Foundations of Nursing Nursing Process Prepared by: Mark Fredderick R. Abejo R.N, M.A.

A. Collecting Data: Data collection is the process of gathering information about a clients health status. It must be both systematic and continuous to prevent the omission of significant data and reflect a clients changing health status. FOUNDATIONS OF NURSING Nursing Process Lecturer: Mark Fredderick R. Abejo R.N, M.A.N NURSING PROCESS A systematic, rational method of planning providing nursing care. Goal: 1. 2. 3. To identify a clients healthcare status, and actual or potential health problems To establish plans to meet the identified needs To deliver specific nursing interventions to address those needs Subjective Data also referred to as symptoms or covert data are apparent only to the person affected and can be described or verified only by that person. Itching, pain, and feelings of worry are examples of subjective data. It all includes the clients sensations, feelings, values, beliefs, attitudes, and perception of personal health status and life situation

I. ASSESSMENT PHASE

Objective Data also referred to as signs or overt data, are detectable by an observer or can be measured or tested against an accepted standard. They can be seen, heard, felt, or smelled, and they are obtained by observation or physical examination. Primary source is the client Secondary source is family or anyone else that is not the client Methods of Data Collection Observing To observe is to gather data by using the sense. Observation is a conscious, deliberate skill that is developed through effort and with an organized approach. It has to aspects: (a) noticing the data and (b) selecting, organizing, and interpreting the data. Interviewing An interview is a planned communication or a conversation with purpose, for example, to get or give information, identify problems of mutual concern, evaluate change, teach, provide support, or provide counseling or therapy. There are two approaches to interviewing: o Directive interview - Nurse directs interview, client responds to questions and has limited chances to discuss concerns. o Nondirective interview rapport-building where the client is in control of the purpose, subject, and pace. Questions : Open-ended invites client to discover and explore, elaborate, clarify, or illustrate their thoughts or feelings. How have you been feeling lately? Closed-ended used in directive interviewing, and are questions that require a yes or no answer.

The nurse carry out a complete & holistic nursing assessment of every patient's needs Utilizes an assessment framework, based on a nursing model or Waterlow scoring wherein problems are expressed as either actual or potential. Assessing is a systematic and continuous collection, organization, validation, and documentation of data (information) Assessing is a continuous process carried out during all phases of the nursing process Nursing assessments focus on a clients responses to a health problem Should include the clients perceived needs, health problems, related experience, health practices, values, and lifestyles

Types of Assessment Initial Assessment Problem-focused Assessment Emergency Assessment Time-lapsed Reassessment The assessment process involves four closely related activities: collecting data, organizing data, validating data, and documenting data.

Foundations of Nursing

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Foundations of Nursing Nursing Process Prepared by: Mark Fredderick R. Abejo R.N, M.A.N

Neutral question a question that the client can answer without direction. Why do you think you had the operation? Leading question directs the clients answer. Youre stressed about surgery tomorrow, arent you?

Examining The physical examination or physical assessment is a systematic data-collection method that uses observation (i.e., the senses of sight, hearing, smell, and touch) to detect health problems. To conduct the examination the nurses uses techniques of inspection, auscultation, palpation, and percussion.

D. Documenting Data: To complete the assessment phase, the nurse records client data. Accurate documentation is essential and should include all data collected about the clients health status. Data are recorded in a factual manner and not interpreted by the nurse o The nurse records the clients breakfast intake (objective) as coffee 240 mL, 1 egg, and 1 slice of toast II. DIAGNOSIS PHASE

