UNIT 3: NURSING PROCESS

Definition and purpose of nursing process Steps of nursing process

Nursing assessment
Collection and organization of data A critical thinking approach to assessment Types of data Sources of data Methods of data collection-history taking, physical examination, measurement, diagnostic, laboratory data etc. Data documentation

NURSING PROCESS
The nursing process is a professional nurses approach for selecting, organizing, and delivering appropriate nursing care to a patient. Characteristics:
Within legal scope of practice Planned Based on knowledge research based Patient centered Goal directed Prioritized Dynamic

Purpose of nursing process

(1) Assess the patient to determine the need for nursing care; (2) determine nursing diagnoses for actual and potential health problems; (3) identify expected outcomes and plan care; (4) implement the care; and (5) evaluate the results.

Steps of nursing process

Assessment
Data collection & verification Data analysis

Diagnosis
Analysis of data

Planning
Goals prioritized Set expected outcomes Prescribe nursing interventions

Implementation
Interventions

Evaluation
Goals met? Reassessment

NURSING ASSESSMENT

 It is the deliberate and systematic collection of data to determine a patients current and past health status, functional status, and present and past coping patterns

Key Activities
Collecting data Validating data Organizing (clustering) data Identifying patterns Testing first impressions Reporting & recording data

 PURPOSE: To establish a data base (all the information about the client):
nursing health history physical assessment the physicians history & physical examination results of laboratory & diagnostic tests material from other health personnel

- To establish baseline information on the client - To determine the clients normal function - To determine the clients risk for dysfunction - To determine the clients strengths - To provide data for the diagnosis phase

FOUR Types of Assessment Initial assessment assessment performed within a specified time on admission Ex: nursing admission assessment Problem-focused assessment use to determine status of a specific problem identified in an earlier assessment Ex: problem on urination-assess on fluid intake & urine output hourly Emergency assessment rapid assessment done during any physiologic/physiologic crisis of the client to identify life threatening problems. Ex: assessment of a clients airway, breathing status & circulation after a cardiac arrest. Time-lapsed assessment reassessment of clients functional health pattern done several months after initial assessment to compare the clients current status to baseline data previously obtained.

DATA COLLECTION
Types of Data Subjective data
also referred to as Symptom/Covert data Information from the clients point of view or are described by the person experiencing it. Information supplied by family members, significant others; other health professionals are considered subjective data. Example: pain, dizziness, ringing of ears/Tinnitus

Objective data
also referred to as Sign/Overt data Those that can be detected observed or measured/tested using accepted standard or norm. Example: pallor, diaphoresis, BP=150/100, yellow discoloration of skin

Sources of data: Primary source data directly gathered from the client using interview and physical examination. Secondary source data gathered from clients family members, significant others, clients medical records/chart, other members of health team, and related care literature/journals. Patient Family and significant others Health care team Medical records Other records and the literature

Methods of data collection

1. interview and health history: A planned, purposeful conversation/communication with the client to get information, identify problems, evaluate change, to teach, or to provide support or counseling. it is used while taking the nursing history of a client 2. Physical examination: An investigation of the body to determine its state of health. Techniques used are: inspection, palpation, percussion, auscultation and smell should be conducted systematically:
Cephalocaudal approach head-to-toe assessment Body System approach examine all the body system Review of System approach examine only particular area affected

 Observation of patients behavior:

Use to gather data by using the 5 senses and instruments. Throughout an interview and physical examination Helps to obtain objective data

Diagnostic and laboratory data:

To identify or verify alterations questioned or identified during the nursing helath history and physical examination

DATA VALIDATION
Comparing data with another source to avoid making incorrect inferences. Purposes of data validation ensure that data collection is complete ensure that objective and subjective data agree obtain additional data that may have been overlooked avoid jumping to conclusion differentiate cues and inferences

Examples of cues and inferences Example 1 Group of cues client has - Blurry vision or visual defect - Headache - Tingling and numbness in extremities - Dizziness Possible inferences - Client has a brain tumor - Client is having warning signals of a stroke - Client may be diabetic - Client is anxious

