on the care Interpersonal Skills plan as nursing orders.  Which includes therapeutic communication,  Nursing orders are instructions for the specific active listening, conveying knowledge and individualized activities the nurse performs to information, developing trust or rapport-building help the client meet established health care goals. with the patient, and ethically obtaining needed  The term order connotes a sense of and relevant information from the patient which accountability for the nurse who gives the order is then to be utilized in health problem and for the nurse who carries it out. formulation and analysis.IV. IMPLEMENTATION / INTERVENTION PHASE Technical Skills  Which includes knowledge and skills needed to properly and safely manipulate and handle appropriate equipment needed by the patient in performing medical or diagnostic procedures, such as vital signs, and medication administrations. Process of Implementing The process of implementing normally includes: Reassessing the Client  Just before implementing an intervention, the nurse must reassess the client to make sure the intervention is still needed.  Even though an order is written on the care plan, the client’s condition may have changed. Determining the Nurse’s Need for Assistance  When implementing some nursing interventions, the nurse may require assistance for one of the following reasons:  The methods by which the goal will be achieved  The nurse is unable to implement the are also recorded at this stage. nursing activity safely alone (e.g.,  The methods of implementation must be ambulating an unsteady obese client). recorded in an explicit and tangible format in a  Assistance would reduce stress on the way that the patient can understand should he client (e.g., turning a person who wish to read it. experiences acute pain when moved).  Clarity is essential as it will aid communication  The nurse lacks the knowledge skills to between those tasked with carrying out patient implement a particular nursing activity care. (e.g., a nurse who is not familiar with a  Implementing consists of doing and particular model of traction equipment documenting the activities that are specific needs assistance the first time it is applied). nursing actions needed to carry out theFoundations of Nursing Abejo
  • 7. Foundations of NursingNursing ProcessPrepared by: Mark Fredderick R. Abejo R.N, M.A.N  To evaluate is to judge or to appraise.Implementing the Nursing Interventions  Evaluating is a planned, ongoing, purposely  It is important to explain to the client what activity in which clients and health care interventions will be done, what sensations to professionals determine expect, what the client is expected to do, and (a) the clients progress toward achievement of what the expected outcome is. goals/outcomes  For many nursing activities it is important to (b) the effectiveness of the nursing care plan. ensure the client’s privacy, for example by  The purpose of this stage is to evaluate progress closing doors, pulling curtains, or draping the toward the goals identified in the previous client. stages. If progress towards the goal is slow, or if  When implementing interventions, nurses should regression has occurred, the nurse must change follow these guidelines: the plan of care accordingly  Base nursing interventions on scientific knowledge, nursing research, and Process of Evaluating Client Responses professional standards of care whenever  Before evaluation, the nurse identifies the possible. desired outcomes (indicators) that will be used to  Clearly understand the orders to be measure client goal achievement implemented and question any that are not  Desired outcomes serve two purposes: they understood. establish the kind of evaluative data that needed  Adapt activities to the individual client. to be collected and provide a standard against  Implement safe care. which the data are judged.  Provide teaching, support, and comfort.  The evaluation process has five components:  Be holistic.  Respect dignity of the client and enhance the client’s self-esteem. Collecting Data  Encourage clients to participate actively in  Using the clearly stated, precise, and measurable implementing the nursing interventions. desired outcomes as a guide, the nurse collects data so that conclusions can be drawn aboutSupervising Delegated Care whether the goals have been met.  If care has been delegated to other health care  It is usually necessary to collect both objective personnel, the nurse responsible for the client’s and subjective data. overall care must ensure that the activities have been implemented according to the care plan. Comparing Data with Outcomes  Other caregivers may be required to  If the first two parts of the evaluation process communicate their activities to the nurse by have been carried out effectively, it is relatively documenting them on the client record, reporting simple to determine whether a desired outcome verbally, or filling out a written form. has been met.  