B. Organizing Data: Using a written or computerized format that organizes the assessment data. Most schools of nursing and health cause agencies have developed their own structured assessment format. Frameworks: o Gordon 11 functional health patterns o Orem 8 universal self-care requisites of humans o Roys adaptation model o Maslows hierarchy of needs C. Validating Data: The information gathered during the assessment phase must be complete, factual, and accurate because the nursing diagnoses and interventions are based on this information. Validation is the act of double-checking or verifying data to confirm that it is accurate and factual. Cues vs. Inferences: o Cues subjective or objective data that can be directly observed by the nurse, either what the client says or what the nurse can see. o Inferences nurses interpretations or conclusions based on the cues. (A nurse observes the cues that an incision is red, hot, and swollen; the nurse makes the inference that the incision is infected.) You dont have to check all data (like birth dates, height, weight and most lab studies) Validating data helps the nurse complete these tasks: Ensure that assessment information is complete. Ensure that objective and related subjective data agree. Obtain additional information that may have been overlooked. Differentiate between cues and inferences. Avoid jumping to conclusions and focusing in the wrong direction to identify problems. The term diagnosing refers to the reasoning process, whereas the term diagnosis is a statement or conclusion regarding the nature of a phenomenon. The standardized North American Nursing Diagnosis Association (NANDA) names for the diagnoses are called diagnostic labels; and the clients problem statement, consisting of the diagnostic label plus etiology (causal relationship between a problem and its related Types of Nursing Diagnoses The five types of nursing diagnoses are actual, risk, wellness, possible, and syndrome. An actual diagnosis is a client problem that is present at the time of the nursing assessment. Examples are Ineffective Breathing Pattern and Anxiety. An actual nursing diagnosis is based on the presence of associated signs and symptoms. A risk nursing diagnosis is a clinical judgment that a problem does not exist, but the presence of risk factors indicates that a problem is likely to develop unless nurses intervene. A wellness diagnosis describes human responses to levels of wellness in an individual, family or community that have a readiness for enhancement A possible nursing diagnosis is one in which evidence about a health problem is incomplete or unclear. A possible diagnosis requires more data either to support or to refute it. Syndrome diagnosis is a diagnosis that is associated with a cluster of other diagnoses.

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Foundations of Nursing Nursing Process Prepared by: Mark Fredderick R. Abejo R.N, M.A.N

The Diagnostic Process The diagnostic process uses the critical-thinking skills of analysis and synthesis. Critical thinking is a cognitive process during which a person reviews data and considers explanations before forming an opinion. Analysis is the separation into components, that is, the breaking down of the whole into its parts . Synthesis is the opposite, that is, the putting together of parts into the whole. T he diagnostic has three steps: analyzing data, identifying health problems, risks, and strengths, and formulating diagnostic statements. A. Analyzing Data In the diagnostic process, analyzing involves the following steps: o Compare data against standards (identify significant cues). o Cluster cues (generate tentative hypotheses). Identify gaps and inconsistencies. B. Identifying Health Problems, Risks, and Strengths. After data are analyzed, the nurse and client can together identify strengths and problems. This is primarily a decision-making process. Determining problems and risk After grouping and clustering the data, the nurse and client together identify problems that support tentative actual, risk, and possible diagnoses. In addition, the nurse must determine whether the clients problem is a nursing diagnosis, medical diagnosis, or collaborative problem. Determining strengths At this stage, the nurse and client also establish the clients strengths, resources, and abilities to cope. Most people have a clearer perception of their problems or weakness than of their strengths and assets, which they often take for granted. A clients strengths can be found in the nursing assessment record (health, home life, education, recreation, exercise, work, family and friends, religious beliefs, and sense of humor). C. Formulating Diagnostic Statements Most nursing diagnoses are written as two-part or three-part statements, but there are variations of these. Basic two-part statements The basic two-part statement includes the following: Problem (P): statement of the clients response. Etiology (E): factors contributing to or probable cause of the responses.

Basic three-part statements The basic three-part nursing diagnosis statement is called the PES format and includes the following: Problem (P): statement of the clients response. Etiology (E): factors contributing to or probable cause of the responses. Signs and Symptoms (S): defining characteristics manifested by the client.

