Nursing process.pdf

Nursing process.pdf

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  INTRODUCTION OF NURSINGPROCESS Yonas Wegayehu (BSc. N & MSc. AHN) Yonaswegayehu21@gmail.com June 6, 2023 Definition: Nursing Process is an orderly, systematic manner of determining the patients’ problems, making plans to solve them, initiating the plan or assigning other to implement it & evaluating the extent to which the plan was effective in resolving the problems identified. ✓ Nursing process:- is a systematic method for assessing health status, diagnosing health care needs, formulating a plan of care, initiating plan & evaluating the effectiveness of a plan ✓ It is a frame work for proving nursing care to patient, family and community Purposes: ❖ To identify clients health status, actual and potential health core problems or need ❖ To establish plans to meet the identified needs ❖ To deliver specific nursing intervention PROPERTIES OF NURSING PROCESS The nursing process has 6 properties 1- It is purposeful: because it is goal directed; here the nurse utilizes the phases of process to provide qualitative client centered care. 2- It is systematic: because it involves the use of an organized approach to achieve its purpose. 3- It is dynamic: because it involves continuous change. It is ongoing process focus on the response patient. 4- It is Interactive: because the interactive nature is based on the reciprocal relationship that occurs between the nurse, & the patient, family & other health professionals. 5- It is flexible: because it can be adapted to nursing practice in any setting/ area of specialize actions dealing with group, communities or individual. 6- It is theoretically based: because the process is devised from a broad base of knowledge
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  STEPS OF NURSINGPROCESS ✓ The nursing process a cyclical process and consists of 5 sequential & interrelated phase 1. Nursing Assessment 2. Nursing Diagnosis 3. Nursing Planning 4. Nursing Implementation 5. Nursing Evaluation NURSING ASSESSMENT  It is the first phase of nursing process  Assessment is a systematic collecting, organizing, validating and recording of subjective and objective data with the goal of making a clinical nursing judgment about a patient or family.  It enables nurses to determine the patient’s health status and to identify any actual or potential health problems. Purpose: ❖ To establish a trusting relationship with the patient ❖ To develop under sting about the patient ❖ To Guide physical examination ❖ Provide information for appropriate diagnosis ❖ It can be therapeutic Types of Assessment 1. Initial assessment: Performed at the time the patient enters the health care facility. ✓ Very broad and leads us to a center of our diagnosis ✓ Aim – Collection of data concerning actual or potential dysfunction 2. Focus Assessment: is concentrated on certain diagnosis and ✓ It leads us to the general condition of the specific diagnosis. ✓ Aim:- Determine status of a specific problems identified during previous assessment 3. Time Lapsed assessment: is the final assessment done after a period of time ✓ Assessment is focused type. ✓ Aim:- Comparing the patient’s current status to baseline obtained previously after an extended period of time 4. Emergency assessment: is assessment done on the life treating situation
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  ✓ Assessment shouldbe fast, correct, and leading to aggressive management. ✓ Aim:- identification of life threatening situation Assessment skills a. Observation : ability to observe and identify problems b. Interviewing history: the ability to communicate with others. c. Physical examination: Analysis of bodily function using techniques of – inspection palpitation, percussion and auscultation Assessment activities 1. Collect data:- Compiling information about the patient 2. Recording data 3. Validate data is double checking: it is the process of confirming the accuracy of assessment data e.g. “ I feel hot” check Temperature 4. Organize data :- use functional health pattern Source of Data a) Primary sources – the patient b) Secondary sources – family members or significant others health record laboratory test Types of data 1. Subjective data ✓ Also know as symptoms or covert include the patients feeling and statements about his or her health problems ✓ If should always be taken by the patient words E.g. I get sharp pain in my chest.” 2. Objective data ✓ Also known as sign or overt cues art observable and measurable ✓ It is an information witnessed by the examiner E.g. Bp. RR NURSING DIAGNOSIS  The second phase of nursing process  Nursing diagnosis- refers to the clinical judgment about individual, family or community responses to actual and potential health problems /life process  To diagnose means to analyze assume information and drive meaning.  In this phase, the nurses starts clusters and analyses the data and ask “what are the actual and potential health problems for the client, what factors contribute to this problems?”
