Nursing Process

Nurse MSC. Andréa Cardoso

State University of Roraima - UERR
Good View/2013
We believe that:

taking care of life is the most important attribute

valuable that Nursing has the

to offer to humanity...

WATSON –1988
Nursing Process

The term was used for the first time

once through Ida Orlando, in 1961, to
explain nursing care.
Nursing Process

It is the dynamics of systematized actions

and interrelated, aiming at assistance
to the human being. It is characterized by the inter-
relationship and dynamism of its phases
or steps (Horta, 1998).
Nursing Process

It is a private activity of the nurse.

that guides the activities of the entire team
of Nursing, since technicians and
assistants perform their functions at
starting from the nurse's prescription.
Nursing Process

The nursing process has

a holistic approach helps to
ensure that interventions are
elaborated for the individual and not
only for the disease.
It presses the diagnoses and the treatment of
potential and ongoing health problems.
Reduces the incidence and the duration of stay in
hospital
Promotes flexibility of thought
independent
Improves communication and prevents errors,
omissions and unnecessary repetitions;
Promote job satisfaction for nurses.
Phases of the nursing process

1. Nursing History.

2. Nursing Diagnosis.

3. Care Plan.

4. Care Plan or Prescription of

Nursing.

5. Evolution.

6. Prognosis.
Nursing History

Systematized script for data collection of the being

humans that make it possible to identify their
problems.

This data, after being analyzed and evaluated

Nursing Diagnosis
2. Nursing Diagnosis

It consists of identifying the needs of the being

human who needs assistance and the
determination by the nurse of the degree of
dependency of this service in nature and
in extension.
3. Care Plan

It consists of the global determination of assistance from

nursing that the human being should receive
in light of the established diagnosis.
It is programmed to assist in
nursing, that is:
Supervision,
Forwardings,
Guidance,
Help,

Perform.
4. Care Plan or Prescription of
Nursing

Implementation of the assistance plan by

daily schedule (appointed) that coordinates the
nursing team's action in
execution of the appropriate care to
basic and specific needs of the being
human.
It is frequently evaluated
5. Evolution of Nursing

Daily account of successive changes

that occur in humans, while
to be under professional assistance.

Allows evaluating the response of

patient/client to assistance of
implemented nursing.
6. Nursing Prognosis

Estimation of human capacity

to meet your basic needs
altered after the implementation of the plan
assistance and evolution of nursing.
Nursing Process
Introduced the terms:
Nursing Assistance - application
done by the nurse of the process of
nursing, aiming to meet the
basic needs of the patient.
Nursing care consists of
planned or automatic action of the
nurse, resulting from his perception,
observation and analysis of the condition of being
human.
Instruments for the Process of
Nursing

Observation,
Communication,
Application of the scientific method,

Application of scientific principles,

Manual dexterity,

Planning,
Evaluation,
Creativity,
Teamwork,
Utilization of resources from
community.
Basic Human Needs
(N.H.B)
In this theory, nursing has as
purpose to assist the human in
meeting your basic needs and,
for that, always seek to accumulate
knowledge and empirical techniques,
related to each other, which seek to explain
the facts in light of the natural universe.

Needs
Psychosocial/Psychobiological/Psycho-spiritual
 Yes Theorist Main Emphasis

1952 Hildegard E. Peplau The interpersonal process - maturation

for the personality
1960 Faye Abdellah The patient's problems
determine the care
1967 Myra E. Levine Holism - conservation of
integrity
1970 Martha Rogers People and environment are fields of
energy that evolves
1970 Wanda de A. Horta Basic human needs