Problem Statement describes the clients health problem or response for which nursing therapy is given Qualifiers added words to give additional meaning to the diagnostic statement Altered change from baseline Impaired made worse, weakened, damaged Decreased smaller in size, amount or degree Ineffective not producing the desired effect Acute severe or of short duration. Chronic lasting a long time Diagnostic Labels o Describes the clients health problem or response for which nursing therapy is given. o Independent function areas of health care that are unique to nursing and separate and distinct from medical management. o Dependent function- Nurses are obligated to carry out physician-prescribed therapies and treatments.

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Foundations of Nursing Nursing Process Prepared by: Mark Fredderick R. Abejo R.N, M.A.N

Differentiating Nursing Diagnoses from Collaborative Problems o Collaborative monitoring the clients condition and preventing development of the potential complication and using physician-prescribed interventions. o Nursing Diagnoses involve the human response, which vary from one person to the next. COMMON ERRORS IN FORMULATING NURSING DIAGNOSES 1. Using medical diagnosis INCORRECT: Self-care deficit related to stroke CORRECT: Self-care deficit related to neuromuscular impairment 2. Relating the problem to an unchangeable situation 3. Confusing the etiology or signs/symptoms for the problem INCORRECT: Post-operative lung congestion related to bed rest CORRECT: Ineffective airway clearance related to general weakness and immobility 4. Use of a procedure instead of a human response INCORRECT: Catheterization related to urinary retention CORRECT: Urinary retention related to perineal swelling 5. Lack of specificity INCORRECT: Constipation related to nutritional intake CORRECT: Constipation related to inadequate dietary bulk and fluid intake 6. Combining two nursing diagnosis INCORRECT: Anxiety and fear related to separation from parents CORRECT: Anxiety related to change in environment and unmet needs 7. Relating one nursing diagnosis to another INCORRECT: Coping, individual ineffective related to anxiety CORRECT: Anxiety, severe related to change in role functioning and socio-economic status 8. Use of judgmental/value-laden language Ineffective airway clearance related to bad habit 9. Making assumptions INCORRECT: Risk for altered parenting related to inexperience CORRECT: Deficient knowledge regarding child care issues related to lack of previous experience, unfamiliarity with resources 10. Writing a Legally Inadvisable Statement INCORRECT: Skin integrity related to not being turned every 2 hours CORRECT: Impaired skin integrity related to pressure and altered circulation

A Nursing Diagnosis Is A statement of a patient problem Actual or potential Within the scope of nursing practice Directive of nursing intervention

Is not

A medical diagnosis A nursing action A physician order A therapeutic treatment

III. PLANNING PHASE

The third phase of the nursing process, in which the nurse and client develop client goals/desired outcomes and nursing interventions to prevent, reduce, or alleviate the clients health problems. Planning is a deliberative, systematic phase of the nursing process that involves decision making and problem solving. In planning, the nurse refers to the clients assessment data and diagnostic statements for direction in formulating clients goals and designing the nursing interventions required to prevent, reduce, or eliminate the clients health problems. A nursing intervention is any treatment, based upon clinical judgment and knowledge that a nurse performs to enhance patient/client outcomes

Types of Planning Planning begins with the first client contact and continues until the nurse-client relationship ends, usually when the client is discharges from the health care agency. Initial Planning The nurse perform the admission assessment usually develops the initial comprehensive plan of care. This nurse has the benefit of the clients body language as well as some intuitive kinds of information that are not available solely from the written database. Planning should be initiated as soon as possible after the initial assessment, especially because of the trend toward shorter hospital stays.