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  Nursing diagnosis canbe 1. Actual nursing diagnosis describe human response to a health problem that is currently being manifested 2. A potential or high risk nursing diagnosis is a clinical judgment that a person, family or community is more vulnerable to develop the problem Components of nursing diagnosis  It should contain the problem + related factors (cause) + defining characteristics (evidenced factors  Actual Nursing diagnosis 1. Definition or problem 2. Related factors described the etiology or likely cause of the problem 3. Defining characteristics: are the major and minor clinical features that validate the presence of actual nursing diagnosis. NURSING PLANNING  It is a systematic approach in developing a plan of action based on a careful assessment  In this phase, the strategies are developed to prevent minimize or correct the problems identified in the nursing diagnosis.  Involves the series of steps in which the nurse and the client set priorities, goal and outcome criteria to resolve or minimizing the identified problems of the clients. Purpose ✓ Direct or guide patient care activities ✓ Ensure continuity of care ✓ Focus charting requirements ✓ Allow for the delegation of specific activities The Activities in this phase include 1. Establish priorities – based on nursing diagnosis and patient ne 2. Establish patient goal and outcome criteria ✓ Setting objective with the patient/family to correct, minimize or prevent the problem. ✓ The objective should be SMART (Specific, Measureable, Attainable, Relevant and Time bounded) ✓ Goal is an educated guess
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  ✓ Goal isthe broad statement about the state of the patient after the nursing interventions are carried out. ✓ If addresses directly the problem stated in nursing diagnosis ✓ They answer the questions who, what action under what circumstance. How well and when 3. Plan nursing intervention that will lead to achievement of the proposed objective 4. Recording /writing/ nursing care plan. ✓ Nursing care plan is a structure which provides clear picture about the problem, reason, objectives, method, action and evaluation for nurses to render prompt services for the patient. ✓ The nursing care plan is a blue printed structure to provide standard nursing care to the patient. ✓ The nursing care plan consists of at least 5 components which are abbreviated by PRONE. 1. Problem: can be actual or potential perceived gap. 2. Reason: may be causes, events, signs & symptoms of illness or conditions prevailed in the patients during visit or interview or observation. 3. Objective: statement of an intended result or outcomes of an action or programme 4. Nursing interventions: are specific approach designed to assist the client to achieve objective. 5. Evaluation NURSING IMPLEMENTATION  It is translation of the planning in to practice according to the principle of nursing  Without implementation, plans remain theoretical  Implementation in the initiation & completion of the actions necessary to achieve the objective defined in the planning stage  It can be carried out by members of the health team, the patient or the patient’s family.  Refers to the action phase of the nursing process in which nursing care is provided.  It is defined as the actual initiation of the plan, evaluation of the response to the plan and recording of nursing action.  The part in which the nursing care plan put in to action
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   This phaseends when the nurse records the care given and the clients response to the care given to him  Activities a. Reassess: Every time do the nurse assess the patients functional health (for all patients) b. Set priorities: based on the patient’s condition, new information from reassessment , time and resources available for nursing intervention, feedback from the patient and family and the nurse’s experience in assessing situations and setting priorities c. Perform nursing interventions d. Record nursing action.  Implementation skills A. Intellectual skills-> problem solving decision making and teaching skills B. Technical skills-> to carry out treatment and procedures C. Interpersonal skills-> ability to work with others. NURSING EVALUATION  The fifth element of nursing process  Evaluation – the judgment of effectiveness of nursing care to meet patient’s goal  It is the phase in which the nurse compares the patients behavioral response with predetermined patients foals and outcome criteria.  Evaluation is determination of the patients’ responses to the nursing implementation and then comparing the response to the extent to which the goal and the outcome criteria written in the care plan have been achieved.  The nurse determines the extent to which the goals have been achieved. It includes: ✓ Review of patient goal and outcome criteria ✓ Collection of data: subjective and objective data to judge patient’s response to nursing intervention. ✓ Measuring goal achievement: which may be achieved completely, partially or not achieved or new problems may develop ✓ Revise /modify the nursing care plan
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  1. DEVELOP NURSINGCARE PLAN The nursing care plan is a blue printed structure to provide standard nursing care to the patient. Documenting the plan of care, or writing the nursing care plan, is the final step in the planning phase for the nursing process for the registered nurse. Nursing care plans are written for individuals, families, groups, or communities. The purposes of the nursing care plan are: ✓ To provide a framework for nursing care ✓ To promote quality, client-centered care ✓ To promote continuity of care ✓ To provide for evaluation of the effectiveness of nursing care ✓ To promote communication among nursing staff and other health team members. In essence, the nursing care plan is the blueprint for directing nursing activities, as written guideline for client care. The nursing care plan is the total plan which is needed to implement the nursing process from assessment through evaluation. Why must nursing care plans be written? With the many functions and responsibilities of the nurse, why must time be spent in documenting nursing care plan? In order for the nursing care plan to be effective, it must be documented. This documentation provides a mechanism for communication among health team members which can help to ensure consistent, coordinated, effective care for the client. By writing the care plan, a permanent record is made of the care the client should receive and what he or she actually has received. The nursing care plan, when properly written, should provide direction for the nurse in terms of the type and frequency of observations to be made, what nursing measures to implement and how often, as well as what to teach the client and family. The nursing care plan indicates what should be documented in the nurse’s notes or progress notes. It also guides the nurse in evaluating the effectiveness of the care given to the client. Care plans facilitate nurses in delivering high-quality, consistent, and effective care. When should the care plan be developed? The most appropriate time is immediately after the first contact with the client. Once the assessment is completed and the data base has been reviewed, the registered nurse can begin to identify actual and potential problems (nursing diagnoses), and plan care accordingly. The initial nursing care plan will need to be revised and refined after further interactions with the client. While the registered nurse will begin to
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  formulate the nursingcare plan, other staff members will participate in evaluating and refining the care plan based on their assessments and identification of actual or potential problems. Nursing care plans should be readily available to all health team members involved in the care of the client. Access increases the use of the care plan. In some institutions, care plans are kept at the bedside; others keep the care plan in the chart or Kardex. Computerized facilities now keep the care plans in computerized medical charts. Nursing care plans are useful not only within the client’s current setting, but also as an important communication tool when clients are transferred from one department or unit to another, from one institution to another, or from an institution to home health care. The nursing care plan provides the essential ingredients for continuity of care. The components of the written nursing care plan most frequently used are: 1. Nursing diagnosis 2. Goals or expected outcomes 3. Nursing actions or interventions 4. Evaluation 2. STANDARDIZED NURSING CARE PLANS To facilitate the preparation and use of written nursing care plans, many institutions use standardized care plans. The advantages of standardized care plans are: ✓ They are developed by clinical experts and become the standards of care for clients with a particular diagnosis; thus, they can be used to educate nurses unfamiliar with certain medical or nursing diagnoses. ✓ They reduce the time nurses spend writing nursing care plans; thus, standardized care plans increase the efficiency of nursing care planning. Standardized care plans are usually categorized according to specific medical-surgical conditions. (There are also standardized care plans for obstetrics, pediatrics, and other specialties.) Standardized care plan formats typically include nursing diagnoses, goals/expected outcomes, and nursing interventions. Because standardized care plans include the usual or predictable problems associated with the specific medical diagnoses, the plans must be individualized for each client.