1971 Dorothea E. Orem Self-care maintains integrity.

 Yes Theorist Main Emphasis

1971 Imogene M. King Achievement of goals

1974 Sister Callista Roy Stimuli break a

adaptive system

1978 Madeleine M. Leininger Transcultural care

P. Benner & J. Wrube Essential care - help

1989 mutual
Nursing History
Nursing History
It is the systematic script for the
data collection of the human being,
making it possible to identify your
problems.
Data collection is the first phase of
nursing process;
Moment of interaction between professionals and
clients
Interaction between the Basic Instruments
of Nursing;
Nursing History
Improvement in the quality of
assistance;
Favors the development of
scientific papers of Nursing
and demonstrates the complexity of
care;
Leads to the diagnosis of
nursing.
The interview is preferably used.
informal, promoting interaction
nurse-patient
The presentation is essential.
people, explaining to you what it will be
done and why.
The history must be done in
patient admission.
The Nursing History is
composed of:

Interview

2. Physical examination.
TYPES OF DATA COLLECTION
Objectives: information related to
patients collected through observation
the measurement;

ex: propaedeutic methods, exams, ssvv.

Subjective: information obtained in

moment of the interview, where the
patient expresses the perception that
he has of himself;
Complaints, Previous History
DATA SOURCES

Primary: Information provided by

own patient;
Secondary: Information provided by
relatives, team members of
health, exams, medical record of
patient
Characteristics:

A) Concise - Clear and objective,

B) Information that allows
to provide immediate care,
C) Individualization,
D) Do not duplicate information.
Interview

Identification;
Main Complaint;
History of Current Illness;
Personal Medical History;
Family Medical History;
Lifestyle Habits and Social Habits;
SSVV and Ectoscopy (General State);

Interviewer Perceptions
IDENTIFICATION DATA
Name (Initials + bed/ward)
Age
Sex
Core
Marital status
Profession / Occupation
Origin (Residence / Others)
Birthplace and Nationality
MAIN COMPLAINT

Always in quotes and with

words used by the patient;
If possible, include its duration;

I came to operate on the belly!

I'm in pain in my fourth molars!
CURRENT DISEASE HISTORY

Describe in chronological order and of

importance
Conduct the semiology of the symptoms;
Inquire about the associated symptoms and
correlates;
Do not induce answers;
Accelerate evolution, exams and treatment performed;

The story should have: Beginning, middle, and end.

MORBID BACKGROUND
PERSONAL
Previous Medical History:
DIC's, Allergies, Infections/Infestations,
Underlying Diseases, Surgeries (type, period,
anesthetics, complications and results) and
Traumatismos (tipo, período, complicações
and sequels).
Physiological History:
Conditions of Gestation, Birth,
Vaccination Schedule, Growth and
Psychomotor Development, Puberty
(menarche), Sexual History (cycle
menstrual, libido, pregnancies, abortions
promiscuity and choice) and Climacteric
(sintomas, período)
MEDICAL HISTORY
RELATIVES

Ancestors: health status, causes

deaths, age;

Family Diseases: Cancer, Hypertension, Diabetes Mellitus, Stroke,

Cardiopatias, Nefropatias, Psicopatias;

LIFE HABITS AND SOCIAL HABITS

Nutrição: (quantidades, tipos, preferências)

Hidratação: (quantidades, tipos,
preferences)
Activity/Occupation
Physical Activity and Leisure: (sports and
hobbies)
Sound and Rest: (insomnia)
Habitação: (tipo de casa,
sanitation, sanitary installations
drinking water, livestock farming.
Hábitos: (tabaco, álcool, drogas
illicit, drugs...)
VITAL SIGNS AND ECTOSCOPY

VS: PA, Pulse/HR, RR, Temp and Pain;

General State;
Skin Coloring and Hydration;
Level of Consciousness and Orientation;
Nutritional Status;
Typical and atypical facies;
Speech and language;
Posture and position in bed;
Dermatological lesions.
INTERVIEWER PERCEPTIONS

Interview evaluation;
Truthfulness of facts;
Gestures and mimics produced by
patient during the interview;
Moments of escape, after certain
questions;
Voice tone and emotional state.
Physical Examination:
Allows for identifying problems of
nursing.
Necessary material:
Sheet;
Maca or bed;
Clinical scale with anthropometer;
Gloves;
Apron
Thermometer;
Sphygmomanometer;
Stethoscope;
Spatula;
Measuring tape;
Lantern
Watch;

Cotton balls with alcohol.