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Foundations of Nursing Nursing Process Prepared by: Mark Fredderick R. Abejo R.N, M.A.N

Ongoing Planning Is done by all nurses who work with the client. As nurses obtain new information evaluate the clients responses to care, they can individualize the initial care plan further. Ongoing planning 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, is a crucial part of comprehensive health care and should be addressed in each clients care plan. NURSING CARE PLAN Types of NCP Informal Nursing Care Plan o Strategy for action that exists in the nurses mind. Formal Nursing Care Plan o Written or computerized guide for organizing information Standardized Nursing Care Plan o Formal plan that specifies the nursing care for groups of clients with common needs. o Not for individuals o Preprinted guides for the nursing care of a client who has a need that arises frequently in the agency. o Problem -> Goals/desired outcomes -> Nursing interventions -> Evaluation Individualized Nursing Care Plan o Is tailored to meet the unique needs of a specific client. - When nurses use the clients nursing diagnoses to develop goals and nursing interventions, the result is a holistic, individualized plan of case that will meet the clients unique needs. - During planning phase, the nurse must decide which of the clients problems need individualized plans and which problems can be addressed by standardized plans and routine care, and write unique desired outcomes and nursing interventions for client problems that require nursing attention beyond preplanned, routine care. Guidelines for writing a Nursing Care Plan Date and sign the plan Use category headings Nursing Diagnoses Goals/Desired Outcomes Use standardized medical or English symbols and key words rather that complete sentences to communicate your ideas. Be specific Refer to procedure books or other sources of info rather than including all steps on something
Foundations of Nursing

Tailor plan to the client: Ask when the best time is for the client to do interventions Ensure that the plan incorporates preventive and health maintenance aspects as well as restorative ones. Ensure that the plan contains interventions for ongoing assessment of the client. Include collaborative and coordination activities in the plan Include plans for the clients discharge and home care need

The Planning Process In the process of developing client care, the nurse engages in the following activities: Priority Setting Is the process of establishing a preferential sequence for addressing nursing diagnoses and interventions. The nurse and client begin planning by deciding which nursing diagnosis requires attention first, which second, and so on. Instead of rankordering diagnoses, nurses can group them as having high, medium, or low priority. Life-threatening problems such as loss of respiratory or cardiac function are designated as high priority. The nurse must consider a variety of factors when assigning priorities, including the following: Clients health values and beliefs Clients priorities Resources available to the nurse and client Urgency of the health problem Medical treatment plan Establishing Client Goals/Desired Outcomes After establishing priorities, the nurse and client set goals for each nursing diagnosis. On a care plan the goals/desired outcome describe, in terms of observable client responses, what the nurse hopes to achieve by implementing the nursing interventions. The term goal and desired outcome are used interchangeably in this text, except when discussing and using standardized language. Selecting Nursing Interventions and Activities Nursing interventions and activities are the actions that a nurse performs to achieve client goals. The specific interventions chosen should focus on eliminating or reducing the etiology of the nursing diagnosis, which is the second clause of the diagnostic statement. Types of Nursing Interventions Independent interventions Are those activities that nurses are licensed to initiate on the basis of their knowledge and skills. They include physical care, ongoing assessment, emotional support and comfort, teaching, counseling, environmental management, and making referrals to other health care professionals.
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Foundations of Nursing Nursing Process Prepared by: Mark Fredderick R. Abejo R.N, M.A.N

Dependent interventions Are activities carried out under the physicians orders or supervision, or according to specified routines. Collaborative interventions Are actions the nurse carries out in collaboration with other health team members, such as physical therapist, social workers, dietitians, and physicians. Criteria for Choosing Nursing Interventions The following criteria can help the nurse to choose the best nursing interventions. The plan must be: Safe and appropriate for the individuals age, health, and condition. Achievable with the resources available. Congruent with the clients values, beliefs, and culture. Congruent with other therapies. Based on nursing knowledge and experience or knowledge from relevant sciences. Within established standards of care as determined by state laws, professional associations, and the policies of the institution. Writing Nursing Order After choosing the appropriate nursing interventions, the nurse writes them on the care plan as nursing orders. Nursing orders are instructions for the specific individualized activities the nurse performs to help the client meet established health care goals. The term order connotes a sense of accountability for the nurse who gives the order and for the nurse who carries it out. IV. IMPLEMENTATION / INTERVENTION PHASE

