Nursing Process

NURSING PROCESS Nursing process is a systematic, rational method of planning and providing nursing care. Its purpose is to identify a client’s health care status, and actual or potential health problems, to establish plans to meet the identified needs, and to deliv deliver er speci specific fic nursi nursing ng interv intervent ention ions s to addre address ss those those needs needs.. The The nursi nursing ng process is cyclical; that is, its component follows a logical sequence, but more than one component may be involved at one time. At the end of the first cycle, care may be terminated if goals are achieved, or the cycle may continue with reassessment, or the plan of care may be modified. Characteristics of Nursing Process The nursing process has distinctive 5 characteristics that enable the nurse to respond to the changing health status of the client. These characteristics include its cyclic centeredness; focus on problem solving and decision making, interpersonal and collaborative style, universal applicability, and use of critical thinking. •

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Data from each phase provide input into the next phase. Findings from evaluation evaluation feed back into the assessment. assessment. Hence, the nursing process is a regularly repeated event or sequence of events (a cycle) that is continuously changing (dynamic) rather than staying the same (static) The nursing process is client centered. The nurse organizes the plan of care according to client problems rather than nursing goals. In the assessment phase, the nurse collects data to determine the client’s habits, routines, and needs, enabling the nurse to incorporate client routines into the care plan as much as possible. The nursing process is an adaptation of problem solving and system theory. It can be viewed as parallel to but separate from the process used by physicians (the medical model). Both processes (a) begin with data gathering and analysis, (b) bas action (intervention or treatment) on a problem statement (nursing diagnosis or medical diagnosis), and (c) includ include e an evalu evaluat ate e compo componen nent. t. Howe However ver,, the medic medical al mode modell focuses on physiological systems and the disease process, whereas the nursing process is directed toward a client’s responses to disease illness. Decision making is involved in every phase of the nursing process. Nurses can be highly creative in determining when and how to use data to make decisions. They are not bound by standard responses and may may apply apply their their repert repertoir oire e of skill skills s and and knowl knowledg edge e to assis assists ts clients. This facilitates the individualization of the nurse’s plan of care. The nursing process is interpersonal and collaborative. It requires the nurse nurse to comm commun unica icate te direc directly tly and and consi consist stent ently ly with with clien clients ts and and families to meet their needs. It also requires that nurses collaborate, as members of the health care team, in a joint effort to provide quality client care.

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There are 5 phases of nursing process: assessing, diagnosing, planning, implementing, and evaluating.

ASSESSING Assessi Assessing ng is the systema systematic tic and continu continuous ous collecti collection, on, organiza organization tion,, validati validation, on, and docume documentat ntation ion of data data (inform (informatio ation). n). In effect, effect, assessi assessing ng is a continuous process carried out during all phases of the nursing process. For exam exampl ple, e, in the the eval evalua uati tion on phas phase, e, asse assess ssme ment nt is done done to dete determ rmin ine e the the outcomes of the nursing strategies and to evaluate goal achievement. All phases of the nursing process depend on the accurate and complete collection of data. There are 4 different types of assessments: initial assessment, problem-focused problem-focused asse assess ssme ment nt,, emer emerge genc ncy y asse assess ssme ment nt,, and and time time-l -lap apse sed d reas reasse sess ssme ment nt.. Assessments vary according to their purpose, timing, time available, and client status. The assessment process involves 4 closely related activities: collecting data, organizing data, validating data, and documenting data. Types of Assessment TYPE Init Initia iall Asse Assess ssm ment ent

Problem-focused Assessment

TIME PERFORMANCE Perf Perfor orme med d withi ithin n specified time after admission to a health care agency

PURPOSE

EXAMPLE

To establish a Nursing admission complete database for problem identification, reference, and future comparison

Ongoi Ongoing ng proces process s To deter determin mine e the the integrated with status of a specific nursing care proble problem m identi identifie fied d in an earlier assessment

Hourly assessment of client’s fluid intake and urinary output in an ICU Assessment of clie client nt’s ’s abil abilit ity y to perfo perform rm selfself-car care e while assisting the client to bathe







overlooked problems

a cardiac arrest Assessment suicidal tendencies potential violence.