ORGANIZING/CLUSTERING DATA
Uses a written or computerized format that organizes assessment data systematically. Maslows basic needs Body System Model

DATA ANALYSIS & INTERPRETATION

Recognizing patterns and trends, compare data against standard and identify significant cues to reach conclusion. Standard/norm are generally accepted measurements, model, pattern:
Ex: Normal vital signs, standard Weight and Height, normal laboratory/diagnostic values, normal growth and development pattern

DATA DOCUMENTATION
nurse records all data collected about the clients health status Should be timely thorough and accurate data are recorded in a factual manner not as interpreted by the nurse Record subjective data in clients word; restating in other words what client says might change its original meaning.

HISTORY TAKING
Collection of information about the effect of the clients illness on daily functioning and ability to cope with the stressor (the human response) Subjective data
May be called covert data Not measurable or observable Obtained from client (primary source), significant others, or health professionals (secondary sources). For example, the client states, I have a headache

Objective data
May be called overt data Can be detected by someone other than the client Includes measurable and observable client behavior For example, a blood pressure reading of 190/110 mmHg.

PURPOSE: To find out the patients condition To support for nursing care To support for diagnosis, treatment and management TECHNIQUES: Be dressed neatly and culturally acceptable Establish rapport, greet warmly, be friendly and congenial, make patient feel secure and free to talk Maintain privacy Quiet, calm and separate room Seating arrangement Show respect Explain the purpose of interview Indicate approximate among of time required Conversation at patients level of understanding

Maintain eye contact Be attentive listener Do not interrupt Observe non verbal clues Use history taking format Keep data obtained in interview confidential

COMPONENTS OF HEALTH HISTORY History.doc

INTERVIEW
The purpose of an interview is to gather and provide information, identify problems of concerns, and provide teaching and support. The goals of an interview are to develop a rapport with the client and to collect data An interview has 3 major stages:
Opening: purpose is to establish rapport by creating goodwill and trust; this is often achieved through a self introduction, nonverbal gestures (a handshake), and small talk about the weather, local sports team, or recent current event; the purpose of the interview is also explained to the client at this time. Body: during this phase, the client responds to open and closedended questions asked by the nurse. Closing: either the client or the nurse may terminate the interview, it is important fro the nurse to try to maintain the rapport and trust that was developed thus far during the interview process.

 Types of questions
Closed questions used in directive interview
Re____ short factual answers; e.g. Do you have pain? Answers usually reveal limited amounts of information Useful with clients who are highly stressed and/or have difficulty communicating

Open-ended questions used in nondirective interview

Encourage clients to express and clarify their thoughts and feelings; e.g. How have you been sleeping lately? Specify the broad area to be discussed and invite longer answers Useful at the start of an interview or to change the subject

Leading questions
Direct the clients answer; e.g. You dont have any questions about your medications, do you? Suggests what answer is expected Can result in client giving inaccurate data to please the nurse Can limit client choice of topic for discussion

CRITICAL THINKING
Ability to thoughtful observations, judgments, and choices. Both a process and a set of skills. It is active, organized, cognitive process used to carefully examine ones thinking and the thinking of others. It involves recognizing that an issue exists, analyzing information related to the issue, evaluating information and drawing conclusions. Skills: interpretation, analysis, inference, evaluation, explanation, self-regulation.

Aspects of critical thinking: Reflection, language, intuition Levels of critical thinking: Basic critical thinking Complex critical thinking Commitment Critical thinking competencies: General: scientific method, problem solving, decision making Specific: diagnostic reasoning, clinical inferences and clinical decision making In nursing: nursing process.