interventions that were developed in the planning step and then concludes the implementing step by recording nursing activities and the resulting client responses. Implementing Skills To implement the care plan successfully, nurses need cognitive, interpersonal, and technical skills. These skills are distinct from one another; in practice, however, nurses use them in various combinations and with different emphasis, depending on the activity. Having these skills contributes to the greater improvement of the nurse's delivery of health care to the patient, including the patient's level of health, or health status. Cognitive or Intellectual Skills Such as analyzing the problem, problem solving, critical thinking and making judgments regarding the patient's needs. Included in these skills are the ability to identify, differentiate actual and potential health problems through observation and decision making by synthesizing nursing knowledge previously acquired. Interpersonal Skills Which includes therapeutic communication, active listening, conveying knowledge and information, developing trust or rapport-building with the patient, and ethically obtaining needed and relevant information from the patient which is then to be utilized in health problem formulation and analysis. Technical Skills Which includes knowledge and skills needed to properly and safely manipulate and handle appropriate equipment needed by the patient in performing medical or diagnostic procedures, such as vital signs, and medication administrations. Process of Implementing The process of implementing normally includes: Reassessing the Client Just before implementing an intervention, the nurse must reassess the client to make sure the intervention is still needed. Even though an order is written on the care plan, the clients condition may have changed. Determining the Nurses Need for Assistance When implementing some nursing interventions, the nurse may require assistance for one of the following reasons: The nurse is unable to implement the nursing activity safely alone (e.g., ambulating an unsteady obese client). Assistance would reduce stress on the client (e.g., turning a person who experiences acute pain when moved). The nurse lacks the knowledge skills to implement a particular nursing activity (e.g., a nurse who is not familiar with a particular model of traction equipment needs assistance the first time it is applied).
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The methods by which the goal will be achieved are also recorded at this stage. The methods of implementation must be recorded in an explicit and tangible format in a way that the patient can understand should he wish to read it. Clarity is essential as it will aid communication between those tasked with carrying out patient care. Implementing consists of doing and documenting the activities that are specific nursing actions needed to carry out the

Foundations of Nursing

Foundations of Nursing Nursing Process Prepared by: Mark Fredderick R. Abejo R.N, M.A.N

Implementing the Nursing Interventions It is important to explain to the client what interventions will be done, what sensations to expect, what the client is expected to do, and what the expected outcome is. For many nursing activities it is important to ensure the clients privacy, for example by closing doors, pulling curtains, or draping the client. When implementing interventions, nurses should follow these guidelines: Base nursing interventions on scientific knowledge, nursing research, and professional standards of care whenever possible. Clearly understand the orders to be implemented and question any that are not understood. Adapt activities to the individual client. Implement safe care. Provide teaching, support, and comfort. Be holistic. Respect dignity of the client and enhance the clients self-esteem. Encourage clients to participate actively in implementing the nursing interventions. Supervising Delegated Care If care has been delegated to other health care personnel, the nurse responsible for the clients overall care must ensure that the activities have been implemented according to the care plan. Other caregivers may be required to communicate their activities to the nurse by documenting them on the client record, reporting verbally, or filling out a written form. The nurse validates and responds to any adverse findings or client responses. Documenting Nursing Activities After carrying out the nursing activities, the nurse completes the implementing phase by recording the interventions and client responses in the nursing progress notes. These are a part of the agencys permanent record for the client. Nursing care must not be recorded in advance because the nurse may determine on reassessment of the client that the intervention should not or cannot be implemented. V. EVALUATION PHASE

To evaluate is to judge or to appraise. Evaluating is a planned, ongoing, purposely activity in which clients and health care professionals determine (a) the clients progress toward achievement of goals/outcomes (b) the effectiveness of the nursing care plan. The purpose of this stage is to evaluate progress toward the goals identified in the previous stages. If progress towards the goal is slow, or if regression has occurred, the nurse must change the plan of care accordingly