Time-lapsed Reassessment

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Seve Severa rall month onths s To com compare are the after initial clien lientt’s cur current assessment status to baseline data ata pre previou iously sly obtained

of or for

Reasses Reassessme sment nt of a client’s funct function ional al healt health h patterns in a home care or outpatient setting or, in a hosp hospit ital al,, at shif shiftt change

Collecting Data

Data collection is the process of gathering information about a client; it includes the health theory, physical assessment, primary care provider’s history and physical examination, results of laboratory and diagnostic tests, and material contributed by the other personnel. Client data should include past history as well as current problems. For example, a history of an allergic reaction to penicillin is a vital piece of historical data. Past surgical procedures, folk healing practices, and chronic diseases are also example of historical data. Current data relate to present circumstances, such as pain, nausea, sleep patterns, and religious practices. To collect data accurate accurately, ly, both the client client and nurse must activel actively y partici participate pate.. Data can be subjective or objective and constant or variable types, and from a primary or secondary source. Types of Data Subjective data, referred to as symptoms or covert data, are apparent only to the person affected and can be described or verified only by that person. Itching, pain, and feeling of worry are examples of subjective data. Subjective data include include the client’s client’s sensatio sensations, ns, feeling feelings, s, values, values, beliefs beliefs,, attitude attitudes, s, and perception of personal health status and life situation. Objective data , also referred to as signs or overt data, are detectable by an observer or can be measured or tested against an accepted standard. They







Constant data is information that does not change over time such as race or blood type. Variable data can be change quickly, frequently, or rarely and include such data as blood pressure, age, and level of pain. Source of Data Sources of data are primary and secondary. The client is the primary sour source ce of data data.. Fami Family ly memb member er or othe otherr supp suppor ortt pers person ons, s, othe otherr heal health th professi professiona onals, ls, records records and reports reports,, laborato laboratory ry and diagnost diagnostic ic analyse analyses, s, and relevant literature are secondary or indirect sources. Data Collection Methods The principa principall methods methods used to collect collect data are observ observing, ing, intervie interviewing wing,, and examining. Observing To obser observe ve is to gathe gatherr data data by using using the sens senses. es. Observa Observatio tion n is a conscious, conscious, deliberate skill that is developed through effort and with an organized approach. Interviewing An inte interv rvie iew w is a plan planne ned d comm commun unic icat atio ion n or a conv conver ersa sati tion on with with a purpose, for example, to get or give information, identify problems of mutual concern concern,, evaluate evaluate change, change, teach, teach, provide provide support support,, or provide provide counse counseling ling or therapy. There are two approaches to interviewing: directives and non-directives. The directive interview is highly structured and elicits specific information. The nurse establishes the purpose of the interview and controls the interview, at least at the outset. the client responds to questions but may have limited opportunity to ask questions or discuss concerns. Duri During ng a non-directive non-directive interview, interview, or rapp rapport ort-bu -build ilding ing interv interview iew,, by contrast, the nurse allows the client to control the purpose, the subject matter, and pacing. Rapport is an understanding between two or more people. Examining The physical examination or physical assessment is a systematic data collection method that uses observation (i.e., the senses of sight, hearing, smell and touch) to detect health problems. To conduct the examination the nurse uses techniques of inspection, auscultation, palpation, and percussion. •

Organizing Data

The nurse uses a written (or computerized) format that organizes the assessment data systematically. This is often referred to as a nursing history,







The information gathered during the assessment phase must be complete, factual and accurate because the nursing diagnoses and interventions are based on this information. Validation is the act of “double checking” or verifying data to confir confirm m that that it is accura accurate te and and factu factual. al. Valid Validat ating ing data data helps helps the the nurs nurse e to complete these tasks: • • • •

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Ensure that assessment information is complete Ensure that objective and related subjective data agree Obtain additional information that may have been over-looked. Differen Differentia tiate te between between cues cues and inferen inferences. ces. Cues are subjecti subjective ve or objective data that can be directly observe by the nurse; that is, what the clients says or what the nurse can see, hear, smell, or measure. Inference are the nurse’s interpretation or conclusions made based on the cues (e.g., a nurse observes the cues that an incision is red, hot and and swol swolle len; n; the the nurs nurse e make makes s an infe infere renc nce e that that the the inci incisi sion on is infected). Avoid jumping to conclusions and focusing in the wrong direction to identify problems.