Nursing Diagnosis

It is the second phase of the process of

nursing
It consists of the identification of the
basic needs affected and of
degree of patient dependence in
regarding nursing care
(Total - T or Partial/Help - A).
INITIAL CONSIDERATIONS

Linguagem padronizada;
Important for carrying out a
correct nursing intervention
systematized;
Allows greater reliability autonomy;
Provides the basis for interventions of
Nursing to achieve
the results for which the nurse is
held accountable.
As for nature, the degree of
dependency can be:
Total (Perform, do)
Partial (Help, guidance, supervision
the referral).
History of the Diagnosis

1859 (Modern Nursing) with

Florence Nightingale, when she stated
that nursing was unaware of its
specific elements, that is, their
elements or phenomena.
1966, Henderson identified and listed 14
NHB, which encompasses the functions of
nursing, which aimed at
describe the necessary care for the being
human to preserve or recover its
health, regardless of care
doctors.
NHB: breathing, feeding,
elimination, movement, sleep and
repouso, vestimentas, temperatura
corporal, hygiene, control of
environment, communication, practice
religious, realization, activity of
laser and learning
1973, National Classification Group of
Nursing Diagnoses, called
NANDA, I Conference on classification
two nursing diagnoses;
In 1982, NANDA developed a list of
nursing diagnosis, in order
alphabetical, originating Taxonomy I, more
used in the world;

NANDA: North American Nursing Diagnosis Association

DIAGNOSTIC COMPONENTS:

Title: establishes a name for a

diagnosis. It is a term or
concise expression that represents
a pattern of related indications.
Impaired Skin Integrity
Definition: it is the clear and precise description;
allows to outline its meaning and helps to
differentiate it from similar diagnoses.

Damaged Skin Integrity: State

in which the individual presents, or is in
risk of presenting, tissue alteration
epidermal and/or dermal.
Defining Characteristics: are indications/
observable inferences that group together
as manifestations of a diagnosis of
real or wellness nursing.
Greater (Must be present)
Tears of the epidermal and dermal tissue.
Minors (May be present)
Erythema,
Injuries,
Itching.
Related factors: factors that
seem to show some type of relation
standardized with the diagnosis of
nursing.
See Impaired Tissue Integrity.
Risk Factors: environmental factors and
physiological and psychological elements,
genetic or chemical factors that increase the
vulnerability of an individual, a
family or a community to an event
insalubrious.

Age extremes, immobilization

physics, wet skin, immune deficiency
mechanical factors etc...
 Real Diagnosis
X
Risk Diagnosis

Real Diagnosis:
TÍTULO + DEFINIÇÃO +
DEFining CHARACTERISTICS +
RELATED FACTORS
 Risk Diagnosis:

TÍTULO + DEFINIÇÃO + FATORES DE

RISK
EXAMPLE OF DIAGNOSIS
NURSING REALITY

Urinary Elimination Title

Harmed

Disorders in elimination Definition

from urine
Dysuria, Polyuria, Urinary Hesitation
Incontinência, Noctúria Characteristics
Urinary Retention, Urinary Urgency defining
MANIFESTATIONS

1- Sensory-motor damage Factors

Urinary Tract Infection Related
3- Multiple causes (CAUSAS)
4- Anatomical Obstruction
 Example of Risk Diagnosis of
Nursing - NANDA

