nursing process introduction for MSN I unit

NUrinsg Process

1. Nursing Process 2

2. Session objective At the end of this session, students will be able to: Define nursing process List out purpose of nursing process List out characteristics of nursing process Discuss about component of nursing process 3 8/17/2024 by SANJAIKUMAR.A

3. What is nursing process? Common definitions Nursing process is an organised, systematic and deliberate approach to nursing in partnership with the patient and their family with the aim of improving standards in nursing care (Rush et al, 1996) It is a holistic and interactive approach through which nursing care provision is organised to achieve patient centred nursing interventions (Arnold and Boggs, 1999 and Heaven and Maguire, 1996) . N.B. Linda Hall first introduces the term nursing process in 1965 4 8/17/2024 by SANJAIKUMAR.A

4. What is Nursing Process? Common definitions... It is a systematic problem solving approach to client care. It is a series of planned steps and actions directed toward meeting the need and solving problems of people and their significant others It is an organised, systematic method of giving goal oriented, humanistic care that is both effective and efficient. Nursing process is the cornerstone of the nursing profession 5 8/17/2024 by SANJAIKUMAR.A

5. Purpose of Nursing Process 1. To identify clients health care needs 2. To establish nursing care plan so as to meet those needs 3.To give scientific based, holistic, individualized care for the patient; 4. An opportunity to work collaboratively with patients and others; 5. Achieve continuity of care and; 6. Encourages the health care team to observe and interact with the patient, and not just the task they are performing such as a administering an injection, dressing change, or a bed bath. 7. The process provides a roadmap that ensures good nursing care and improves patient outcomes. 6 8/17/2024 by SANJAIKUMAR.A

6. Characteristics of the Nursing Process Problem-oriented Goal-oriented Orderly, planned, systematic Open to accepting new information during its application Interpersonal Permits creativity among nurses and clients Universal; It is applicable to individuals, families, and communities 7 8/17/2024 by SANJAIKUMAR.A

7. Benefits of the NP for the Patient Access to quality nursing care Continuity of care Reduces the incidence of hospital stay Patient participation reflects respect for human dignity 8 8/17/2024 by SANJAIKUMAR.A

8. Benefits of the NP for the Nurse Consistent and systematic nursing education and care provision Job satisfaction Professional development Avoidance of legal action Meeting code of ethics and professional nursing standards Speed up diagnosis and treatment of actual and potential health problems Promotes flexibility and independent thinking 9 8/17/2024 by SANJAIKUMAR.A

9. Phases of Nursing Process 10

10. Components of the NP Components of the Nursing Process ‘ADPIE’ 11 8/17/2024 by SANJAIKUMAR.A

11. Nursing Process in the community Promote Prevent Maintain Restore 12

12. ASSESSMENT 13

13. Assessment Assessment is the systematic collection of data ( subjective and objective data ) to determine the patient’s health status and to identify any actual or potential health problem . It is the f irst step in the Nursing Process and includes: Collection of data Validation of data Organizing data Recording data 14 8/17/2024 by SANJAIKUMAR.A

14. Assessment… Data collection Nursing History from client as a primary source A comprehensive physical examination that helps to identify the client’s response to disease; to establish an initial data base for later comparison, and to validate subjective data presented by the client during the interview- Not toward identification of disease; Laboratory Nursing Records Relevant Literature Input from family and significant others 15 8/17/2024 by SANJAIKUMAR.A

15. Assessment… Ways of Designing Assessment Tool Use the Nursing Model– Functional Health Pattern This model changes from medical model ( disease oriented ) to Nursing model (holistic, human response oriented –Bio-psycho-social human being) 16 8/17/2024 by SANJAIKUMAR.A

16. 17 Sources of information : Primary Source – information of assessment comes from the client Secondary Source includes family members, significant other health care professionals, health records, and literature review

17. 18 Two categories of data collected: Subjective data – consists of client’s opinions, feelings about what is happening. Only the client can tell you that he/she is afraid or in pain. Sometimes the client can communicate through body language: gesture, facial expressions and body posture. To obtain subjective data you need sharp interviewing, listening and observation skills Objective data (precise, accurate measurements or clears descriptions) – include all the measurable and observable pieces of information about the client and his or her overall state of health.