Documenting Data

To complete the assessment phase, the records client data. Accurate documentation is essential and should include all data collected about the client’s health status. Data are recorded in a factual manner and not interpreted by the nurse. For example, the nurse records the client’s breakfast intake (objective data) as “coffee 240 ml, juice 120 ml, 1 egg, and 1 slice of toast,” rather than as “appetite good” (a judgment). A judgment or conclusion such as “appetite good” or “nor “norma mall appet appetite ite”” may may have have differ different ent mean meaning ings s for for differ different ent people people.. To increase accuracy, the nurse records subjective data in the client’s own words, using quotation marks. Restating in other words what someone says increase the chance of changing the original meaning.







Diagnosing is the second phase of the nursing process. In this phase, nurses use critical thinking skills to interpret assessment data and identify client’s strengths and problems. Diagnosing is a pivotal step in the nursing process. Activiti Activities es precedin preceding g this phase are directed directed toward formulat formulating ing the nursing nursing diagnoses; the care-planning activities following this phase are based on the nursing diagnoses. Types of nursing diagnoses The five types of nursing diagnoses are actual, risk, wellness, possible, and syndrome. 1. An actual actual diagno diagnosis sis is a client client problem problem that that is present present at the the time of the nursing nursing assessm assessment ent.. Example Examples s are ineffec ineffective tive breathi breathing ng pattern pattern and anxi anxiet ety. y. An actu actual al nurs nursin ing g diag diagno nosi sis s is base based d on the the pres presen ence ce of associated signs and symptoms. 2. A risk nursing diagnosis is a clinical judgment that a problem does not exist, but the presence of risk factors indicates that a problem is likely to develop develop unless unless nurses nurses interven intervene. e. For example, example, all people people admitte admitted d to hospital have some possibility of acquiring an infection; however, a client with diabetes diabetes or a comprom compromised ised immune immune system system is at higher higher risk than others. Therefore, the nurse would appropriately use the label risk for infection to describe the clients health status. 3. A wellness wellness diagnosis diagnosis “describes “describes human human responses responses to to levels of wellness in an ind individ ividu ual, al, family ily or communit nity that have ave a rea readines ness for enhancement”. Examples of wellness diagnoses would be readiness for enhanced spiritual well-being or readiness for enhance family coping. 4. A possi possibl ble e nurs nursing ing diagn diagnos osis is is one one in which which evide evidence nce about about a healt health h problem is incomplete or unclear. A possible diagnosis requires more data either to support or to refute it. Fro example, an elderly widow who lives alone is admitted to the hospital. The nurse notices that she has no visitors and is pleased with attention and conversation from the nursing staf staff. f. Unti Untill more more data data are are coll collec ecte ted, d, the the nurs nurse e may may writ write e a nurs nursin ing g diagnosis of possible social isolation related to unknown etiology. 5. A syndrome syndrome diagnos diagnosis is is a diagnosis diagnosis in which which is associate associated d with a cluster cluster of other diagnoses. Currently six syndrome diagnoses are on the NANDA inte intern rnat atio iona nall list list.. Risk Risk for for disu disuse se synd syndro rome me,, for for exam exampl ple, e, may may be exper experien ience ced d by long-t long-term erm bedrid bedridde den n clien clients. ts. Cluste Clusters rs of diagno diagnoses ses associated with this syndrome include impaired physical mobility, risk for impaired tissue integrity, risk for activity intolerance, risk for constipation, risk risk for for infe infect ctio ion, n, risk risk for for inju injury ry,, risk risk for for powe powerl rles ess, s, impa impair ired ed gas gas exchanged, and so on.