Risk of Infection
Title

Increased risk of being invaded

by pathogenic organisms Definition

Pharmaceutical agents
(immunosuppressants);
Inadequate primary defenses;
Malnutrition; Risk factors
Invasive procedures;
Chronic disease.
Diagnosis
Ineffective breastfeeding related to
inverted nipples, evidenced by
baby arching and crying at
seio.
Intolerance to Related Activity
cancer, evidenced by dyspnea,
paleness and dizziness.
Care Plan or Prescription of
Nursing
Planning:
Care Plan or prescription of
nursing
It consists of the daily (or scheduled) itinerary.
that coordinates the team's action of
nursing in appropriate care for
meeting basic needs and
specific to the human being
The prescription must be written as
an operational objective and the verb
always used in the infinitive.
Total dependence: the verbs must
indicate what to do for the patient, by
apply, execute, lubricate, weigh and
etc.
Partial dependence: Used verbs,
help, accompany, assist
provide, allow, etc.
Guidance dependency: to guide,
["clarify","discuss","inform","explain"]
and etc.
Dependency on supervision: the verb
should correspond to the action of
observe and control, e.g.: observe,
control, evaluate, inspect
supervise, etc.
Items in a prescription of
nursing
What to do?
How to do it?
When to do it?
Where to do it?

How often should I do it?

For how long to make or how much
to do?
The prescriptions must still include the
date of the writing and the signature of
nurse responsible for your
manufacturing (Alfaro-LeFreve, 2005).
How the prescription should be
nursing?
Complete;
Well written;
Make an impact on assistance;
Awakening the interest of the team
nursing through reading, performing, and reflecting
about what is prescribed by
nurse
Important information

Nurses do not prescribe nor

they address the medical conditions and yes
prescribe care for the
reactions of clinical conditions that
correspond to physical complications
logics.
Important information:
Medical professionals prescribe the
treatment.
The nurse should focus their attention
in the prescription of patient care.
The delegation of care prescription
other professionals compromises the
definition of the role of the nurse
Types of prescriptions

Dependents - it is the completed action

according to medical request, but that
requires judgment or decision
nurse's decision.
Independents - are those in which
can solve the problems of
client, without consultation or collaboration
doctor
Interdependent - are carried out
with mutual participation and with the
collaboration from other members of the
health team.
It is important to emphasize that:

For each DE there must be a

expected result;
To achieve each result the
the nurse should prescribe
nursing care;
Just as the DEs are prioritized, the
the nurse should also prioritize the
order of execution of prescriptions
of nursing
Correct ways to prescribe

Example
Wrong. Place hydrocolloid dressing on the
client injury.

Sure. Apply hydrocolloid dressing —

plate - 10x10, in the sacral area, today.
Fill out and sign. Protect edges with
Micropore. Change the dressing every 7 days, or
first, if it is dirty, damp or loose.
Register the aspect of the injury in the record.
Example
Wrong. Give a bed bath.

Sure. Bathe the bed once a day and

whenever the client needs.
Notify the nurse whenever
highlight skin lesions and
in mucous membranes. Pay attention to changes
(shortness of breath, fatigue, and dizziness).
NURSING RECORDS

We learned that we must register

all procedures and care
what we do in the assistance of
nursing.

BECAUSE MANY TIMES NOT HIM

SHALL WE?
 NURSING RECORDS

The nursing records

besides being a duty, it is a
obligation of professionals
of nursing.
DOCUMENT

The printed materials for notes of

nursing are documents
legal documents in which it must appear
all patient data.
Since your admission to the hospital
until the moment of your departure
ETHICAL

The code of ethics of

nursing professionals.

Law No. 5.905.73

Resolution 311/2007
WHAT SHOULD I WRITE?

Everything related to
patient treatment.

The annotation is made by the professional.

that provides assistance to the patient.

The notes must be:

Descriptive, clear, concise, complete
exact, objective and free from judgment.
WHAT SHOULD I NOT WRITE?

What is not related to

patient treatment;

Things that may compromise the

professionals or the institution.
IDENTIFICATION DATA OF
FILE:
NOME COMPLETO DO PACIENTE

INTERNMENT REGISTRATION NUMBER

UNIT - BED

DATE AND TIME OF PROCEDURES

DOCTOR'S SIGNATURE-CRM

SIGNATURE OF THE PROFESSIONAL OF

NURSING and stamp
MOST COMMON TYPES OF SHAVES:

USE OF CORRECTOR

RISC OS

Glue Paper

WRITE OVER WHAT J

IT IS WRITTEN
All medication and or
care provided must be
checked and signed by
professional.

