The Nursing process explained in broad detail

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1. Nursing process MR NJAGI 10/16/2023

2. Def: nursing process “Nursing process is an organized ,systematic method of giving individualized nursing care that focuses on identifying and treating unique responses of individuals or groups to actual or potential alterations in health”. It is a systematic method that directs the nurse and patient in planning care , and enables them to organize and deliver nursing care

3. Characteristics of NP Systematic: it consist of five steps during which nurses take deliberate steps to maximize efficiency and attain long term beneficial results . Dynamic/Holistic/Broad-involves moving back and forth between the steps, sometimes combining activities, yet still setting the same end results Humanistic-considers the unique interests, values and desires of the client/patient

4. Cont. 4) Outcome oriented/result oriented-Designed to keep nurses focused on determining whether the clients are getting the best results in the most efficient way. 5) Specific documentation requirements provides key data that can be studied to improve results for other patients in similar situations. 10/16/2023

5. Five Steps of the Nursing Process ADPIE Assessment – collection of patient data Diagnosis – identifies patients actual and potential problems Planning – develop the specific holistic desired goals and nursing interventions to assist the patient Implementation/intervention – carry out the plan of care Evaluation – determine the effectiveness of the plan of care Document all your findings

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7. Cont Step 1;Assessment; Gathering of information about a patient physiological, psychological, sociological and spiritual status. The purpose of nursing assessment is to identify the patients nursing problems It involves five areas Data collection Data validation Data organization Identifying patterns Report and recording (documentation)

8. Cont Data collection; Ways of collecting data include taking vital signs, lab investigations, physical examination, and history taking Types of Data ; Subjective data – what the patients tells you Objective data – what you observe or data obtained Historical data- past events e.g. hospitalization in August,2022 Current data – present events e.g. vital/labs on admission Risk factors – cues which point to potential problems ( Cues; A word used to describe the individual pieces of data or “hints” about what is going on with the client Also called assessment findings/ indicators 10/16/2023

9. Cont Sources of Data; Primary : from the client, considered the most reliable if the client is deemed a good historian Secondary: significant others, the medical or health record, lab tests, diagnostic procedures, other health team members.

10. Cont. Data Validation; The process of checking and verifying the collected information, to ensure data is free from error and misinterpretation. Data organization; Need to use an organized assessment framework to help cluster assessment data (cues) into meaningful groups Gordon’s Functional Health Patterns adopted. 10/16/2023

11. Marjore Gordon’s 11 Functional Health Patterns Marjorie Gordon proposed functional health patterns as a guide for establishing a comprehensive nursing data base of pertinent client assessment information. These 11 categories make possible a systematic and standardised approach to data collection, and enable the nurse to determine the following aspects of health and human function in order to plan the required nursing care for their clients. Consider the questions that you will need to ask your client to collect relevant and pertinent information for each of the 11 functional health patterns.

12. Gordon Functional health pattern (North America Nurses Diagnosis Association -NANDA) 1. Health Perception-Health Promotion Pattern; Data collection is focused on how the person manages his health. Habits that may be detrimental to health are also evaluated, including smoking and alcohol or drug use. Immunization levels, past surgery and why. 2.Nutritional-Metabolic Pattern; Assessment is focused on the pattern of food and fluid consumption and regularity. 3.Elimination & Exchange Pattern; Data collection is focused on excretory patterns (bowel, bladder, skin). Excretory problems such as incontinence, constipation, diarrhoea, and urinary retention may be identified. 10/16/2023

13. Cont 4. Activity/ Exercise Pattern; Assessment is focused on the activities of daily living requiring energy expenditure(exercises, and leisure activities) The status of major body systems involved with activity and exercise is evaluated, including the respiratory, cardiovascular, and musculoskeletal systems . 5. Sexuality—Reproductive Pattern; Assessment is focused on the person's satisfaction or dissatisfaction with sexuality patterns and reproductive functions. Concerns with sexuality may he identified( libido,sexual partners,mernache,menaupose )

14. Cont 6 . Comfort/Relaxation(sleep $ rest) ; Assessment is focused on the person's sleep, rest, and relaxation practices. 7. Perceptual / cognitive Pattern; Assessment is focused on the ability to comprehend and use information and on the sensory functions. Sensory experiences such as pain and altered sensory input may be identified and further evaluated. Issues like memory /loss of memory are addressed. 8. Role and Relationships Pattern; Assessment is focused on the person's roles in the world and relationships with others( ccupation,responsibility in the family) Satisfaction with roles, role strain, or dysfunctional relationships may be further evaluated.

15. Cont 9. Coping/Stress Tolerance Pattern Assessment is focused on the person's perception of stress and on his or her coping strategies Support systems are evaluated, and symptoms of stress are noted(anger…) 10. Safety & protection Pattern Actual or potential problems related to safety and health management may be identified as well as needs for modifications in the home or needs for continued care in the home. 11. Life Principles/Values and Belief Pattern Assessment is focused on the person's values and beliefs (including spiritual beliefs), or on the goals that guide his or her choices or decisions. 10/16/2023

16. Cont Step 2: Nursing Diagnosis: Nursing diagnosis is a clinical judgment about individual, family, or potential health problems/life processes. Nursing diagnosis provides the basis for selection of nursing interventions to achieve outcomes for which the nurse is accountable. Nursing Diagnosis naming is done according to North America Nurses Diagnosis Association (NANDA) NANDA was established in 1973 to identify standards and classify health problems treated by nurses. Its conferences are held every two years to continue progress in defining, classifying and describing diagnoses

17. Categories of Nursing Diagnosis 1. Actual Nursing Diagnosis: Actual evidence of signs/symptoms / indicator of diagnosis exist. It has three parts i.e. diagnostic label/problem, contributing factor/etiology (“related to”), and signs and symptoms (“as evidenced by” or “as manifested by ”) Use accepted qualifying terms using NANDA guideline e.g. Altered, ineffective, decreased, increased, impaired

