NURSING PROCESS“ A Systematic method of providing Nursing care”• It provides a framework for planning and implementing Nursing care.• This involves a problem-solving approach that enables the nurse to identify patient problems and potential at-risk needs (problems) and to plan, deliver, and evaluate nursing care in an orderly, scientific manner.
Components of nursing process:The nursing process consists of five dynamic and interrelated phases:1. assessment2. diagnosis3. planning4. implementation5. evaluation.
How the nursing process applies to the scientific methodScientific method Nursing processState an observed problem AssessmentForm a hypothesis about the Nursing diagnosisproblemDevelop a method to test the Outcome Identification andhypothesis PlanningCollect the data ImplementationAnalyze the dataDraw conclusions about the Evaluationhypothesis 4
AssessmentAssessment involves the systemic collection of Patient data.(collect data, validate data, organize data, document data)Data Collection ( subjective &objective data)• Nursing history( Biographic data, current physical &emotional complaints, past medical history, past and current ability to perform ADL’S, socio-economic factors)• Physical Assessment.• Review of lab &Diagnostic test results.• Review other available Health Information.
Validation of dataThe information gathered during the assessment phase must be complete, factual, and accurate Because the nursing diagnosis interventions are based on this information.Validation is the act of "double-checking“ or verifying data to confirm that it is accurate and factual.Organization of dataThe nurse uses a written or computerized format that organizes the assessment data systematically. The format may be modified according to the clients physical status.
Documenting data:To complete the assessment phase, the nurserecords clients data.Accurate documentation is essential and shouldinclude all data collected about the clientshealth status. Data are recorded in a factualmanner and not interpreted by the nurse. E.g.: the nurse record the clientsbreakfast intake as" coffee 240 ml. Juice 120 ml, 1egg". Rather than as "appetite good".
PURPOSE OF ASSESSMENT:• To validate a diagnosis• To provide basis for effective nursing care.• It helps in effective decision making• Basis for accurate diagnosis• It promote holistic nursing care• To provide effective and innovative nursing care• To collecting data for nursing research• To evaluation of nursing care
TYPES OF ASSESSMENTType Aim Time frame1- Initial assessment Initial identification of normal Within the specified time function, functional status, and frame after admission to a collection of data concerning hospital, nursing home, actual or potential dysfunction. ambulatory healthcare center. Baseline for reference and future comparison.2- Focus assessment Status determination of a Ongoing process, integrated specific problem identified with nursing care, a few during previous assessment. minutes to a few hours between assessments. Comparison of client’s current Several months (3,6,9 months3- Time – lapsed status to baseline obtained or more) between assessmentreassessment previously, detection of changes in all functional health patterns after an extended period of time has passed Identification of life – AT anytime4- Emergency threatening situationassessment
NURSING DIAGNOSISNursing diagnosis is a clinical judgment about individual, family, or community responses to actual or potential health problems/life processes. Nursing diagnoses provide the basis for selection of nursing interventions to achieve outcomes for which the nurse is accountable (NANDA, 1997).Steps:Each Nursing Diagnosis has three components:*Label an actual or potential health problems that Nursing care can affect.*Related factors- Factors that may precede, contribute to or be associated with the human response.*Evidence – Signs symptoms that point to the Nursing Diagnosis.
TYPES OF NURSING DIAGNOSIS• Actual Diagnosis: An actual diagnosis is a statement about a health problem that the client has, and could benefit from nursing care. An example of an actual nursing diagnosis is:---Ineffective airway clearance related to decreased energy and manifested by an ineffective cough.• A risk diagnosis is a statement about a health problem that the client doesnt have yet, but is at a higher than normal risk of developing in the near future. An example of a risk diagnosis is:---Risk for injury related to altered mobility and disorientation.
While walking Mrs. Lin to the bathroom, she complains of dizziness:• Ask her if the dizziness is related to an activity• Take her blood pressure in lying and standing positions• Determine what interventions will reduce her dizziness• Later, in the day, check with her if additional episodes have occurred• Teach her to change her position slowly• Formulate the nursing diagnosis “High Risk for Injury related to vertigo secondary to postural hypotension”
• A complete nursing diagnosis is written in the format problem related to cause of problem as evidenced by symptoms of problem• An example of such a nursing diagnosis would be Impaired gas exchange related to excessive secretions as evidenced by O2 saturation of 86%.