Attitudes for critical thinking Confidence Independence Fairness Responsibility Risk taking Discipline Perseverance Creativity Curiosity Integrity humiliy

Standards for critical thinking Intellectual standard Clear, precise, specific, accurate, relevant, plausible, consistent, logical, deep, broad, complete, significant, adequate, fair Professional standards Ethical criteria for nursing judgment Criteria for evaluation Professional responsibility

NURSING DIAGNOSIS
Definition Critical thinking and the nursing diagnostic process- analysis and interpretation of data, identification of the clients needs, formulation of the nursing diagnosis Nursing diagnosis statement- eg. Nanda. Diagnosis error Difference between nursing diagnosis and medical diagnosis Advantages and limitations of nursing diagnosis

 A nursing diagnosis is a clinical judgement about individual, family, or community responses to actual and potential health problems or life processes. (NANDA International 2005) a clients actual or potential health problems that a nurse can identify and for which she can order nursing interventions to maintain the health status, to reduce, eliminate or prevent alterations/changes. A medical diagnosis is the identification of a disease condition based on a specific evaluation of physical signs, symptoms, history, diagnostic tests, and procedures. A collaborative problem is a physiological complication that nurses monitor to detect the onset or changes in patients status. Eg: bledding, infection, cardiac arrest.

Medical diagnosis Defines the patients health problem in relation to the pathological condition It usually remains the same through out his illness It is treatable by the physician within the scope of medical practice

Nursing diagnosis Focuses on the patients response to the pathological condition It varies with the same patient with his changing condition Treatable within the scope of nursing practice.

Critical thinking and nursing diagnosis: It uses the critical-thinking skills analysis and synthesis in order to identify client strengths & health problems that can be resolves/prevented by collaborative and independent nursing interventions.
Analysis separation into components or the breaking down of the whole into its parts. Synthesis the putting together of parts into whole

Purpose: Provides basis for selection of nursing interventions to achieve outcomes for which nurse is accountable Leads to the development of an individualized plan of care so that patient and family adapt well to changes resulting from health problem.

Activities during diagnosis: Compare data against standards Cluster or group data Data analysis after comparing with standards Identify gaps and inconsistencies in data Determine the clients health problems, health risks, strengths Formulate Nursing Diagnosis prioritize nursing diagnosis based on what problem endangers the clients life

Types of nursing diagnosis

1. Actual Nursing Diagnosis a client problem that is present at the time of the nursing assessment. It is based on the presence of signs and symptoms. Examples: Imbalanced Nutrition: Less than body requirements r/t decreased appetite nausea. Disturbed Sleep Pattern r/t cough, fever and pain. 2. Potential Nursing diagnosis one in which evidence about a health problem is incomplete or unclear therefore requires more data to support or reject it; or the causative factors are unknown but a problem is only considered possible to occur. Examples: Possible nutritional deficit Possible low self-esteem r/t loss job Possible altered thought processes r/t unfamiliar surroundings 3.

3. Risk Nursing diagnosis is a clinical judgment that a problem does not exist, therefore no S/S are present, but the presence of RISK FACTORS is indicates that a problem is only is likely to develop unless nurse intervene or do something about it. No subjective or objective cues are present therefore the factors that cause the client to be more vulnerable to the problem are the etiology of a risk nursing diagnosis. Examples: Risk for Impaired skin integrity (left ankle) r/t decrease peripheral circulation in diabetes. Risk for interrupted family processes r/t mothers illness & unavailability to provide child care. 4. Syndrome diagnosis: diagnosis associated with a cluster of other diagnoses. Eg. Disuse syndrome 5. Wellness diagnosis: indicates a healthy response of client. Eg: potential for enhanced spiritual wellbeing.

Characteristics of Nursing Diagnosis It states a clear and concise health problem. It is derived from existing evidences about the client. It is potentially amenable to nursing therapy. It is the basis for planning and carrying out nursing care. Components of A nursing diagnosis (PES or PE) Problem statement/diagnostic label/definition = P Etiology/related factors/causes = E Defining characteristics/signs and symptoms = S *Therefore may be written as 2-Part or a 3-Part statement.

