NURSING PROCESS- INTRODUCTION:Framework for professional quality Nsg careDirects activities forUsed in every practice setting
1955-lydia hall termed Nsg process1953-FRY uesd the term NP , (unpopular)1959-Johnson devpd1961-Orlando used NP1963-widenback further dvpd1963 THREE STEP NP
1967-Yura & Walsh wrote a book on NP BY 4 STEPS
1973- Eight standards of practice published by ANA1974-started (NANDA) NORTH AMERICAN NURSINGDIANGNOSIS ASSOCIATION , nursing diagnosis was added into nsg process.1991-ANA made revision of standards & included outcomeidentification as a specific parts of the planning phase.Nursing process –definitionIs a assertive problem solving approach to the identification &treatment of patient problems
provide care for clients(individualized ,holistic, effective &efficient mannerHelps to provide professional ,quality of nsg careDirects nsg activities for health promotion, health protectionAnd disease preventionProvides an organizing framework for nursesBy using NP the nurse can focus on unique responses ofpatients
Nursing ModelsAll models have 4 core components,The person,Their environment,Health andNursing(but all have different emphasis)
The Person*Body (physical/ biological)*Activities of daily living*Genetic makeup*Gender*Nature/ Nurture
SOCIETYFAMILY & FRIENDSWORKPLAYEFFECTS OF ILLNESS
SPRITBelief systems about the meaning oflife, death, hope, suffering, it may involve organized religion,other customs or “New age”spirituality.
ENVIRONMENTHome , neighborsWork, social activities,Town , country,Political affairs
MIND (PSYCOLOGICAL)Healthy, impaired or damaged Intellect AttitudesEffect of illness stress,fears,memories Emotional support
A process is a series of steps/acts that leads to accomplishmentof some goals / purposeNP is A dynamic & requires creativity for its applicationIn NP the steps remains same but applications & results will bedifferent In each settingsNP is designed to be used with clients throughout the life span& in any clinical setting
Characteristics of data:1.Descriptive2.Concise3.Complete4.Asst should include, Inferences, statements5.Always use open ended questionsTypes of data collection: Structured interviewSemi structured interview
1. Non verbal observation Sight-Physical,psychological (and social) Touch -Skin temp, hydration, pulse/BPSound-Breath wheeze ,strider Smell-breath body fluids infections, gangrene2. Verbal Communication Patients/ clients Family and friends (Meaningful others)Nursing colleaguesMedical colleagues Other members of multidisciplinary team
Written records G.P LetterTransfer letter Old notes
Why are good communication skills required? To establish and maintain a relationship with patients and their familiesTo encourage patients to describe all relevant aspects of their problemsTo get and give accurate information To use time and opportunity effectively To improve patient satisfaction with the care given To improve thrust and cooperation with the care To reduce negative emotions and fear
Prepare adequately Introduce yourself- prepare patientUse nonverbal communication Be courteous Use sensitivity, compassion and empathy Use focused questions (opened and closed) Listen ClarifySummarize what they describeMake notesreflect
Definition:It is a clinical judgment about individual, family, (or) communityResponses to actual & potential health problems/life process.Nursing diagnosis provide the basis for selection of nursinginterventions to achieve outcomes for which the nurse isaccountable *NANDA
Medical diagnosis Nursing diagnosisTerminology used for clinical Terminology used for a clinicaljudgment by the (DR) that identifies judgment by the professional nurse(or)determines a specific disease, That identifies the clients actual risk,condition (or)pathological state wellness (or) syndrome responses to a health state, problem/ condition CASE (ETIOLOGY ) FOCUSED CARE FOCUSED FOCUSED ON DISEASE PROCESS FOCUS ON THE HUMAN RESPONSE TO STIMULAI
COMPARISON OF MEDICAL/NURSING DIAGNOSIS Medical diagnosis Nursing diagnosisCOPD Ineffective breathing pattern Altered cerebral perfusionCVAAPPENDECTOMY Pain acute (abdomen) AMPUTATION DISTURBED BODY IMAGE DIARRHOEA FLUID VOLUME DEFICIT
