Nursingprocess
Nursing process is to provide a systematic method for nurses to plan and implement client care to achieve desired outcomes.
Importantof nursing process
Systematically collect patient data
Clearly identify patient strengths and actual and potential problems (diagnosing)
Develop a holistic plan of individualized care that specifies the desired patient goals and related outcomes and the nursing interventions most likely to assist the patient to meet those expected outcomes (planning)
Execute the plan of care (implementing)
Evaluate the effectiveness of plan of care in terms of patient goal achievement (evaluating)
Stepsof the Nursing Process
Assessment
Diagnosis (nursing) or analysis
Planning
Implementation
Evaluation
Characteristicsof the nursing process
Systematic
Dynamic
Interpersonal
Outcome oriented
Assessment
Assessment is the first step of the nursing process when client information is gathered and examined in preparation for the second step diagnosis.
Assessmentphase include the following activities:
1.Collecting data: Gathering information about the patient or client
The following summarizes the resources for gathering data
Patient/ client (primary source)
Family/ significant others
Nursing records
Medical records
Record of diagnostic studies.
Patient interview.
Physicalexamination By
Inspection: Examination by careful and critical observation.
Auscultation: Examination by listening with stethoscope.
Palpation: Examination by touching and felling.
Percussion: Examination by touching, tapping, and listening.
Validating data: Making sure that you know which data is actually fact and which data are questionable.
Organizing Data; clustering the data into groups of information that will help you to identify patterns of health or disease.
Identifying Patterns: making an initial impression about patterns of information, and gathering additional data impression about patterns of information, and gathering additional data to fill in the gaps to describe more clearly what the data mean.
Communicating /Recording data: reporting significant data to expedite treatment, and completing the data base
Preparingfor data collection
Establishing Assessment Priorities
Before beginning to collect data on any patient, the nurse should have a good sense of the type of data needed to develop a satisfactory plan of care. For example, pediatric nurses are careful to establish the developmental age and milestones obtained by children admitted to a pediatric unit.
Another example, A school nurse who suspects child abuse pays careful attention to the child's statement about living conditions at home and relationships with family members and caregivers.
Health Orientation
Assess patient knowledge and believe about illness and wellness
Developmental stage
Nursing assessments are modified according to the developmental needs of patients. For example, when assessing an infant, special attention is given to weight gain and physical growth, feeding and elimination problems, sleep-activity cycles, and the parenting skills of caregivers.
Needfor nursing
When assessing patients is to gather only data that are helpful when planning and delivering care. It would be inappropriate, for example, to collect a detailed sexual history on a patient admitted to the hospital overnight after a slight concussion.
Practical considerations
Data already collected from the patient and in the patient record should not be repeatedly sought from the patient unless there is a need to validate them.
Data Collection
Types of data
Subjectiveand objective
Subjective
Subjective data are information perceived only by the affected person; these data cannot be perceived or verified by another person. Examples of subjective data are feeling nervous, nauseated, or chilly and experiencing pain.
Objective
Objective data are observable and measurable data that can be seen, heard, or felt by someone other than the person experiencing them. Example, elevated body temperature
Characteristicsof data
Complete
As much as possible, all the patient data needed to understand a patient health problem and develop a plan of care to maximize health and well-being should be identified. For example, knowing that a patient has lost weight is not fully meaningful until the nurse discovers (1) if the weight loss was intentional or unintentional, (2) If it was related to a change in eating or exercise patterns. (3) how the patient views and is responding to the weight loss.
Accurate
Both the patient and the nurse may intentionally or unintentionally misrepresent patient information. For example, a patient who values being thin may describe a weight gain of several pounds as the onset of obesity.
Relevant
NursingDiagnosis
Nursing Diagnosis: An actual or potential health problem that is focuses upon the human response of an individual or group, and that nurses are responsible and accountable for identifying and treating independently.
WritingDiagnostic Statements for Actual Nursing Diagnoses
When you write a diagnostic statement for actual nursing diagnoses, you should use the PES (problem, etiology, signs and symptoms) system to describe the diagnosis. That is, you write a three-part statement, which includes the following:
1.The problem(P)
2.Its cause or etiology(E)
3.The signs and symptoms(defining characteristics) that are evident in the patient(S)
Rule: to write a diagnostic statement for an actual nursing diagnoses, link the problem and its etiology by using‘’’related to’’. Add ‘’ as manifested by’’ or ‘’as evidenced by
Diagnostic statement: Ineffective Airway Clearance related to weak cough and incisional pain, as manifested by poor or no cough effort and statements that incision hurts too much when he coughs.
WritingDiagnostic Statements for Potential Problem
Potential and Possible Nursing Diagnosis (two-part statement):
Problem +Etiology
Potential Ineffective Airway Clearance Related to Smoking
Planning
Establishthe goals, interventions and outcomes
GeneralGuidelines for Setting Priorities
Take care of immediate life-threateningissues.
Safety issues.
Patient-identified issues.
Nurse-identified priorities based on theoverall picture, the patient as a whole person, and availability of time andresources.
NurseIdentified Priorities
Composite of all patient’s strengths and health concerns.
Moral and ethical issues.
Time, resources, and setting.
Hierarchy of needs.
Interdisciplinary planning.
Implementation
Implementation refers to the action phase of the nursing process in which nursing care is provided. It is the actual initiation of the plan and recording of nursing actions. Its purpose is to provide technical and therapeutic nursing care required to help the client achieve an optimal level of health.
Evaluation
Evaluation, the sixth phase of the nursing process, follows implementation of the plan of care. Evaluation is defined as the judgment of the effectiveness of nursing care to meet client goals based on the client's behavioral responses. This phase involves a thorough, systematic review of the effectiveness of nursing interventions and a determination of client goal achievement.