The Nursing Process


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The Nursing Process

  2. 2. Objectives: <ul><li>At the end of 3 hours, the student should be able to: </li></ul><ul><li>Define nursing process </li></ul><ul><li>State importance of nursing process in nursing profession </li></ul><ul><li>State and define interrelated phases of nursing process </li></ul><ul><li>Be able to identify subjective and objective data gathered </li></ul><ul><li>Be able to formulate nursing diagnosis according to NANDA using the nursing process </li></ul>
  3. 3. NURSING PROCESS <ul><li>The cornerstone of the nursing profession </li></ul><ul><li>Includes: ADOPIE – Assessment, Diagnosis, Outcome identification, Planning, Implementation and Evaluation </li></ul>
  4. 4. <ul><li>NURSING PROCESS IS: </li></ul><ul><li>ORGANIZED & SYSTEMATIC </li></ul><ul><ul><li>6 sequential and interrelated steps </li></ul></ul><ul><li>HUMANISTIC </li></ul><ul><ul><li>The plan of care is developed and implemented with great consideration to the unique needs and concerns of the individual client </li></ul></ul><ul><ul><li>It is individualized </li></ul></ul><ul><ul><li>It involves aspect of human dignity </li></ul></ul>
  5. 5. <ul><li>EFFICIENT </li></ul><ul><ul><li>Relevant to the needs of the client </li></ul></ul><ul><ul><li>Promotes client satisfaction and progress </li></ul></ul><ul><li>EFFECTIVE </li></ul><ul><ul><li>Utilizes resources wisely in terms of human, time, cost resources </li></ul></ul>
  6. 6. <ul><li>THE HEART OF THE NURSING PROCESS </li></ul><ul><ul><li>Knowledge – broad, varied </li></ul></ul><ul><ul><li>Skills </li></ul></ul>K – knowledge; S – skills; C - caring A. MANUAL B. INTELLECTUAL C. INTERPERSONAL TECHNICAL SKILLS <ul><li>CRITICAL THINKING </li></ul><ul><li>careful deliberate, goal-directed – to solve problems/make decisions </li></ul><ul><li>check for evidence </li></ul><ul><li>Keeping an open mind </li></ul><ul><li>Avoid jumping into conclusions </li></ul>TO ESTABLISH POSITIVE INTERPERSONAL RELATIONSHIPS, WITH CLIENT, CO-WORKERS (REQUIRES COMMUNICATION SKILLS)
  7. 7. <ul><li>CARING – WILLINGNESS AND ABILITY TO CARE </li></ul><ul><li>UNDERSTANDING OURSELVES </li></ul><ul><li>To be able to understand others </li></ul><ul><li>To be more objective / non-judgmental </li></ul><ul><li>Requires ability to listen empathetically </li></ul><ul><li>Listen with intent </li></ul><ul><li>Enter into another’s way of thinking and viewing the world </li></ul><ul><li>Connecting with another’s feelings and perception </li></ul>
  8. 8. <ul><li>Identify with another’s struggles, frustrations and desires </li></ul><ul><li>Being able to detach from feelings and returning to our own frame of reference </li></ul><ul><li>WILLINGNESS TO CARE </li></ul><ul><li>Keep the focus on what is best for the patient </li></ul><ul><li>Respect beliefs / values of others </li></ul><ul><li>Stay involved </li></ul><ul><li>Maintain a healthy lifestyle </li></ul>
  9. 9. <ul><li>CARING BEHAVIORS </li></ul><ul><li>Inspiring someone / instilling hope and faith </li></ul><ul><li>Demonstrating patience, compassion and willingness to persevere </li></ul><ul><li>Offering companionship </li></ul><ul><li>Helping someone stay in touch with positive aspect of the life </li></ul><ul><li>Demonstrating thoughtfulness </li></ul><ul><li>Bending the rules when it really counts </li></ul><ul><li>Doing the little things </li></ul><ul><li>Keeping someone informed </li></ul><ul><li>Showing your human side by sharing “stories” </li></ul>
  10. 11. ASSESSMENT <ul><li>Collecting, validating, organizing and recording data about the client’s health status (individual, family, community) </li></ul><ul><li>PURPOSE: To establish a data base </li></ul><ul><li>ACTIVITIES: </li></ul><ul><ul><li>COLLECTING DATA: </li></ul></ul><ul><ul><li>Gathering information. </li></ul></ul><ul><ul><li>Include the physical, psychological, emotional, socio-cultural, and spiritual factors </li></ul></ul>