NURSING PLANNINGThe third step of the nursing process; includes the formulation of guidelines that establish the proposed course of nursing action in the resolution of nursing diagnoses and the development of the client’s plan of care.The planning of nursing care occurs in three phases:(initial, ongoing, and discharge.)Each type of planning contributes to the coordination of the client’s comprehensive plan of care.
The four critical elements of planning1.Establishing priorities.In establishing priorities, the nurse examines the client’s nursing diagnoses and ranks them in order of physiological or psychological importance.One of the most common methods of selecting priorities is the consideration of Maslow’s hierarchy of needs, which requires that a life- threatening diagnosis be given more urgency than a non life threatening diagnosis.
2.Setting goals and developing expected outcomesA goal is a specific and measurable objective designed to reflect the patient highest level of wellness and independence in function.There are 2 categories in goals.• Short term – Can be met fairly and quickly (hours or days)• Long term – cover a long time spane.g.The patient will be free of infection throughout hospitalization.
3. Developing Expected outcomesExpected outcome define when a patient goal has been met and assist in evaluating the extent to which the Nursing diagnosis has been resolved.e.g.Goal : The patient lung will remain clear post operatively .Expected outcomes:- The sputum will remain white- The patient will remain afebrile- The lungs will be clear to auscultation
4.Planning nursing interventions (with collaboration and consultation as needed)Nursing interventions are treatment, based upon clinical judgment and knowledge that a nurse performs to enhance patient / client outcomes.Dependent – a nursing action based on the instruction of another professional.Independent – requires no supervision.Interdependent – actions carried out by the nurse in collaboration with another health care professional.• Nursing interventions must be specifically designed to meet the identified goal.• Each intervention should be supported by a scientific rationale.
IMPLEMENTATIONWhile implementing nursing orders, the nurse continues to reassess the client at every contact, gathering data about the client’s responses to nursing activities and about any new problems that may develop.To implement the care plan successfully, nurses need cognitive, interpersonal, and technical skills. These skills are distinct from one another.The cognitive skills (intellectual skills) include problem solving, decision making, critical thinking, and creativity.
When implementing interventions, nurses should follow these guidelines:• Base nursing interventions on scientific knowledge, nursing research, and professional standards of care whenever possible.• Clearly understand the order to be implemented and question any that are not understood.• Adapt activities to the individual client, a client’s beliefs, values; age, health status, and environment are factors that can affect the success of a nursing action.• Implement safe care• Provide teaching, support and comfort to enhance the effectiveness of nursing care plans.• Be holistic; view the client as a whole.• Respect the dignity of the client and enhance the client’s self- esteem• Encourage client to participate actively in implementing the nursing interventions.
Documenting Nursing Activities,• the nurse complete the implementing phase by recording the interventions and client responses in the nursing process notes.• The nurse may record routine or recurring activities such as mouth care in the client record at the end of shift, while some actions recorded in special worksheets according to agency policy.• Immediate recording helps safeguard the client to prevent double actions.
EVALUATION• The last phase of the nursing process, follows implementation of the plan of care, it’s the judgment of the effectiveness of nursing care to meet client goals based on the client’s behavioral responses.When determining whether a goal has been achieved, the nurse can draw one of the three possible conclusions: – The goal was met, that is the client response is the same as the desired outcomes. – The goal was partially met, that is either a short term goal was achieved but the long term was not, or the desired outcome was only partially attained. – The goal was not met.
“When goals have been partially met or when goals have not been met, two conclusions may be drawn: • The care plan may need to be revised, since the problem is only partially resolvedOR • The care plan does not need revision, because the client merely needs more time to achieve the previously established goals. • So the nurse must reassess why the goals are not being partially achieved.