Formula in writing nursing diagnosis (PES or PE) Actual nursing diagnosis = Patient problem + Etiology (related factor can be pathophysiolgical, situational, treatment related, and maturational) + S/S Risk Nursing diagnosis = Problem + Risk Factors Possible nursing diagnosis = Problem + Etiology Qualifiers words added to the diagnostic label/problem statement to gain additional meaning. deficient - inadequate in amount, quality, degree, insufficient, incomplete impaired made worse, weakened, damaged, reduced, deteriorated decreased lesser in size, amount, degree ineffective not producing the desired effect

Guidelines to write nursing diagnosis Write in terms of persons response rather than nursing need Use related to rather than due to or caused by to connect the two parts of statement Write the diagnosis in legally advisable terms Write the diagnosis without value judgments-the behavior of the client should not be judged by nurses personal values and attendants. Avoid reversing the part Do not include medical diagnosis in the nursing diagnosis statement State clearly and concisely Avoid including signs and symptoms of illness in the first part of the statement. Be sure that the two parts of diagnosis do not mean the same thing.

DIAGNOSTIC ERRORS
SOURCES OF ERROR: Errors in data collection Errors in interpretation and analysis Errors in data clustering Errors in the diagnostic statement

To avoid data collection errors: Review your competence with interview and physical assessment Approach assessment in steps. Complete interview before examination Review clinical assessment Be organized, have appropriate forms and examination equipments. To avoid data interpretation errors Review your database to decide if it is accurate and complete Validate the data Consider patients cultural background also

To avoid data clustering errors: Avoid premature and incorrect clustering Formulate nursing diagnosis only after grouping data Dont try to fit nursing diagnosis into signs and symtoms.. It should come from data not other way To avoid errors in diagnostic statement Word sentence in appropriate, concise and precise language Use correct terminology Use standard nursing language. NANDA DIAGNOSIS.docx

PLANNING
Establishing priorities Establishing goals and expected outcomes- goals of care, expected outcomes, guidelines for writing goals and expected outcomes Planning nursing care- purpose of care plans, care plans in various set up in health care systems Writing the nursing care plan involving the client Consulting other health care professionals as per need.

 It is the decision making step of the nursing process During this a set of diagnoses are identified, priorities are set, patient centered goals and expected outcomes are set and nursing interventions are prescribed PURPOSE: To achieve an improved level of health and functioning To maintain the patients present level of health and function To make adjustments to a reduced level of health and functioning when cure is not possible To prepare as much as possible for terminal illnesses, when the patients survival is threatened.

TYPES OF PLANNING: Initial planning: initial comprehensive plan of care at the time of admission Ongoing planning: obtain new information and evaluate clients response to care and individualize the initial care plan. Discharge planning: process of anticipating and planning for needs. ESTABLISHING PRIORITIES Involves ranking nursing diagnoses in order of importance. Allows to attend most important needs and to organize your ongoing care activities. Help to anticipate and sequence nursing interventions Mutual agreed on priorities based on urgency.

Classification of priorities: High: diagnoses if not treated will harm to patient Intermediate: non emergent, no life threatening needs of patient Low priority: needs not directly related to specific illness but may affect the patients future well being. Guidelines: Remember Maslow's hierarchy of needs Consider patients potential effect of the future problems Consider availability of time and resources. Involve the patient in priority setting Keep conditions of patient in mind as priorities change with condition of the patient.

GOALS AND EXPECTED OUTCOME: Specific statements of patient behavior or physiological responses that you set to achieve as a result of your patient care. GOAL OF CARE Specific and measurable behavior or response that reflects the patients highest possible level of wellness and independence in function. Characteristics: realistic, based on patient needs and resources, represents predicted resolution of a problem, includes evidence of improved health status or maintenance of health, contains only one patient behavior, is time-limited (short term goals and long term goals).

Significance: Gives direction to nursing intervention Serves a guide for nursing action Motivates patient as well as nurse to continue their effort Serves as a criterion to evaluate the effectiveness of nursing interventions Guidelines: Should be related to response Client centered Should address what the client will do, when and what extent it will accomplish Goals should be observable and measurable Time limited, realistic and mutual agreement

EXPECTED OUTCOMES: Specific measurable change in a patients status that you expect to occur in response to nursing care. Purpose: provides focus or direction to nursing care plan Many expected outcomes can be set for each nursing diagnosis and goal Always write expected outcomes sequentially with time frames Critical thinking in planning nursing care Clinical decisions by choosing the interventions most appropriate to patients need.