  11. 12. <ul><ul><li>TYPES OF DATA: </li></ul></ul><ul><ul><li>SUBJECTIVE DATA (SYMPTOMS) </li></ul></ul><ul><ul><li>- experienced by the client </li></ul></ul><ul><ul><li>- EX. Pain, dizziness, </li></ul></ul><ul><ul><li>OBJECTIVE DATA (SIGNS) </li></ul></ul><ul><ul><li>- those that can be observed and measured </li></ul></ul><ul><ul><li>- EX. Pallor, diaphoresis, blood pressure, reddish urine, body temp. </li></ul></ul><ul><ul><li>METHODS OF COLLECTING DATA: </li></ul></ul><ul><ul><li>INTERVIEW. Planned purposeful conversation </li></ul></ul><ul><ul><li>OBSERVATION. (use of senses, lab results interpretation, physical examination) </li></ul></ul>
  12. 13. <ul><ul><li>SOURCE OF DATA: </li></ul></ul><ul><ul><li>PRIMARY: Patient/ Client </li></ul></ul><ul><ul><li>SECONDARY: Family members, S.O., patient’s chart/record, health team members, related literature </li></ul></ul><ul><ul><li>VERIFYING / VALIDATING DATA. Make sure your information is accurate. </li></ul></ul><ul><ul><li>ORGANIZING DATA. Cluster facts into groups of information (subjective and objective information) </li></ul></ul>
  13. 14. Let’s review! <ul><li>SUBJECTIVE OR OBJECTIVE??? </li></ul><ul><li>Headache </li></ul><ul><li>Temp 37.9 C </li></ul><ul><li>RR: 20 bpm </li></ul><ul><li>Toothache </li></ul><ul><li>Client states, “ I haven’t moved my bowel since Friday (3 days).” </li></ul><ul><li>Cyanosis </li></ul><ul><li>Urine output: 60ml </li></ul><ul><li>Ate only half of the food served </li></ul>
  14. 15. DIAGNOSING <ul><li>Is a process which results to a diagnostic statement or nursing diagnosis </li></ul><ul><li>The clinical act of identifying problems </li></ul><ul><li>It means to analyze assessment and derive meaning from this analysis. </li></ul><ul><li>PURPOSE: To identify the client’s health care needs and to prepare diagnostic statements </li></ul>
  15. 16. <ul><li>NURSING DIAGNOSIS </li></ul><ul><ul><li>Is a statement of client’s potential or actual alteration of health status. </li></ul></ul><ul><ul><li>Uses critical thinking and skills analysis </li></ul></ul><ul><ul><li>Uses PRS/PES format </li></ul></ul><ul><ul><ul><li>P- PROBLEM </li></ul></ul></ul><ul><ul><ul><li>R-RELATED TO FACTORS </li></ul></ul></ul><ul><ul><ul><li>S- SIGNS AND SYMPTOMS </li></ul></ul></ul><ul><ul><ul><li>P-PROBLEM </li></ul></ul></ul><ul><ul><ul><li>E-ETIOLOGY </li></ul></ul></ul><ul><ul><ul><li>S-SIGNS AND SYMPTOMS </li></ul></ul></ul>
  16. 17. <ul><li>ACTIVITIES DURING DIAGNOSING: </li></ul><ul><ul><li>Organize cluster or group data. Ex. Pallor, dyspnea, weakness, fatigue – pertain to problems with oxygenation </li></ul></ul><ul><ul><li>Compare data against standards (accepted norms). Ex. Amber, clear urine VS cloudy urine or tea colored urine. </li></ul></ul><ul><ul><li>Analyze data after comparing with standards </li></ul></ul><ul><ul><li>Identify gaps and inconsistencies in data </li></ul></ul><ul><ul><li>Determine the client’s health problems, health risks, strengths </li></ul></ul><ul><ul><li>Formulate Nursing Diagnosis statements </li></ul></ul>
  17. 18. <ul><li>Examples of Nursing Diagnoses: </li></ul><ul><ul><li>Anxiety related to insufficient knowledge regarding surgical experience </li></ul></ul><ul><ul><li>Ineffective airway clearance related to tracheobronchial infection as manifested by weak cough, adventitious breath sounds, and copious green sputum production. </li></ul></ul>
  18. 19. Types of Nsg. Diagnoses: <ul><li>ACTUAL NURSING DIAGNOSIS </li></ul><ul><ul><li>A judgment about the client’s response to a health problem that is present at the time of nursing assessment </li></ul></ul><ul><ul><li>Based on the presence of signs and symptoms </li></ul></ul><ul><ul><li>Ex. - ALTERED COMFORT: PAIN </li></ul></ul><ul><ul><li>- PAIN: SEVERE HEADACHE RELATED TO FEAR OF ADDICTION TO NARCOTICS </li></ul></ul><ul><ul><li> </li></ul></ul>