18. Assessment… Subjective data: consists the client’s opinions, feelings about what is happening. To obtain subjective data you need sharp interviewing, listening, and observation skills. E.g . "I feel sick to my stomach." "I have a stabbing pain in my side." "I feel like nobody likes me." 19 8/17/2024 by SANJAIKUMAR.A

19. Assessment… Objective data: include all the measurable and observable pieces of information about the client and his or her overall state of health. Objective data are concrete, observable information such as: - vital signs, laboratory studies, and changes in physical appearance Example: Blood pressure of 110/70 mmHg. Rash on right arm Urinated 150 ml clear urine The term objective means that only precise, accurate measurements or clear descriptions are used. N.B. S- S = Subjective data are Stated . O-O = Objective data are Observable . 20 8/17/2024 by SANJAIKUMAR.A

20. Assessment… Method of data collection 1. Observation: is an assessment tool that relies on the use of the five senses (sight, touch, hearing, smell and taste) to discover information about client. 2. Health interview: the health interview is a way of soliciting information from the client. This interview may also be called a nursing history . 3. Physical examination: done from head to toe or on particular body area depending on the clients condition 21 8/17/2024 by SANJAIKUMAR.A

21. DIAGNOSIS 22

22. Nursing diagnosis Nursing diagnosis is a clinical judgment about an individual, family or community response to actual or potential health problems. It tells us the health care needs of the patient Nursing diagnosis are those problems for which nurses can legally prescribe definitive interventions independently. Type of Nursing Diagnosis: Actual Nursing Diagnosis Potential Nursing Diagnosis Wellness Nursing Diagnosis 23 8/17/2024 by SANJAIKUMAR.A

23. 24 Types of Nursing diagnosis Actual diagnosis - present at the time of nursing assessment Risk Nursing Diagnosis – problem does not exist, but the presence of risk factors indicates that a problem is likely to develop unless nurses intervene Wellness diagnosis – describes human responses to levels of wellness in an individual, family or community that have readiness for enhancement Possible nursing diagnosis - one in which evidence about a health problem is incomplete or unclear; requires more data either to support or to refute it. Syndrome diagnosis – a diagnosis that is associated with a cluster of other diagnoses

24. 25 Nursing Diagnosis Example Actual diagnosis - Deficient Fluid Volume related to nausea and vomiting as manifested by dry skin and mucous membranes and decreased oral intake of fluids Risk diagnosis - Risk for Infection related to presence of invasive lines (intravenous line and indwelling bladder catheter) Possible diagnosis - Possible Imbalanced Nutrition: Less Than Body Requirements related to insufficient oral intake Wellness diagnosis - Readiness for Enhanced Spiritual Well-Being

25. 26 Formulating Diagnostic Statement Formulating Diagnostic statements Problem (P): statement of the client’s response (NANDA label) Etiology (E): factors contributing to or probable cause of the responses The two parts are joined by the words 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

26. Example of 2-part Nursing diagnoses Problem Related to Etiology Constipation Related to Prolonged laxative use Ineffective Breastfeeding Related to Breast engorgement 27

27. 28 B. Basic three-part statements PES format and includes the following: Problem (P): statement of the client’s response (NANDA label) Etiology (E): factors contributing to or probable cause of the response Signs and Symptoms (S): defining characteristics manifested by the client

28. Example of PES format Problem Related to Etiology As manifested Signs and Symptoms ineffective airway clearance Related to (r/t) incisional pain as manifested by As manifested by ( a.m.b .) poor cough effort” 29

29. 30 C . One-part statements Some diagnostic statements such as wellness diagnoses and syndrome nursing diagnoses consist of a NANDA label only. As the diagnostic labels are refined they tend to become more specific, so that nursing interventions can be derived from the label itself. Therefore, an etiology may not be needed. Example: Rape-Trauma Syndrome

30. Actual nursing diagnosis Actual nursing diagnosis should be written as a three-part statement(s) which includes: The problem (P ), its cause or etiology (E) , Signs and symptoms (S) (defining characteristics or evident) (the ‘PES’ format) Therefore, the diagnostic statement should have Problem (Health Problem) Etiology Sign and symptom Examples: “ ineffective airway clearance related to incisional pain as manifested by poor cough effort” 31 8/17/2024 by SANJAIKUMAR.A