18. Examples Impaired verbal communication related to pressure of the vocal cords by the tumor evidenced by hoarseness of voice . Anxiety  related to stress as evidenced by increased tension and expression of concern regarding upcoming  surgery Acute pain  related to decreased myocardial flow as evidenced by grimacing, expression of pain Ineffective breathing pattern related to pressure of the larynx by the tumor evidenced by dyspnea & coughing . 10/16/2023

19. Cont 5) Chronic pain related to ulceration of the larynx evidenced by facial grimace(distortion of face) & Patient verbalizing of throat pain. 6) Imbalanced nutrition, related to inability to ingest food secondary to swallowing difficulties evidenced by loss of body weight & emaciation. 7)Activity intolerance related to general malaise evidenced by patient not able to feed, dress and bath himself. 8)Fluid volume deficiency related to dysphagia secondary to pressure of the esophagus by the tumor evidenced by dry lips and low urine output

20. 2.Potential/Risk for diagnosis Client’s data base contains risk factors of diagnosis, but no true evidence. It has two parts; The first part is the diagnostic label and the second is the validation for a risk nursing diagnosis or the presence of risk factors . It’s not possible to have a third part because signs and symptoms do not exist 10/16/2023

21. Examples; P atient report that he is vomiting and has diarrhea, but no dry lips and has normal urine output ( No signs and symptoms but patient is at risk for Fluid Volume Deficit) Risk for fluid volume deficit related to diarrhea and vomiting Risk for infection related to weakened immune system response Risk for Impaired skin integrity related to emaciation & immobility.

22. Cont Medical Diagnosis; Identification of a disease condition based on a specific evaluation of physical signs, symptoms, history, diagnostic tests, and procedures The goals of a medical diagnosis is to identify the cause of illness or injury and design a treatment plan 10/16/2023

23. Medical vs. Nursing diagnosis Medical diagnosis: Identify disease Physician directs treatment Remains the same as long as the disease is present Example; Pneumonia. 10/16/2023

24. Nursing Diagnosis: Focus on unhealthy response to health or illness Nurse treats problem within scope of independent nursing practice May change from day to day as the patient’s responses change Example:Fear,Altered health maintenance, Knowledge deficit,Pain . 10/16/2023

25. Step 3. Planning It involves setting priorities ,writing goals and desired outcomes, and establishing a written plan for nursing intervention (NURSING CARE PLAN) Skills needed in planning is critical thinking

26. Selecting priorities The process of establishing a preference order for nursing diagnosis and interventions. Diagnoses are grouped as – high, medium, low Life-threatening situations should be given highest priority. Use the principle of ABC’s (airway, breathing, circulation) 10/16/2023

27. P urpose for desired outcomes/goals Provides direction for planning nursing care Serve as criteria for evaluating client progress Enable the client and the nurse to determine when problem is resolved Motivation for nurse and client as a sense of achievement is provided . 10/16/2023

28. Short Term vs. Long Term Goals Short term goal can be achieved in a reasonable amount of time ( few hours to few days) Long term goals may take weeks/months to be achieved Client will ambulate down the hall within 2 days. Client will walk the length of the hallway independently by the end of 2 weeks Patient will have moist lips and increased urine output of one litre in 12 hours

29. Example F or a patient at Risk for Impaired skin integrity related to immobility; Desired outcome/goal would be; The patient will have no signs of skin breakdown( redness) & swelling in 24 hours. Outcome needs to be time bound. ( state time period to achieve goal)

30. Determining Interventions Nursing interventions are actions performed by nurse to reach goal or outcome Monitor health status Minimize client risks Eg;allaying anxiety, giving pain killers in case of pain, bathing the patient, dressing the wound to alleviate the risk of infection.

31. Nursing Care Plan The nursing care plan serves to communicate the following information to all members of the nursing team : The nursing diagnosis and priorities The goals of the nursing intervention The nursing interventions which are expressed in the form of nursing orders The expected outcomes which identify the expected behavioral responses of the patient The critical time periods within which each outcome must be met

32. NB You must write down the precise behavior expected in the nursing care plan. It should be written in a systematic manner that facilitates its use by all nursing personnel . You should provide space in the care plan for the documentation of the patient's response in the nursing interventions and the outcomes The nursing care plan is subject to change as the patients problems change or as the priorities of the problem and resolution of the problems shift and as additional information about the patient's state of health is collected.

33. NB v. As you implement nursing interventions, the patient's responses are evaluated and documented and the care plan changed accordingly. vi.A well-developed and continuously updated nursing care plan is the greatest assistance to the patient, since their nursing diagnosis will be resolved and their needs will be met. 10/16/2023

34. Step 4. I mplementation Implementation is the carrying out of nursing interventions. Putting the plan into action It incorporates all the activities performed to promote health, prevent complications, treat problems and facilitate the clients coping with alterations in health status. Skills used in implementing are cognitive, interpersonal and technical skills. 10/16/2023

35. Step 5. Evaluation During evaluation the clients health status and the effectiveness of the care plan in achieving clients goals is evaluated The desired goals /outcome formulated during the planning phase serve as criteria for evaluating clients progress and improve health status Judgments that can be made are: 1.Resolved 2. Revise 3. Continue

36. Benefits of the NP Speeds up diagnosis and treatment reducing the hospital stay Has precise documentation which improves communication Prevent clinician from losing sight of the importance of human factor Promotes flexibility and independent thinking Tailors interventions to the individual clients needs Help clients and relatives to realize their input is important Nurses have the satisfaction of getting results Has precise documentation 10/16/2023

37. S ummary 10/16/2023