  19. 20. <ul><li>RISK NURSING DIAGNOSIS </li></ul><ul><ul><li>A clinical judgment that a problem does not exist, but the presence of risk factors indicates that a problem is likely to develop </li></ul></ul><ul><ul><li>Ex. RISK FOR INFECTION </li></ul></ul><ul><ul><li>RISK FOR CONSTIPATION </li></ul></ul>
  20. 21. <ul><li>POSSIBLE NURSING DIAGNOSIS </li></ul><ul><ul><li>Is one in which evidence about a health problem is unclear or the causative factors are unknown. </li></ul></ul><ul><ul><li>Requires more data either to support or to refute it. </li></ul></ul><ul><ul><li>Ex. Possible Social Isolation related to unknown etiology </li></ul></ul>
  21. 22. COMPONENTS of a NANDA NURSING DIAGNOSIS <ul><li>PROBLEM (diagnostic label) and DEFINITION </li></ul><ul><ul><li>Describes the client’s health status clearly and concisely in a few words </li></ul></ul><ul><ul><li>Qualifiers: </li></ul></ul><ul><ul><ul><li>Deficient – inadequate in amount, quality, or degree; not sufficient </li></ul></ul></ul><ul><ul><ul><li>Impaired – made worse, weakened, damaged </li></ul></ul></ul>
  22. 23. <ul><ul><ul><li>Ineffective – not producing the desired effect </li></ul></ul></ul><ul><li>ETIOLOGY (related factors & risk factors) </li></ul><ul><ul><li>Identifies one or more probable causes of health problem </li></ul></ul><ul><ul><li>Gives direction to what health needs to attend to. </li></ul></ul>
  23. 24. <ul><li>DEFINING CHARACTERISTICS </li></ul><ul><ul><li>A cluster of signs and symptoms that indicate the presence of a particular diagnostic label </li></ul></ul><ul><ul><li>ACTUAL DX: signs and symptoms </li></ul></ul><ul><ul><li>HIGH RISK/ RISK: factors that cause the client to be more vulnerable to the problem </li></ul></ul>
  24. 25. <ul><ul><li>Ex. ACTIVITY INTOLERANCE RELATED TO IMMOBILITY as manifested by verbal reports of fatigue or weakness during leg exercises </li></ul></ul><ul><li>Formulating statements: </li></ul><ul><ul><li>Problem – Etiology format </li></ul></ul><ul><ul><li>Problem – etiology – signs and symptoms format </li></ul></ul>
  25. 26. OUTCOME IDENTIFICATION <ul><li>Refers to formulating and documenting measurable, realistic, client – focused goals. </li></ul><ul><li>Provides the basis for evaluating nursing diagnosis and interventions. </li></ul>
  26. 27. <ul><li>ACTIVITIES INCLUDE: </li></ul><ul><ul><li>ESTABLISH PRIORITIES. </li></ul></ul><ul><ul><ul><li>Life-threatening should be given highest priority </li></ul></ul></ul><ul><ul><ul><li>ABC’s (airway, breathing, circulation) </li></ul></ul></ul><ul><ul><ul><li>Maslow’s hierarchy of needs (physiologic needs over psychosocial) </li></ul></ul></ul><ul><ul><ul><li>Unstable clients vs. clients with stable conditions </li></ul></ul></ul><ul><ul><ul><li>Actual problems vs. potential concerns </li></ul></ul></ul>
  27. 28. <ul><ul><li>ESTABLISH GOALS & OUTCOME CRITERIA </li></ul></ul><ul><ul><ul><li>GOALS: broad statements </li></ul></ul></ul><ul><ul><ul><ul><li>SHORT-TERM GOAL (STG) </li></ul></ul></ul></ul><ul><ul><ul><ul><li>LONG-TERM GOAL (LTG) </li></ul></ul></ul></ul><ul><ul><ul><li>OUTCOME CRITERIA: specific, measurable, realistic statements of goal attainment </li></ul></ul></ul><ul><ul><ul><ul><li>S – M – A – R – T </li></ul></ul></ul></ul><ul><ul><ul><ul><li>Specific, measurable, attainable, time-framed </li></ul></ul></ul></ul>
  28. 29. <ul><li>Ex. </li></ul><ul><li>GOAL: The client will be able to improve mobility and the ability to bear weight on left leg </li></ul><ul><li>DESIRED OUTCOMES: </li></ul><ul><ul><li>By the end of the week, client will be able to ambulate with crutches </li></ul></ul><ul><ul><li>By end of the month, client will be able to stand without assistance </li></ul></ul>