31. Actual nursing diagnosis... Summary of a 3-part statement for actual nursing diagnosis 1. Health Problem : Ineffective Airway Clearance N.B. Use one of the NANDA - approved nursing diagnostic labels to state the problem (NANDA- North American Nursing Diagnosis Association) 2. Etiology : related to weak cough and incisional pain 3. Signs and symptoms as manifested by poor or no cough (defining characteristics) 32 8/17/2024 by SANJAIKUMAR.A

32. Actual nursing diagnosis... PES Format: The PES format describes the problem and its causes(etiology), together with data(signs and symptoms) that validate the chosen diagnosis. To write the nursing diagnostic statement, you link the problem and its cause by using “ related to ” then add “ as manifested by ” or “ as evidenced by ” and state the major signs and symptoms that validate the diagnosis 33 8/17/2024 by SANJAIKUMAR.A

33. Potential nursing diagnosis Writing Diagnostic Statements for Potential Nursing Diagnoses If you assess a patient and note there are some high-risk factors present that may cause him to have a certain nursing diagnosis, then you have identified a potential nursing diagnosis. Use a two part format using “related to” to link the potential problem with the risk factor present 34 8/17/2024 by SANJAIKUMAR.A

34. Potential nursing diagnosis... Example : You were caring for an elderly woman who was very thin, immobile, and bedridden. She may have had excellent care at home, and as a result, has beautiful, healthy-looking skin. However, you should be aware that her age, weight, immobility, and confinement to bed can be contributing or etiological factors for Impaired Skin Integrity . 35 8/17/2024 by SANJAIKUMAR.A

35. Potential nursing diagnosis... Document the potential nursing diagnosis by writing a two-part statement that describes both the problem and its cause E.g. Potential Impaired Skin Integrity related to advanced age, immobility, and confinement to bed You would then establish a plan of care that would prevent irritated or broken skin E.g. establish a regimen of monitoring for pressure points and of turning, repositioning, and massaging to promote circulation to the skin 36 8/17/2024 by SANJAIKUMAR.A

36. Physician Vs Nursing diagnosis Physician Vs Nursing Diagnosis Physician diagnosis is disease focused, for e.g. “Ato Yidnek has pain and swelling in all joints. Diagnostic studies indicate that he has rheumatoid arthritis”. Nursing diagnosis is holistic, considering both the problem and its effect on the patient and family, for e.g. “Ato Yidnek has pain and swelling in all joints, making it difficult to feed and dress himself. He has voiced that it's difficult to feel worthwhile when he can't even feed himself”. 37 8/17/2024 by SANJAIKUMAR.A

37. Avoiding errors when writing Diagnostic Statements Don’t state the nursing diagnoses using the medical terminology ; focus on the person’s response to the medical problems; Don’t state two problems at the same time; e.g. anxiety and pain Don’t state the nursing diagnosis based on a value judgment 38 8/17/2024 by SANJAIKUMAR.A

38. 39 PLANNING

39. Nursing care plan (planning) Planning: development of goals and a plan of care designed to assist the patient in resolving the diagnosed problems. It includes: Setting priorities, establishing expected outcomes, and selecting nursing interventions & recording the plan of care Nursing care plan: is a record of nursing interventions that will address the identified problems; it’s a legal document that identifies the care to be given, and it shows who planned and gave that care, it aids continuity of care, it is a logical and systematic flow of ideas through from the initial assessment to the final evaluation (Rush and Fergy, 1996). 40 8/17/2024 by SANJAIKUMAR.A

40. Types of Planning Initial planning Usually developed by the admitting nurse who performs the assessment Planning should be initiated as soon as possible after the initial assessment, especially because of the trend toward shorter hospital stay Ongoing planning Is done by all nurses who work with the client Also occurs at the beginning of a shift as the nurse plans the care to be given that day Discharge planning The process of anticipating and planning for needs after discharge 41

41. 42 Developing a Nursing Care Plan Informal nursing care plan – is a strategy for action that exist in the nurse’s mind Formal nursing care plan – written or computerized guide that organizes information about the client’s care Standardized care plan – a formal plan that specifies the nursing care for groups of clients with common needs Individualized care plan – tailored to meet the unique needs of a specific client

42. 8/17/2024 by SANJAIKUMAR.A 43 Long –Term and Short-Term Goals Long-term goal Often used for client who live at home and have chronic health problems and for clients in nursing homes, extended care facilities, and rehabilitation centers. Short-term goal Useful for clients who require health care for a short time For clients who are frustrated by long-term goals that seem difficult to attain and who need the satisfaction of achieving a short-term goal