If the action is not taken

an error occurred or took place in the
annotation, justify the no
execution of care.
HOW TO JUSTIFY?
CIRCULAR AND OPEN NEW SCHEDULE

PLACE BETWEEN
PARENTHESIS(......)I SAY......

SUSPEND

MODIFY

OPEN NEW ITEM

WRITE THAT IT IS CANCELLING

DETERMINED ITEM.
WHAT ARE THE RECORDS THAT THE PROFESSIONAL OF
Nursing must do

You must record all the

observations made regarding
to the patient, with explanation
of results, intercurrences
of treatment, care
provided, the evolution of
signs and symptoms and the
guidelines provided.
NURSING RECORDS
Vital Signs

HYGIENE AND •HEMOTHERAPIES

COMFORT

•FOOD
MEDICAÇÕES

SORE THERAPY •ELIMINATIONS

NURSING RECORDS

MONITORING
CATHETERIZATIONS
DRESSINGS
DRAINAGE RECORDS OF
NURSING
VENTILATION-OXYGENATION-
ASPIRATION
HEMODYNAMIC CHANGES
SENSOR CHANGES
GUIDELINES
Nursing records

Wandering

RESTRICTIONS

TRANSPORT

Collection of exams

OUTCOMES FOR EXAMS FOR A DO

HOSPITAL
Nursing Records

PREPARATION FOR SURGERIES

PRE AND POST OPERATIVE CARE

WATER BALANCE

INTERACTIONS

OBITUARY
NURSING RECORDS

INFORMATION NO

REGISTERED IS

LOST INFORMATION
 The incorrect, incomplete annotation,
false or nonexistent in the medical record,
of facts related to patients
hospitalized
Can you characterize a type of crime
denomination of ideological falsehood,
provided for in the Penal Code, art 299
Composition of nursing notes under
point of view
ethical and legal

Incisive: decisive, prompt, direct, straightforward

["exact","certain","defined","clear"]
Concise: summarized, succinct, brief
complete, finished
Correct: free of errors, elegant, appropriate
Objective: real, existing
Clara: easy to understand
 What should NOT be included in the medical record
paint
Do not use terms that give connotation of
value, such as:
- ["well","bad","very","quite","little"]
reasonable
Avoid vague terms such as:
- “regular”, “bom”, “normal”, “comportamento
anormal”, “bem desenvolvido”.
- normal physiological habits, without
intercurrences
All medication and/or
care provided must
to be checked and signed
by the professional, if applicable
the action was not taken
There was an error in the
annotation, justify the no
execution of care.
Facilitating items in the process of
records

Register the fact as soon as possible

Do not trust memory
Objectively record, without judgment of
values
Subjective data, record in quotes
Keep a short record
Never leave blank lines
Communicate and record abnormal data
Register important actions
Register variations of normalities
Register any action taken
Focus on significant problems
Register the failure or refusal in
follow the care
Use resources to organize the
nursing records
Supine Position
Ventral decubitus or prone
Lithotomy Position
Lateral Decubitus:
Activities:

[Link] the patient's positions

used for conducting exams
and its purposes.
Differentiate the terms: Antisepsis
Asepsis and Degerming.
BIBLIOGRAPHY
SiteSITE:[Link] New Code of
Brazilian Nursing Ethics - COFEN Resolution No. 311
May 2007.
Constitution of the Federative Republic of Brazil;
Brazilian Civil Code
Consumer Defense Code;
Universal Declaration of Human Rights;
Patient's Bill of Rights, based on the Manual of
Joint Commission for Hospital Accreditation
Latin America and the Caribbean;

Patients' Rights - Health Citizenship - Dr. E. C.

Gauderer;
Patient Rights Handbook prepared by
Health Secretariat of the State of São Paulo;
Virtual Hospital - Instruments of Life: The Rights of
Patients Seen by the Patient.
 LEADERSHIP MANAGEMENT IN
Nursing assistance
UBS, CS, PSF, PACS