2. Cluster Cluster cues cues (generat (generate e tentative tentative hypoth hypothesis esis). ). 3. Identify Identify gaps gaps and and incons inconsiste istencie ncies. s. For experienced nurses, these activities occur continuously rather than sequentially. Comparing data with Standards Nurs Nurses es draw draw a knowl knowledg edge e and and exper experien ience ce to comp compare are client client data data to standards and norms and identify significant and relevant cues. A standard or norm is generally accepted measure, rule, model, or pattern. The nurse uses a wide range of standards, such as growth and developmental patterns, normal vital signs, and laboratory values. Clustering Cues Data Data Clus Cluste teri ring ng or grou groupi ping ng cues cues is a proc proces ess s of dete determ rmin inin ing g the the relatedness of facts and determining whether any patterns are present, whether the data represent isolated incidents, and whether the data are significant. This is the beginning of synthesis. Identifying Gaps and Inconsistencies Skillful assessment minimizes gaps and inconsistencies in data. However, data analysis should include a final check to ensure that the data are complete and concrete. Inconsistencies are conflicting data. Possible sources of conflicting data include measurement error, expectations, and inconsistent or unreliable reports. For example, the nurse may learn from the nursing history that the client reports not having seen a doctor in 15 years, yet during the physical health examination, examination, he states, “My doctor takes my blood pressure every year.” All inconsistencies inconsistencies must be clarified before a valid pattern can be established.

Identifying Health Problems, Risks, and Strengths Afte Afterr data data are are anal analyz yzed ed,, the the nurs nurse e and and clie client nt can can toge togeth ther er iden identi tify fy







Formulating Diagnostic Statements Most nursing diagnoses are written as two-part or three-part statements, but there are variations of these. Basic Two-Part Statements The basic two-part statement includes the following: 1. Problem (P): statement of the client’s response 2. Etiology (E): factors contributing to or probable causes of the responses. The two-parts are joined by the words related related to rather than due to. The phrase due to implies that one part causes or is responsible for the other part. By contrast, the phrase related to merely implies a relationship.

3.

Basic Three-Part Statements The basic three-part nursing diagnosis statement is called the PES format and includes the following: 1. Problem (P): statement of the client’s response causes of the response 2. Etiology (E): factors contributing to or probable causes Signs and Symptoms (S): defining the characteristics manifested by the client. Actual Actual nursing nursing diagnos diagnoses es can be documen documented ted by using using the three-pa three-part rt statement because the signs and symptoms have been identified. This format cannot be used for risk diagnoses because the client does not have signs and symptoms of the diagnosis. The PES format is especially especially recommended recommended for beginning beginning diagnosticians diagnosticians because the signs and symptoms validate why the diagnosis was chosen and make the problem statement more descriptive. One-Part Statement Some diagnostic statements, such as wellness, diagnoses and syndrome







PLANNING Planning is a deliberative, systematic phase of the nursing process that involves decision making and problem solving. In planning, the nurse refers to the the clie client nt’s ’s asse assess ssme ment nt data data and and diag diagno nost stic ic stat statem emen ents ts for for dire direct ctio ion n in formulat formulating ing client client goals goals and designi designing ng the nursing nursing interven intervention tions s require required d to prevent, reduce, or eliminate the client’s health problems. problems. A Nursing intervention intervention is “any treatment, based upon clinical judgment and knowledge that a nurse performs to enhance patient/client outcomes”. The end product of the planning phase is a client care plan. Although planning is basically the nurse’s responsibility, input from the client and support persons is essential if a plan is to be effective. Nurses do not plan for the client, but encourage the client to participate actively to the extent possible. In a home setting, the client’s support people and caregivers are the one’s who implement the plan of care; thus, its effectiveness depends largely on them. Types of planning Planning begins with first client contact and continues until the nurse-client relation relationshi ship p ends, ends, usually usually when when the client is discharg discharge e from the health health care care agenc agency. y. All All plann plannin ing g is multi multidis discip ciplin linary ary (invol (involve ves s all healt health h care care provid providers ers interacting with the client) and includes the client and family to the fullest extent possible in every step. Initial planning The nurse who performs the admission assessment usually develops the initial comprehensive comprehensive plan of care. This nurse has the benefit of the client’s body language as well as some intuitive kinds of information that are not available solely from the written database. Planning should be initiated as soon as possible after after the initial initial assessm assessment ent,, especia especially lly becaus because e of the trend trend toward toward shorter shorter hospital stays.







Discharge planning Discharge planning, the process of anticipating and planning for needs after discharge, is a crucial part of comprehensive health care and should be addressed in each client’s care plan. Because the average stay of clients in acute care hospitals has become shorter, people are sometimes discharge still needing care. Although many clients are discharge to other agencies (e.g. longterm term care care facili faciliti ties) es),, such such care care is increa increasin singly gly being being deliv delivere ered d in the home. home. Effe Effect ctiv ive e disc discha harg rge e plan planni ning ng begi begins ns at firs firstt clie client nt cont contac actt and and invo involv lves es comprehensive and ongoing assessment to obtain information about the client’s ongoing needs.