Cont…. 1.THE DIAGNOSTIC LABEL: Consists of one (or) more nouns also include adjectives, that the name of the diagnosis & can be a word or phrase that describes the pattern of related cues2.DEFINITION:It provides a clear description & differentiates one diagnosis from other similar diagnosis3.DEFININIG CHARACTERISTICS:These are the observable cues/inferences that cluster as manifestations , of an actual (or) potential/ wellness diagnosis
Cont…4. RISK FACTORSThese are elements that increase the chances of anIndividual, family (or) community being susceptible to aDisease state, (or) life events that will have an impact on health5.RELATED FACTORSIt can precede , be associated with, contribute to, (or)beRelated to nursing diagnoses , in some type of patterned relationship
FORMAT OF NURSING DIAGNOSIS Two part statement: Consists of two components 1st components is a problem statement (or) diagnostic label That describes the patients response to an actual/potential health problems/ wellness condition problem + etiology: 1. Feeding self care deficit ( problem ) 2. related to decrease strength and endurance ( Etiology )
The dignostic lable + etiology are linked with the term ‘Related to’’ Ex: disturbed body image (RT)loss of left lower limb extremity Activity intolerance (RT)decreased oxygen carrying capacity of the cells
THREE PART STATEMENTIt consists of problem + Etiology + Defining characteristicsDefining characteristics: These are collection of data, that are also known as signs/ symptoms, subjective data, objective data, (or)Clinical manifestations.In three part nsg diagnosis format, the 3rd part is joined to the first two components with the connecting phrase ‘’ AS EVIDENCED BY “
1. Feeding self care deficit ( problem ) 2. Related to decrease strength and endurance ( Etiology ) 3. As evidenced by inability to maintain fork in hand from plate to mouth.
1.Actual diagnosis:Are those problems identified by the nurse that are already in existence2.Risk diagnosis:Are identified by the nurse when there is a recognized vulnerability for the individual human response to a problem (or) life process, but when, that response has not yet manifested itself3.wellness diagnosis:Identifies the individual (or) aggregate condition (or) state of being healthy that may be enhanced by deliberate health promoting activitiesOne part statement( readiness for enhanced community coping) ‘’ there is no (R/T) phrase.
4.Syndrome diagnosis - "A clinical judgment describing a specific cluster of nursing diagnoses that occur together, and are best addressed together and through similar interventions." An example of a syndrome diagnosis is: Approved NANDA Syndrome Diagnoses•Rape Trauma Syndrome•Disuse Syndrome•Post-trauma Syndrome•Relocation Stress Syndrome•Impaired Environmental Interpretation Syndrome
GUIDELINE TO WRITE NSG DIAGNOSIS1.The medical diagnosis should not be included in theNsg diagnosis2.The nsg diagnosis statement must be written with the scope of independent nsg function3.The nsg diagnosis should not be influenced by personal bias4.Phrase the nsg diagnosis in terms of problem not a need5.Check the client problem precedes the etiology & 1, 2 are linked by (R/T), not as due to , or , caused by6.Defining characteristics should follow the etiology & it should be linked with by the phrase AS MANIFESTED BY
7.Use only the approved NANDA nsg diagnosis for the problem8.Always write problem 1st & etiology 2nd9.Be sure the problem statement indicates what is unhealthy about the client (or) what the client wants to10.Use legally defining terms to write nsg diagnosis11.Avoid using the defining characteristics by medical diagnosis12.The diagnostic statement should give direction for nsg interventions
PLANNINGDefinition –planning:Planning is the 3rd step of nursing process; it includes the formulation of guidelines that establish & proposed course of action in the resolution of nursing diagnoses, and the development of the clients plan of care.
PLANNINGPurposes of planning;1.helps to deliver the competent nsg care.2.helps to maintain /improve health at an optimal level.3.acts as framework for basic scientific nsg practice.