The nurse validates and responds to any adverse  Both the nurse and the client play an active role findings or client responses. in comparing client’s actual responses with the desired outcomes.Documenting Nursing Activities  After determining whether a goal has been met,  After carrying out the nursing activities, the the nurse writes an evaluative statement (either nurse completes the implementing phase by on the care plan or in the nurse’s notes). recording the interventions and client responses  An evaluation statement consists of two parts: a in the nursing progress notes. conclusion (is a statement that the goal/desired  These are a part of the agency’s permanent outcomes was met, partially met, or not met), record for the client. and supporting data (are the list of client  Nursing care must not be recorded in advance responses that support the conclusion). because the nurse may determine on reassessment of the client that the intervention Relating Nursing Activities to Outcomes should not or cannot be implemented.  The third aspect of the evaluating process is determining whether the nursing activities hadV. EVALUATION PHASE any relation to the outcomes.  It should never be assumed that a nursing activity was the cause of or the only factor in meeting, partially meeting, or not meeting a goal. Drawing Conclusions about Problem Status  The nurse uses the judgments about goal achievement to determine whether the care plan was effective in resolving, reducing, or preventing client problems.  When goals have been met, the nurse can draw one of the following conclusions about the status of the client’s problem:  The actual problem stated in the nursing diagnosis has been resolved; or potential problem is being prevented and the risk factors no longer exist.Foundations of Nursing Abejo
  • 8. Foundations of NursingNursing ProcessPrepared by: Mark Fredderick R. Abejo R.N, M.A.N  In these instances, the nurse documents that the Quality Improvement goals have been met and discontinues the care  Quality improvement (QI) is also known as for the problem. continuous quality improvement (CQI), total  The potential problem stated in the nursing quality management (TQM), performance diagnosis is being prevented, but the risk improvement (PI), or persistent quality factors are still present. In this case, the improvement (PQI) nurse keeps the problem on the care plan.  The actual problem still exists even though Nursing Audit some goals are being met. The nursing  An audit means the examination or review of interventions must be continued. records.  A retrospective audit is the evaluation of aContinuing, Modifying, and Terminating the Nursing client’s record after discharge from an agency.Care Plan  Retrospective means “relating to past events”.  After drawing conclusions about the status of the  These evaluations use interviewing, direct client’s problems, the nurse modifies the care observation of nursing care, and review of plan as indicated. clinical records to determine whether specific  Depending on the agency, modifications may be evaluative criteria have been met. made by drawing a line through proportions of the care plan, or marking portions using a highlighting pen, or writing “Discontinued” (dc’d) and the date.  Whether or not goals were met, a number of decisions need to be made about continuing, modifying, or terminating nursing care for each problem.  Before making individual modifications, the nurse must first determine why the plan as a whole was not completely effective.  This requires a review of the entire care plan and a critique of the nursing process steps involved in its development for a checklist to use when reviewing a care plan.Evaluating the Quality of Nursing Care  In addition to evaluating goal achievement for individual clients, nurses are also involved in evaluating and modifying the overall quality of care given to groups of clients.  This is an essential part of professional accountability.Quality Assurance  A quality-assurance (QA) program is an ongoing, systematic process designed to evaluate and promote excellence in the health care provided to clients.  Quality assurance frequently refers to evaluation of the level of care provided in a health care agency, but it may be limited to the evaluation of the performance of one nurse or more broadly involve the evaluation of the quality of the care in an agency, or even in a country.  It consists of three components of care:  The structure evaluation (focuses on the setting in which care is given. It answers this question: what effect does the setting have on the quality of care?),  The process evaluation (focuses on how the care was given. It answers question such as these: Is the care relevant to the client’s needs? Is the care appropriate, complete and timely?),  Outcome evaluation (focuses on demonstrable changes in the client’s health status as a result of nursing care. Outcome criteria are written in terms of client responses or health status.Foundations of Nursing Abejo