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  2.1.Monitoring and evaluationof nursing care The client/patient’s progress or lack of progress toward goal achievement is determined by the client/patient and the nurse. The patient’s role in the nursing process is never more important than in the evaluation process. The nurse can assess through objective data whether or not the nursing actions were effective. The patient provides necessary subjective data regarding the effectiveness of the plan of care. After all, it is the patient’s problem that is being addressed, and his or her perception of goal achievement is key to evaluation. Through evaluation the nurse determines the patient’s progress toward achievement of the stated goals/expected outcomes. The focus of goal evaluation is the outcome of nursing care in the form of changed client behavior. 1. When evaluating goal achievement for a particular nursing diagnosis, the nurse examines the goal/expected outcome statement in the nursing care plan: 2. What was the expected client behavior? 3. Was the client able to perform the expected behavior in the time specified in the goal statement? 4. Was the client able to perform the behavior as well as described in the expected outcome statement? When the goals are evaluated, they should be signed and dated by the nurse. It should be indicated whether the goal was resolved, partially resolved, or not resolved at all. The client/patient’s progress or lack of progress toward goal achievement directs reassessment, reordering of priorities, new goal setting, and revision of the plan of nursing care, by the RN. Following evaluation of goal achievement, the RN reviews the entire nursing care plan, judging the effectiveness of the nursing actions, strategies, and the plan of care. This review of the care plan keeps it current and responsive to the patient’s changing needs. 2.2. Monitoring general condition of the patient 2.3. Identified/ responding risk and emergency situations 2.4.Self-management for chronic conditions Self management is the ability of the patient to deal with all that a chronic illness entails, including symptoms, treatment, physical and social consequences, and lifestyle changes. With effective self-management, the patient can monitor his or her condition and make
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  whatever cognitive, behavioral,and emotional changes are needed to maintain a satisfactory quality of life. Support of patient self-management is a key component of effective chronic illness care and improved patient outcomes. Self-management support goes beyond traditional knowledge- based patient education to include processes that develop patient problem-solving skills, improve self-efficacy, and support application of knowledge in real-life situations that matter to patients. This approach also encompasses system focused changes in the primary care environment. Steps to Support Self-management in Patients with Chronic illness • Address health literacy issues and medical obstacles to self-management. • Identify problems from the patient’s perspective by asking provocative questions and listening to patient responses • Include goal-setting, action-planning, and problem-solving strategies to overcome barriers based on the patient’s immediate concerns. • Link patients to community-based self management resources. • Provide self-management education. • Follow up with patients systematically about action plans and goals, in person, by phone, • Provide group visits that include self management education. • Schedule planned visits that allow time to address self-management tasks. Setting priority to meet clients need To determine which problems should be addressed first, in the plan of care, the nursing diagnoses must be prioritized. This component of practice is reserved for the RN. 1. In setting priorities, the first consideration is: Are any of the identified nursing diagnoses life threatening? In this patient situation, the answer is no. 2. The next step is to classify the diagnoses according to Maslow’s hierarchy of needs. Remember, the physiological needs are essential for survival. In prioritizing physiological need, those diagnoses, which take highest priority to relate to the need for air and oxygen. After that, needs related to food, water, sleep, and comfort are addressed. Higher level needs, such as those related to self-esteem; take lower priority than physiological needs. It is important to remember that lower level needs do not have to be
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  completely resolved beforeprogressing to higher level needs. Also, there can be unresolved needs on more than one level at the same time. 3. Scientific and nursing practice principles should be considered when prioritizing nursing diagnoses. 4. The patient’s input is essential in prioritizing diagnoses and determining which problems should be addressed first. The nurse should focus first on problems the patient feels are most important as long as the priority does not interfere with medical treatment and is in the best interest of the patient.