PLANNING INTERVENTION Treatment or actions based upon clinical judgment and knowledge that nurses perform to meet patients outcome. Types: Nurse initiated Physician initiated Collaborative Selection of intervention: Characteristics of the nursing diagnosis Expected outcome and goals Evidence base or proven practice guidelines for the intervention Feasibility of the intervention Acceptability of the patient Own competency

NURSING CARE PLAN Is a written guideline for coordinating nursing care, promoting continuity of care, and listing outcome criteria to be used in the evaluation of nursing care. Directs nursing care and decreases the risk of incomplete, incorrect or inaccurate care. Communicates nursing care priorities to other health care professionals. Organize information exchanged by nurses in change of shift reports. Enhances the continuity of nursing care Includes patients long term needs

Types of nursing care plans: Student care plan: useful for learning the problem solving technique, the nursing process, skills of written communication and organizational skills needed for nursing care. It is more elaborate than a care plan in a hospital or community health care agency. Concept maps: a visual representation of patients problems and interventions that show their relationships to one another.step3.jpg Critical pathways: integrated care plans for a projected length of stay or number of visits for the patients with a specific case type.Ann Intern Med 1997 Dec 127(11) 996-1005, Figure 1.ppt

CONSULTING OTHER HEALTH PROFESSIONALS Process in which you seek another health care providers help to identify ways to handle problems in patient care management or problems related to the planning and implementation of programs. Done when you identify a problem that you cannot solve using personal knowledge, skills, and resources. Steps: begins with understanding of a patients clinical problem
Making a consult Direct to appropriate professional Provide relevant information and resources about the problem Do not influence the consultant Discuss consultants finding and recommendations Incorporate recommendations into care plan

NURSING IMPLEMENTATION
Types of nursing care- independent nursing care, protocols and standing orders (eg. Governmental and organizational policies) Critical thinking in implementing nursing care plan Implementation process- reassessing the client, reviewing and revising the existing nursing care plan, organizing available resources and care deliver, implementing nursing care plan. Implementation methods-assisting with activities of daily living (self care), counseling, teaching, providing direct nursing care, infection preventive measures, correct techniques in administering nursing care and preparing a client for procedures, lifesaving measures, achieving goals of care Communicating nursing care plan

 Giving care according to the plan is implementation. Implementation process: Reassessing the patient Reviewing and revising the care plan Organizing resources:
Equipment Personnel Environment Patient

Anticipating and preventing complication Implementation skills: Cognitive skills, interpersonal skills, psychomotor skills

Direct care: Activities of daily living Instrumental activities of daily living Physical care Counseling Teaching Controlling for adverse reaction Preventive measures Indirect care Delegating, supervising and evaluating the work of other staff members

EVALUATION

Evaluation of goal achievement, evaluative measures and sources Care plan revision, discontinuing a care plan, modifying a care plan

 Crucial step to determine whether after application of the nursing process, a patients condition or well being improves Evaluation process: Identifying evaluative criteria and standards Collecting data to determine if you met the criteria or standards Interpreting and summarizing findings Documenting findings Terminating, continuing or revising care plan

CARE PLAN REVISION DISCONTINUING A CARE PLAN: done when expected outcome and goals have been met. Should be documented. MODIFYING A CARE PLAN: when goals are not achieved, factors are identified that interfere with goal achievement. Usually a change in patients condition, needs or abilities makes alteration of the care plan Complete reassessment of all patient factors relating to nursing diagnosis and etiology is necessary when modifying a plan. Compare new data with previously assessed information.

PHYSICAL EXAMINATION
Systematic collection of information about the body systems through the use of observation, inspection, auscultation, palpation and percussion Purpose:
Gather baseline data about the patients health status Supplement, confirm, or refute data obtained in the history Confirm and identify nursing diagnoses Make clinical judgments about a patients Evaluate the physiological outcomes of care. To identify clients eligibility for health insurance, military service or a new job.