Process of Evaluating Client Responses Before evaluation, the nurse identifies the desired outcomes (indicators) that will be used to measure client goal achievement Desired outcomes serve two purposes: they establish the kind of evaluative data that needed to be collected and provide a standard against which the data are judged. The evaluation process has five components:

Collecting Data Using the clearly stated, precise, and measurable desired outcomes as a guide, the nurse collects data so that conclusions can be drawn about whether the goals have been met. It is usually necessary to collect both objective and subjective data. Comparing Data with Outcomes If the first two parts of the evaluation process have been carried out effectively, it is relatively simple to determine whether a desired outcome has been met. Both the nurse and the client play an active role in comparing clients actual responses with the desired outcomes. After determining whether a goal has been met, the nurse writes an evaluative statement (either on the care plan or in the nurses notes). An evaluation statement consists of two parts: a conclusion (is a statement that the goal/desired outcomes was met, partially met, or not met), and supporting data (are the list of client responses that support the conclusion). Relating Nursing Activities to Outcomes The third aspect of the evaluating process is determining whether the nursing activities had any relation to the outcomes. It should never be assumed that a nursing activity was the cause of or the only factor in meeting, partially meeting, or not meeting a goal. Drawing Conclusions about Problem Status The nurse uses the judgments about goal achievement to determine whether the care plan was effective in resolving, reducing, or preventing client problems. When goals have been met, the nurse can draw one of the following conclusions about the status of the clients problem: The actual problem stated in the nursing diagnosis has been resolved; or potential problem is being prevented and the risk factors no longer exist.

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Foundations of Nursing Nursing Process Prepared by: Mark Fredderick R. Abejo R.N, M.A.N

In these instances, the nurse documents that the goals have been met and discontinues the care for the problem. The potential problem stated in the nursing diagnosis is being prevented, but the risk factors are still present. In this case, the nurse keeps the problem on the care plan. The actual problem still exists even though some goals are being met. The nursing interventions must be continued.

Quality Improvement Quality improvement (QI) is also known as continuous quality improvement (CQI), total quality management (TQM), performance improvement (PI), or persistent quality improvement (PQI) Nursing Audit An audit means the examination or review of records. A retrospective audit is the evaluation of a clients record after discharge from an agency. Retrospective means relating to past events. These evaluations use interviewing, direct observation of nursing care, and review of clinical records to determine whether specific evaluative criteria have been met.

Continuing, Modifying, and Terminating the Nursing Care Plan After drawing conclusions about the status of the clients problems, the nurse modifies the care plan as indicated. Depending on the agency, modifications may be made by drawing a line through proportions of the care plan, or marking portions using a highlighting pen, or writing Discontinued (dcd) and the date. Whether or not goals were met, a number of decisions need to be made about continuing, modifying, or terminating nursing care for each problem. Before making individual modifications, the nurse must first determine why the plan as a whole was not completely effective. This requires a review of the entire care plan and a critique of the nursing process steps involved in its development for a checklist to use when reviewing a care plan. Evaluating the Quality of Nursing Care In addition to evaluating goal achievement for individual clients, nurses are also involved in evaluating and modifying the overall quality of care given to groups of clients. This is an essential part of professional accountability. Quality Assurance A quality-assurance (QA) program is an ongoing, systematic process designed to evaluate and promote excellence in the health care provided to clients. Quality assurance frequently refers to evaluation of the level of care provided in a health care agency, but it may be limited to the evaluation of the performance of one nurse or more broadly involve the evaluation of the quality of the care in an agency, or even in a country. It consists of three components of care: The structure evaluation (focuses on the setting in which care is given. It answers this question: what effect does the setting have on the quality of care?), The process evaluation (focuses on how the care was given. It answers question such as these: Is the care relevant to the clients needs? Is the care appropriate, complete and timely?), Outcome evaluation (focuses on demonstrable changes in the clients health status as a result of nursing care. Outcome criteria are written in terms of client responses or health status.

Foundations of Nursing

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