43. Nursing care plan (planning)… In writing the nursing care plan, the nurse should think about:  Who is it for? What are the short term and long term goals? How can you determine that you have reached the goals? (measurable) How will the patient know he/she has achieved the goals? (realistic) 44 8/17/2024 by SANJAIKUMAR.A

44. Nursing care plan (planning)… In writing the nursing care plan, the nurse should think about.. Who is involved in the delivery of the care? (The patient (and family), yourself, the nursing team, medical staff, multidisciplinary team, labs, investigations, procedures etc) nursing centred, and it identifies the scope and depth of the nursing practice How quickly is the problem likely to change? How soon will you need to re-evaluate the plan? How many problems are there? Which order of priority? 45 8/17/2024 by SANJAIKUMAR.A

45. Nursing care plan (planning)… Priority setting Nursing diagnoses are ranked in order of importance. Survival needs or imminent life threatening situations takes the highest priority. For example , the needs for air, water and food are survival needs. Nursing diagnostic categories that reflect these high-priorities needs include Ineffective Airway Clearance and deficient fluid volume. 46 8/17/2024 by SANJAIKUMAR.A

46. Nursing care plan (planning)… Priority setting … During setting criteria, consider the following points: Actual problems take precedence over potential concerns. Airway should always be given highest priority. Clients with unstable condition should be given priority over those with stable conditions. 47 8/17/2024 by SANJAIKUMAR.A

47. Nursing care plan (planning)… Priority setting … Priority setting is based on Maslow's hierarchy of human needs 48 8/17/2024 by SANJAIKUMAR.A

48. Nursing care plan (planning)… Priority setting … Priority 1. - Life threatening problems and those interfering with physiologic needs . (Ex. Problems with respiration, circulation, nutrition, hydration, elimination, temperature regulation, physical comfort); Priority 2. - Problems interfering with safety and security (ex. Environmental hazards, fear) Priority 3. - Problems interfering with love and belonging (ex. Isolation or loss of a loved one) 49 8/17/2024 by SANJAIKUMAR.A

49. Nursing care plan (planning)… Priority setting … Priority 4. - Problems interfering with self esteem (ex. Inability to wash hair, perform normal activities) Priority 5 . - Problems interfering with the ability to achieve personal goals. Exercise- Q. If you had someone with the following problems, which problem would you need to treat immediately? A. diarrhea B. severe dyspnea C. High risk for fluid volume deficit 50 8/17/2024 by SANJAIKUMAR.A

50. Nursing care plan (planning)… Setting client centered goals (Outcomes) Writing client-centered goals ( what the client is expected to achieve) instead of nursing goals (what the nurse aims to achieve) has been recognized as an effective method of writing goal statements. This is because client centered goals focus on the desired result of the plan of care, which is that the client benefit from nursing care.   51 8/17/2024 by SANJAIKUMAR.A

51. Nursing care plan (planning)… Outcome Identification Outcome criteria should be specific, measurable, attainable, realistic and time-bound Example 1 Goal(Outcome): The patient will report a decreased anxiety level regarding surgery Possible outcome criteria: During patient teaching, the patient discusses fears and concerns regarding surgical procedure. After patient teaching, the patient verbalizes decreased anxiety. The patient identifies a support system and strategies to use to reduce stress and anxiety related to the surgical experience. 52 8/17/2024 by SANJAIKUMAR.A

52. Nursing care plan (planning)… Outcome Identification… Example 2 Goal (Outcome) The patient will bring out pulmonary secretions. Possible outcome criteria: After the teaching session, the patient demonstrates proper coughing techniques. The client drinks at least 6 glasses of water per day while in the hospital. The caregiver demonstrates proper techniques of chest physiotherapy including percussion and postural drainage, before discharge 53 8/17/2024 by SANJAIKUMAR.A

53. Nursing Care Plan home take exercise Group exercise Plan the Nursing Care for MS. MARICEL AZUCENA, 28 years of age with Medical Diagnosis (upon admission) of Acute Gastroenteritis Subjective data: States… “I am weak and worried about my condition.”, “My stool is very watery and frequent” and “I’m feeling very feverish” Objective data: Temp = 38.0 C (oral), Pulse = 110 per minute Respiration rate = 32 per minute, Decreased PA O2 , the nurse observed that the patient had diarrhoea x 2-3 times of ½ cup per bout following admission 54 8/17/2024 by SANJAIKUMAR.A