ESTABLISHING PRIORITIES After formulating specific nsg diagnosis the nurse establishes the priority Because most clients have more than one nsg diagnosis So it is necessary to ranking them in order of importance like high, medium, or low priority High priority possess greatest threat to the clients , wellbeing Non life threatening diagnoses are ranked as medium priority Diagnosis that are not specifically related to the current illness & prognosis are considered as low priority Use Maslows hierarchy of needs
MASLOW’S HIERARCHY OF NEEDSI)PHYSIOLOGICAL NEEDS; A) PHYSICAL: Personal hygiene Activity Sexuality B) HOMEOSTATIC: Eating Drinking Vital function(oxygenation) Sleep & rest elimination
II ) SAFTY & SECURITY NEEDS: Religion & philosophy Feelings of well being III) Love & belonging: Communication Affection Modesty Companionship Dependence
IV) self esteem: *recognition V ) self actualization
Establishing priority/goals/objectives/outcomeGOALS/OBJECTIVES:o These are derived from problem statements of the nsg diagnosiso A nsg goal objective is the desired change in the clients health status after nsg intervention.o Realistic goals /objectives give direction to the formation of nsg intervention & also provide the basis for evaluationo The goals/objectives must be written in terms of patient behavior & that must be observable & measurable
PROBLEMS GOALS1.PAIN By the end of evening client will report pain is absent / diminished2. Impaired physical mobility Before discharge, client will ambulate Length of half way independantly
PROBLEMS OBJECTIVES 1.Pain Clients pain reduces before my shift2. Impaired physical Client will ambulate before mobility discharge
Goals may be short term/long term.Depending on the client status.Goals may be broad statement ofoutcomes so it is better to use objectives.While writing nsg care plan, objectivesAre written as the short statements of the expected outcomes.
Selecting nursing interventionWhen selecting nsg interventions theNurse deliberates it out all possibleIntervention to achieve the expectedoutcome By using standard care plan .During planning the nurse reviews clientsneeds, priorities& previous experienceto select the best nsg intervention.As the nurse gains experience this planning process becomes more efficient & experience based.
COMMUNICATING NSG ORDERSNsg interventions are written as nsg orders.Nsg orders should be clear & concise.Nsg order communicates with the entire health care team.Nsg order are signed by the nurse who is prescribing the order .Use only standard abbreviations accepted by health care team.Always refer the nursing procedure manual for all steps of routine.
ACTIVITIES OF IMPLEMENTATION1.ongoing assessment 2. establishing priorities 3. allocation of resources 4.initiation of nursing interventions 5.documentation of interventions & client . response .
ONGOING ASSESSMENT1.Nsg care plan is based on theinitial assessment data collected by the nurse & nsg diagnosisDerived from those data.2.So ongoing asst is necessary tovalidate the relevance of present intervention.3.Ongoing asst demands attention to verbal/ non verbal cues .4.It is important in home health care/ extended care settings because of length of time that requires.
ESTABLISHING PRIORITIESTHE PRIORITIES ARE BASED ON :1.which problem needs most importantby the nurse, client, &family or significant others2.Activities previously scheduled by otherDepartments.3.Available recourses ,based on change of shift reports.5.According to PT change of condition.6.Time management7. Based on flexibility
Delegation is the process of transferring a selected nsg task in a situation to an individual who is competent to perform that specific tasks.The registered nurses are accountable for appropriateDelegation & supervision of care .In general , registered nurses are authorized by law to provide nsg care to clients directly & supervise & instruct others to deliver this nsg care.Decision about delegation are guided by the needs of the client, the number & type of available personnel.
INDEPENDENT NSG INTERVENTION:These are actions involve carrying out nurse prescribed orders, written on nsg care plan. In this type nurse initiate care with out the direction or supervision of another health care professional.The nurses are legally accountable for the assessment they make & for their nsg responses.Ex: designing actions for increasing clients knowledge about nutrition or activities of daily living
DEPENDANT NSG INTERVENTIONThese are actions carrying out physician prescribed orders.Ex: administering a medication, implementing a invasive procedure, changing a dressing & preparing the client for the diagnostic procedure.Each dependent nsg intervention requires specified nsg responsibilities & technical knowledge.Ex: medication administration
INTER DEPENDANT NSG INTERVENTIONSInterdependent/ collaborative interactions are thosePerformed jointly by nurses & other members of the health care team.Ex: implementation of hypertension protocol, changing the drug, iv line diet therapies.
PROTOCOLS & STANDING ORDERSIn addition the nsg intervention may be entirely based onprotocols & standing orders.protocols & standing orders may expand the scope of nsg practice , in certain clearly defined situations.Protocols:These are written plans , details the nsg activities to be executed in specific situations protocols that describe nsg responsibilities when a client is admitted / discharged from the institution.
STANDING ORDERSA standing order is a written documented rules, policies, procedures, regulations & orders for the conduct of client care in various stipulated clinical settings.standing orders are approved & signed by the physician in charge of care before these implementation.
IMPLEMENTATION COMPONENT1.Reasseing the client2. Reviewing and modifying the existing nsg care plan3.Identifying the Ares of assistance4.Implementing nsg interventions