The Nursing process Shurouq Qadose 23/1/2008
The nursing process generally is defined as a systematic problem- solving approach toward giving individualized nursing care. OR The nursing process is a systematic method that directs the nurse and patient as together they accomplish the following: (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.
Phases The six phases of the nursing process are assessment, diagnosis, out come identification, planning, implementation, and evaluation.
Nursing Assessment The first phase of the nursing process, called assessment, is the collection of data for nursing purposes. Information is collected using the skills of observation, interviewing, physical examination, and intuition and from many sources, including clients, their family members or significant others, health records, other health team members.
Reasons for doing assessment:- - To establish baseline information on the client - To determine the client’s normal function - To determine the client’s risk for dysfunction - To determine the client’s strengths - To provide data for the diagnosis phase
- Setting and environment Assessment can take place in any setting where nurses care for clients and their family members: in the client’s home, at a clinic, in a hospital room.
Assessment skills 1- Observation Comprises more than the nurse’s ability to see the client, nurses also use the senses of smell, hearing, touch, and, rarely, the sense of taste. Observation includes looking, watching, examining. Observation begins the moment the nurse meets the client. It is a conscious, deliberate skill that is developed through efforts and with an organized approach. Observation has two aspects:(a) noticing the data and (b) selecting, organizing, and interpreting the data.
Observation done in the following order: • Clinical signs of client distress. • Threats to the client’s safety, real or anticipated. • The presence and functioning of associated equipment. • The immediate environment, including the people in it.
2- Interviewing Is a planned communication or a conversation with a purpose, for example to get or give information, identify problems of mutual concern, evaluate change, teach, provide support. There are two approaches to interviewing, directive and nondirective.
The directive interview is highly structured and elicits specific information. The nurse establishes the purpose of the interview and controls the interview. The client responds to questions but may have limited opportunities to ask questions or discuss concerns. The nondirective interview or rapport-building interview, by contrast the nurse allows the client to control the purpose, subject matter, and pacing.
3- Physical examination techniques Is a systematic data collection method that uses the senses of sight, hearing, smell, and touch to detect health problems. Four techniques are used: inspection, palpation, percussion, and auscultation
- Inspection Is visual examination of the client that is done in a methodical and deliberate manner. The client is observed first from a general point of view and then with specific attention to detail. Effective inspection requires adequate lighting and exposure of the body parts being observed.
- Palpation Uses the sense of touch to assess texture, temperature, moisture, organ location and size, vibrations and pulsations, swelling, masses, and tenderness. Palpation requires a calm, gentle approach and is used systematically, with light palpation preceding deep palpation and palpation of tender areas performed last.
- Percussion Uses short, tapping strokes on the surface of the skin to create vibrations of underlying organs. It is used for assessing the density of structures or determining the location and the size of organs in the body.
- Auscultation Involves listening to sounds in the body that are created by movement of air or fluid. Areas most often auscultated include the lungs, heart, abdomen, and blood vessels.
4- Intuition Use of insight, instinct, and clinical experience to make clinical judgments about the client. Intuition plays a role in the nurse’s ability to analyze cues rapidly, make clinical decisions, and implement nursing actions even though assessment data may be incomplete or ambiguous.
Assessment Activities The activities that make up the assessment are the following: 1- Collect data Data collection, the process of compiling information about the client, begins with the first client contact. Nurses use observation, interviewing, and physical examination.
Types of data: -Subjective data also known as symptoms or covert cues include the client's feeling and statement about his or her health problems and are best recorded as direct quotations from the client, such as '' Every time I move, I feel nauseated.''
- Objective data also known as signs or overt cues, are observable and measurable (quantitative) data that are obtained through observation, standard assessment techniques performed during the physical examination, and laboratory and diagnostic testing.
Sources of data It can be primary or secondary. The client is the primary source of data. Family members or other support persons, other health professionals, records and reports, laboratory and diagnostic analyses, and relevant literatures are secondary or indirect sources.
2- Validate data Validation, commonly referred to as double – checking the information at hand, is the process of confirming the accuracy of assessment data collected. Validation assists in verifying and clarifying cues and inference.
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
3- Organize data After data collection is completed and information is validated, the nurse organizes, or clusters, the information together in order to identify areas of strengths and weaknesses. This process is known as data clustering. How data are organized depends on the assessment model used. One of these model is Head – to – Toe model.
4- Documenting Data To complete the assessment phase, the nurse records client data. Accurate documentation is essential and should include all data collected about the client’s health status. To increase accuracy, the nurse records subjective data in the client’s own words to avoid the chance of changing the original meaning.
Nursing Diagnosis The second step in the nursing process involves further analysis (breaking the whole down into parts that can be examined) and synthesis (putting data together in a new way) of the data that have been collected.