  29. 30. PLANNING <ul><li>Involves determining beforehand the strategies or course of actions to be taken before implementation of nursing care. </li></ul><ul><li>Involve the client and his family </li></ul><ul><li>Begins with the first client contact until client is discharged from the facility </li></ul><ul><li>Activities: </li></ul><ul><ul><li>Plan nursing interventions (also called nursing orders); may be dependent, independent, interdependent. </li></ul></ul>
  30. 31. <ul><ul><li>Write nursing care plan </li></ul></ul><ul><ul><li>a written summary of the care that a client is to receive. </li></ul></ul><ul><ul><li>the “blueprint” of the nursing process </li></ul></ul><ul><ul><li>the plan of care is a step-by-step process evidenced by the following: </li></ul></ul><ul><ul><ul><li>Sufficient data are collected to support nsg. Diagnoses </li></ul></ul></ul><ul><ul><ul><li>At least one goal must be stated for each nsg. dx </li></ul></ul></ul>
  31. 32. <ul><ul><ul><li>Outcome criteria must be identified for each goal </li></ul></ul></ul><ul><ul><ul><li>Each intervention should be supported by scientific rationale </li></ul></ul></ul><ul><ul><ul><li>Evaluation. To assess whether goals are met or unmet. </li></ul></ul></ul>
  32. 33. <ul><li>TYPES OF PLANNING </li></ul><ul><li>Initial planning </li></ul><ul><ul><li>Starts upon initial assessment/admission </li></ul></ul><ul><li>Ongoing planning </li></ul><ul><ul><li>Done by all nurses who work with the client to: </li></ul></ul><ul><ul><ul><li>Determine change in the health status. </li></ul></ul></ul><ul><ul><ul><li>Set priorities for the client’s care during the shift. </li></ul></ul></ul><ul><ul><ul><li>Decide which problems to focus on during the shift. </li></ul></ul></ul><ul><ul><ul><li>Plan nursing activities during the shift. </li></ul></ul></ul>
  33. 34. <ul><li>Discharge planning </li></ul><ul><ul><li>The process of anticipating and planning for needs after discharge. </li></ul></ul><ul><ul><li>Includes: ff. up care, referrals, medications, diet modifications, significant other/care provider, health teachings, which signs and symptoms to watch for. </li></ul></ul>
  34. 35. IMPLEMENTATION <ul><li>Putting the nursing care plan into action </li></ul><ul><li>Purpose: to carry out planned nursing interventions to help the client attain goals and achieve optimal level of health </li></ul><ul><li>Activities: </li></ul><ul><ul><li>Set priorities. To determine the order in which nsg interventions are carried out. </li></ul></ul><ul><ul><li>Perform nsg. Interventions </li></ul></ul><ul><ul><li>Record actions. SOMETHING THAT IS NOT WRITTEN IS CONSIDERED NOT DONE!!! </li></ul></ul>
  35. 36. EVALUATION <ul><li>Is assessing the client’s response to nsg intervention and then comparing the response to predetermined standards or outcome criteria. </li></ul><ul><li>Purpose: </li></ul><ul><ul><li>To appraise the extent to which goals and outcome criteria of nsg care have been achieved </li></ul></ul>
  36. 37. <ul><li>Activities: </li></ul><ul><ul><li>Collect data about the client’s response </li></ul></ul><ul><ul><li>Compare response to goals and outcome criteria </li></ul></ul><ul><ul><li>Assess whether goals are met (partially/completely) or unmet </li></ul></ul><ul><ul><li>Analyze reasons for outcomes </li></ul></ul><ul><ul><li>Modify care plan as needed </li></ul></ul>
  37. 38. <ul><li>BENEFITS OF THE NURSING PROCESS FOR THE CLIENT </li></ul><ul><li>Quality client care. It meets standards of care. </li></ul><ul><li>Continuity of care. </li></ul><ul><li>Participation by the clients in their health care. </li></ul>
  38. 39. <ul><li>BENEFITS OF THE NURSING PROCESS FOR THE NURSE </li></ul><ul><li>Consistent and systematic nursing education </li></ul><ul><li>Job satisfaction </li></ul><ul><li>Professional growth </li></ul><ul><li>Avoidance of legal action </li></ul><ul><li>Meeting professional nsg standards </li></ul><ul><li>Meeting standards of accredited hospitals </li></ul>