54. 55 IMPLEMENTATION

55. IMPLEMENTATION Carrying out the planned nursing interventions Implementing skills include the following: Cognitive skills/intellectual skills Interpersonal skills Technical skills 56

56. Implementing skills include the following: Cognitive skills/intellectual skills –include problem solving, decision-making, critical thinking, and creativity. They are crucial to safe intelligent nursing care Interpersonal skills – all of the activities, verbal and non-verbal, that people use when interacting directly with one another Technical skills – “hands-on” skills such as manipulating equipment , giving injections and bandaging, moving, lifting and repositioning clients. These skills are also called tasks procedures, or psychomotor skills. The psychomotor includes the interpersonal component, for example, the need to communicate with the client 57

57. Nursing care implementation Implementation of established plan of care is putting the plan into action and it includes the following activities: Carrying out the Nursing Interventions and Activities prescribed in the nursing care plan during the planning phase Ongoing collection of information to determine how the patient is responding to nurses’ actions and to identify new problems Recording (Charting) and Communicating patient's health status and response to nursing interventions 58 8/17/2024 by SANJAIKUMAR.A

58. Nursing care implementation… Nurses function during Intervention Independent Interventions Dependent Interventions Collaborative or Interdependent Interventions 59 8/17/2024 by SANJAIKUMAR.A

59. Types of Nursing Interventions Independent interventions (nurse-initiated treatments) – activities that nurses are licensed to initiate on the basis of their knowledge and skills Dependent interventions (physician-initiated treatments) – activities carried out under the physician’s order or supervision, according to specified routines. Collaborative interventions – actions the nurse carries out in collaboration with other health team members, such as physical therapists, social workers, dietitians and physicians 8/17/2024 by SANJAIKUMAR.A 60

60. Nursing care implementation Nurses should use a wide range of interventions designed to (RMP) : Restore, Maintain and Promote Nursing interventions should be: Evidenced based info. On relevant Rx modalities Selected based on the needs and/or desires of the patient and accepted practice Selected according the nurse’s level of practice, education, and certification implemented within established plan of care Adapted to changing patient needs and situations Reviewed in order to understand the progress or lack of progress toward identified goals 61 8/17/2024 by SANJAIKUMAR.A

61. EVALUATION 62

62. Nursing Care Evaluation Nursing evaluation is the regular review of the effect of nursing interventions and the treatment regimen on the patient’s health status and expected health outcomes . During this phase Collect data regarding your client progress Measure goal attainment Revise or modify care plan if necessary 63 8/17/2024 by SANJAIKUMAR.A

63. Nursing Care Evaluation… The following questions should be considered: Have the goals  of the nursing care plan been achieved? If not, why not? Were the goals realistic? Was the patient committed to the goals? Was there enough time to achieve the goals? Did other problems arise that impeded progress? Were interventions consistently performed as prescribed? 64 8/17/2024 by SANJAIKUMAR.A

64. Nursing Care Evaluation… The following questions should be considered... Have any new problems developed that have not been addressed? Could more have been achieved than originally hoped for? Should new goals be set? 65 8/17/2024 by SANJAIKUMAR.A

65. Writing progress note Follow a SOAP format including SOAPE, SOAPIE , and SOAPIER notes. These are acronyms for subjective data (S), objective data (O), assessment (A) and plan (P). Some also use intervention (I), evaluation (E), and response (R). 66 8/17/2024 by SANJAIKUMAR.A

66. Writing progress note… SOAPE… S - Includes subjective data from the client. O- Objective data that can be observed or measured. A- is a conclusion from the subjective and objective data. Assessment is an interpretation of the client’s condition or level of progress. It is a statement of the status of the diagnosis or problem. It determines whether the problem has been resolved or if further care is required. 67 8/17/2024 by SANJAIKUMAR.A

67. Writing progress note… SOAPE… P - Depending on the assessment of the situation, the health care member maintains or revises the previous plan of care. Plans may include specific orders or interventions designed to manage the client’s problem and goals and expected outcomes of care. 68 8/17/2024 by SANJAIKUMAR.A

68. Thank you ! 8/17/2024 by SANJAIKUMAR.A 69