According to the North American Nursing Diagnosis Association (NANDA) a nursing 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. (Carroll-Johnson, 1990, p. 50).
Purposes of nursing diagnosis - Nursing diagnosis is unique in that it focuses on a client’s response to a health problem, rather than on the problem itself, and it provides the structure through which nursing care can be delivered. - Nursing diagnosis also provides a means for effective communication.
- Holistic client, family, and community-focused care are facilitated with the use of nursing diagnosis. - Nursing diagnosis has an important impact on the health care delivery system
Components of a nursing diagnosis:- The Two-Part Statement The components of a nursing diagnosis typically consist of two parts. The first component is a problem statement or diagnostic label. The diagnostic label is the name of the nursing diagnosis as listed in the NANDA. Some examples include stress urinary incontinence, Anxiety.
The second component of a two-part nursing diagnosis is the etiology. The etiology is the related cause or contributor to the problem. The diagnostic label and etiology are linked by the term related to (RT). Examples of nursing diagnoses are Disturbed Body Image RT loss of left lower extremity and Activity Intolerance RT decreased oxygen-carrying capacity of cells.
Descriptive words or terms may be added to clarify specific nursing diagnoses. These descriptive words are called qualifiers and include Acute, Chronic, Decreased, Deficient, Depleted, Disturbed, Dysfunctional, Enhanced, Excessive, Impaired, Increased, Ineffective, Intermittent, Potential for, and Risk. These terms specify a degree of qualification for the identified nursing diagnosis and are placed (used) before the problem statement.
The Three-Part Statement The nursing diagnosis can also be expressed as a three part statement. As in the two-part statement, the first two components are the diagnostic label and the etiology. The third component consists of defining characteristics (collected data that are also known as signs and symptoms, subjective and objective data, or clinical manifestations).
In the three-part nursing diagnosis format, the third part is joined to the first two components with the connecting phrase “as evidenced by” (AEB).
Myocardial infarction (heart attack) is a medical diagnosis. Examples of nursing diagnoses for a person with myocardial infarction include Fear, Altered Health Maintenance, Knowledge Deficit, Pain, and Altered Tissue Perfusion.
Nursing Diagnosis versus Collaborative Problems If such problems require physician – prescribed and nurse – prescribed action, however, they are collaborative health problems. Collaborative problems refer to actual or potential physiologic complications that can result from disease, trauma, treatment, or diagnostic studies for which nurses intervene in collaboration with personnel of other disciplines.
Example 1 56-year-old mother of seven; 167 lb; “Whenever I sneeze lately, I dribble urine. This is embarrassing.” Diagnostic statement Stress Urinary Incontinence related to degenerative changes in pelvic muscles and structural supports associated with advanced age, obesity, gravid uterus
Select nursing responses Teach Kegel exercises to increase muscle tone; explore patient’s willingness and motivation to pursue weight reduction and exercise program; evaluate need for bladder-training program.
Example 2 42-year-old woman; 1 hour after delivery; spinal anesthesia; 1500 mL fluid infused in past 4 hours without patient voiding; unable to void. Diagnostic statement Potential complication: Urinary Retention related to fluid overload and effects of anesthesia.
Select nursing responses Monitor for signs of increasing urine retention; offer bedpan, and encourage voiding with running water, warm water dripped over perineum, and so forth; if no result, administer physician-prescribed medication; if no result, perform physician-prescribed catheterization.
Example 3 “Whenever I have to urinate it burns terribly. I also feel like I have to go all the time—real bad.” Small, frequent voidings, cloudy urine; T—100.8°F Diagnostic statement Cystitis Select nursing responses Report signs and symptoms to physician; obtain urine culture; report results to physician; administer appropriate physician-prescribed antibiotic.
Types of Nursing Diagnoses 1- Actual Nursing Diagnoses Describe a human response to a health problem that is being manifested. They are written as three- part statements: diagnostic label, related factors, defining characteristics. Example – Acute pain related to surgical trauma and inflammation, as evidenced by grimacing and verbal reports of pain.
Q- Which One is accurate nursing diagnosis? 1- Impaired physical mobility related to pain 2- Ineffective movement related to arthritis
2- Risk nursing diagnosis As defined by NANDA, ’’describes human responses to health conditions that may develop in a vulnerable individual, family, or community. It is supported by risk factors that contribute to increased vulnerability’’.
Risk nursing diagnoses are two – part statements because they do not include defining characteristics (diagnostic label, risk factors). Example - Risk for infection related to surgery and immunosuppression. Risk for aspiration related to reduced level of consciousness Risk for Impaired Skin Integrityrelated to inability to turn self from side to side in bed.