Developing a nursing care plan The end product of the planning phase of the nursing process is a formal or informal plan of care. An informal nursing care plan is a strategy for action that exists in the nurse’s mind. For example, the nurse may think, “Mrs. Pham is very tired. I will need to reinforce her teaching after she is rested.” A formal nursing care plan is a written or computerized computerized guide that organizes organizes information about the client’s care. The most obvious benefit of formal written care plan is that it provides for continuity of care. A standardized care plan is a formal plan that specifies the nursing care for groups of clients with common needs. An individualized care plan is tailored to meet the unique needs of specific client-needs that are not addressed by the standardized plan. Guidelines for writing nursing care plan The nurse should use the following guidelines when writing nursing care plans: 1. Date Date and and sign sign the plan. plan.







10.Include plans for the client’s discharge and home care needs.

IMPLEMENTING In the nursing process, implementing is the action phase in which the nurse performs the nursing interventions. Using NIC terminology, implementing consists of doing and documenting the activities that are the specific nursing actions needed to carry out interventions. The nurse performs or delegates the nursing activities for the intervention that were developed in the planning step and then concludes the implementing step by recording nursing activities and the resulting client responses. Implementing Skills To impl implem emen entt the the care care plan plan succ succes essf sful ully ly,, nurs nurses es need need cogn cognit itiv ive, e, interpersonal and technical skills. These skills are distinct from one another; in practice, however, nurses use them in various combinations and with different emphasis emphasis,, depend depending ing on the activit activity. y. For instanc instance, e, when when insertin inserting g a urinary urinary catheter the nurse needs cognitive knowledge of the principles and steps of the procedure, interpersonal skills to inform and reassure the client. And technical skill in draping the client and manipulating the equipment. The cognitive cognitive skills (intellectual skills) include problem solving, decision makin making, g, critic critical al think thinking ing,, and and creati creativi vity. ty. They They are are cruc crucial ial to safe, safe, intell intellig igent ent nursing care. Interpersonal skills are all of the activities, verbal and non-verbal people use when interacting directly with one another. The effectiveness of a nursing action often depends largely on the nurse’s ability to communicate with others. The nurse uses therapeutic communication to understand the client and in turn be understood. A nurse also needs to work effectively with others as a member of the health care team Technical Technical skills are purposely “hands-on” skills skills such such as manipul manipulatin ating g equipme equipment, nt, giving giving injectio injections, ns, bandagin bandaging, g, moving, moving, lifting lifting and reposit repositioni ioning ng the









EVALUATING To evaluate is to judge or to appraise. Evaluating is the fifth and last phase of the nursing process. In this context, evaluating is a planned, ongoing, purposely activity in which clients and health care professionals determine (a) the clie client nt’s ’s prog progre ress ss towa toward rd achi achiev evem emen entt of goal goals/ s/ou outc tcom omes es and and (b) (b) the the effectiveness of the nursing care plan. Evaluation is an important aspect of the nursing nursing process process because because conclus conclusions ions drawn drawn from the evaluat evaluation ion determin determine e whether the nursing interventions should be terminated, continued or changed. Evaluat Evaluation ion is continuo continuous. us. Evaluati Evaluation on done done while while or immedia immediately tely after after impl implem emen enti ting ng a nursi ursing ng order rder enab enable les s the the nurs nurse e to make ake on-t on-the he-s -spo pott modifications modifications in an intervention. Evaluation performed at specified intervals (e.g. once a week for the home care client) shows the extent of progress toward goal achievement and enables the nurse to correct any deficiencies and modify the care plan as needed. Evaluation continuous until the client achieves the health goals or is discharged from nursing care. Evaluation at discharge includes the status status of goal goal achieve achievemen mentt and the client’s client’s self-care self-care abilities abilities with regard to foll follow ow-u -up p care care.. Most Most agen agenci cies es have have a spec specia iall disc discha harg rge e reco record rd for for this this evaluation. Through evaluating, nurses demonstrates responsibility and accountability for their actions, indicate interest in the results of the nursing activities, and demonstrates a desire not to perpetuate ineffective actions but to adopt more effective ones.

Nursing Process

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