APPENDECTOMYClient assessment database:Activity & rest: May report MalaiseCirculation: may exhibit TachycardiaElimination: May report Constipation of recent onset of diarrhea Abdominal distension, tenderness/ rebound tenderness, rigidity, decreasedMay exhibit or absent bowel sound .Food/fluid : may report Anorexia , nausea , VomitingPain/ Discomfort : May report Abdominal pain around the epigastrium and umbilicus, which may have an insidious onset and become increasingly severe (RLQ) at mc Burney’s point.Respiration: May exhibit Tachypnea, Shallow respirations
Diagnostic studies:• CBC: WBC s are often elevated, neutrophil count elevated• Abdominal CT, USG, Abdominal radiographs.Nursing Priorities:• Prevent complication• Promote comfort• Provide information about surgical procedure/prognosis, treatment needs, and potential complications.
Nursing Diagnosis: Risk For infectionOutcome criteria: wound healingActions/ Interventions RationaleIndependentPractice / instruct in good hand Reduces the risk of spread of bacteriawashing and aseptic wound care.Encourage and provide perineal careInspect Incision and dressings. Note Provides for early detection ofcharacteristics of drainage from developing infectious process.wound/drains, presence of erythemaMonitor vital signs . Note if fever, Suggestive of presence of infection/chills diaphoresis, changes in developing sepsis, abscess, peritonitismentation , report if increaseabdominal pain.CollaborativeAdminister antibiotic as appropriate Antibiotics given before appendectomy primarily for prophylaxis of wound infection and continued post operatively
Nursing Diagnosis: Risk For deficient fluid volumeOutcome criteria: hydration(Maintain adequate fluid balance as evidenced by moist mucous membrane, good skin turgor, stable vital signs, adequate urine output.Action/Intervention RationaleIndependentMonitor Vital signs Variations help identify intra vascular volume.Inspect mucous membrane ; assess skin Indicators adequacy of peripheralturgor and capillary refill. circulation and cellular hydration.Monitor I&O; note urine color Decreasing output concentrated urineconcentration, specific gravity. with increasing specific gravity suggests dehydration.Auscultate bowel sounds. Note passing Indicators return of peristalsis , readinessflatus , bowel movement to begin oral intakeProvide clear liquids in small amounts Reduces the risk of gastric irritation/,when oral resumed vomiting and fluid lossGive frequent mouth care with special Dehydration results in drying & painfulcare to protect lips cracking of lips and mouth
CollaborativeMaintain gastric / intestinal suction as To decompress the bowel, promoteindicated intestinal rest, and prevent vomitingAdminister IV fluids and electrolytes The peritoneum reacts to irritation/ infection by producing large amount of intestinal fluid , possibly reducing circulating blood volume, resulting in dehydration and relative electrolyte imbalances.Nursing Diagnosis: Acute pain related to inflammation / presence of surgicalincision.Outcome criteria: report pain relieved / minimizedActions/ interventions RationalePain managementIndependentAssess pain, noting location, Use full in monitoring effectiveness ofcharacteristics, severity (0-10 scale) medication, progression of healing. Changes in characteristics of pain may indicate developing abscess/peritonitis require medical evaluation and interventions
Provide accurate , honest information Being informed about progress ofto client situation provides emotional support, helping to decrease anxietyKeep at rest in semi fowlers position Relieving abdominal tension, which is accentuated by supine position.Encourage early ambulation Promotes normalization of organ functionProvide diversional activities. Refocuses attention , promotes relaxation.CollaborativeKeep NPO/Maintain NG suction initially Decreases the discomfort of early intestinal peristalsis and gastric irritation/vomitingAdminister analgesics as indicated Relief of pain facilitates cooperation with other therapeutic interventions e.g. ambulation , pulmonary toilet.
Nursing Diagnosis: Deficient Knowledge ( regarding condition, prognosis,treatment, self care, and discharge needs.)Outcome criteria: Verbalization of understandingsIndependentTeaching disease processIdentify symptoms requiring medical Prompt interventions reduces risk ofevaluation e.g. increasing pain, edema/ serious complications e.g. delayederythema around wound , presence of wound healing, peritonitisdrainage, feverReview post operative activity Provides information client to plan forrestrictions, e.g. heavy lifting, exercise, return usual routines.sports, drivingEncourage progressive activities as Prevent fatigue, promotes healing andtolerated with periodic rest periods well beingDiscuss the care of incision , including Understanding promotes cooperationdressing changes, bathing restrictions, with therapeutic regimen, enhancingand return to physician. healing and recovery process.