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NURSING PROCESS: Defined
The nursing process is a problem-solving approach that enables the nurse to provide care in an organized scientific manner. The goal of the nursing process is to alleviate, minimize, or prevent actual or potential health problems. The nursing process can be applied in any interaction that involves a nurse and a client. The process can take place in a variety of settings, including a hospital, community setting, private home, or long term care facility. This process requires the skills of critical thinking.
Characteristics of a Critical Thinker
- Curiosity:The desire, not just to know, but to understand how and why, to apply knowledge.
- Systemic Thinking:Uses an organized approach to problem solving, rather than knee-jerk responses
- Analytical:Applies knowledge from various disciplines, approaches a problem by examining the parts ands seeing how they fit together
- Open-Minded:Willing to consider various alternatives
- Self-confident:Sense of assurance that the problem solving process produces a good conclusion/plan
- Maturity:Recognition that many variables are at work in patient situations, and sometimes the best plans do not work
- Truth-seeking:Eager to know, asking questions, seeking answers, reevaluates "common knowledge"
The 5 steps/components of NURSING PROCESS are assessment, nursing diagnosis, planning, implementation, and evaluation. Initially the steps are followed in sequence. After the process has begun, it becomes a continuous cycle.
I. Nursing Process: ASSESSMENT
The collection of data assists us in determining a plan for the client as a part of the nursing process. Assessments are ongoing, and we should not overlook the importance of safety factors that will contribute to the positive outcomes for our clients. Following is some basic information and considerations relating to assessments. Incorporate them into your everyday nursing process to formulate a nursing care plan and to achieve the goals of your client. The nurse collects data about the health status of the client. Subjective data is usually documented in the client’s own words. This data includes such things as previous experiences and sensations or emotions that only the client can describe. The objective data is obtained by the health team, through observation, physical examination, or/and diagnostic testing. Objective data can be seen or measured. Sources of subjective data and objective data are the client, the family and significant others, medical records, and other health care team members. Assessment includes the "HEALTH HISTORY" and "PHYSICAL ASSESSMENT.”
The health history is a collection of subjective data that includes information on both the client's past and present health status. It is used in conjunction with the physical examination and laboratory findings as a basis for drawing conclusions about an individual's state of health. It allows positive aspects, health problems, health habits as well as abnormal symptoms, health problems, health teaching needs, and health concerns to be identified.
Components of a comprehensive Health History
- Date history obtained.
- Source of history.
- Interpreter if used.
- Reason for seeking health care.
- Client Profile Data.
- Present Illness Data.
- Present Health Status.
- Past Personal data.
- Family Medical data.
- Life-style data.
- Health Management data.
- Psychological data.
- Review of Systems.
PHYSICAL ASSESSMENT CAN BE BROKEN DOWN INTO FOUR COMPONENTS
- The priority of data collection is determined by the client's immediate condition or need.
- Pertinent data is collected using appropriate assessment techniques.
- Data collection involves the client, significant others, and health care providers when appropriate.
- The data collection is ongoing.
- Relevant data is recorded according to standards.
PHYSICAL ASSESSMENT: INSPECTION
Defined: Inspection is the visual examination of the client.
Guidelines for Effective Inspection
- Be systematic
- Fully expose the area to be inspected; cover other body parts to respect the client's modesty.
- Use good light, preferably natural light.
- Maintain comfortable room temperature.
- Observe color, shape, size, symmetry, position, and movement
- Compare bilateral structures for similarities and differences.
PHYSICAL ASSESSMENT: PALPATION
Defined:Palpation uses the sense of touch to assess various parts of the body and helps to confirm findings that are noted on inspection. The hands, especially the finger tips are used to assess skin temperature, check pulses, texture, moisture, masses, tenderness, or pain. Ask the Client for permission first and explain to your client what you intend to examine. Establish client trust with being professional. Please remember to use warm hands. Any tender areas should be palpated last.
PHYSICAL ASSESSMENT: PERCUSSION
Defined: Percussion is the striking of the body surface with short, sharp strokes in order to produce palpable vibrations and characteristic sounds. It is used to determine the location, size, shape, and density of underlying structures; to detect the presences of air or fluid in a body space; and to elicit tenderness.
PHYSICAL ASSESSMENT: AUSCULTATION
Defined: Auscultation is listening to sounds produced inside the body. These include breath sounds, heart sounds, vascular sounds, and bowel sounds. It is used to detect the presence of normal and abnormal sounds and to assess them in terms of loudness, pitch, quality, frequency and duration.
The following are examples of information that may be included in the assessment of each system; this is not a complete listing of possible values.
Respiratory: Color of skin, breath sounds, sputum assessment, respiratory rate, quality of respirations (flaring, grunting, laboring, etc.), pulse oximeter or EtCO2 readings, signs and symptoms of URI.
Circulatory: Heart rate, color of skin, complaints of anxiety or shortness of breath, heart tones, edema, complaints of dizziness, pacemaker evaluation.
Integumentary (Skin): Color; texture; turgor; presence of rash, bruising or redness; temperature (localized or general); abrasions; pressure areas; stoma and IV site condition.
Sensory: Vision; condition of eyes, ears, mouth, gums; need for glasses; ability to hear; discharge from ears or eyes; speech; mucosal condition; odor of breath; lesions in mouth; condition of teeth; complaints of any sensory organs.
Gastrointestinal: Adequate nutrition and hydration, ability to swallow, route of nutritional intake (GT, PO, parenteral), weight, complaints or signs of thirst or hunger, bowel patterns, use of or need for bowel aides, abdominal distention, bowel sounds, adequate elimination, ability to feed self, tolerance of feedings, nausea, vomiting.
Urinary: Color and odor of urine, urinary output, incontinence, use of urinary catheter, signs of retention or inability to void, pain with urination.
Neurological: Mental status; orientation to person, place, time; behaviors (anxiety, depression, nervousness); seizures; motor ability; weakness; spasms; tremors; numbness, paresis or paralysis.
Musculoskeletal: Weakness, contractures, joint redness, swelling or pain, recent injury, range of motion, need for ambulatory assistance or adaptive equipment.
Developmental: Describe the activities the client is able to engage in. This may be something as simple as following you with their eyes, startling with loud noises (Use Glasgow Coma Scale if appropriate), or as complex as their ability to perform to the expectations of the teacher. Include their ability to participate in activities of daily living, school, outside interests, etc.
Pain: Perform a complete pain assessment using an appropriate tool (Wong’s Faces, FLACC or 1-10 system).
Environmental and Safety: Assess for their risks related to safety.
RISK OF FIRE:
- Assess for the presence of smoke detectors, fire extinguisher, fire escape, blocked exits, limited exits & and the presence of an escape plan.
- Assess equipment for proper function, frayed electrical cords, and overloaded electrical outlets.
- Assess for proper oxygen use and safety.
RISK FOR INFECTION:
- Assess client for their risks related to infection. Immunosuppressed, wounds, portals of entry (trach, GT, IV lines, wounds, etc.)
- Temperature, pulse, heart rate, oxygen saturation levels, pain
RISK FOR FALL:
- Assess client for use of medications that may lower blood pressure, alter balance, and produce impaired mental state.
- Assess for environmental hazards: Loose rugs, congested and overcrowded hallways; walkways that may cause a fall.
- Assess client for balance, strength, use of assistive devices, impaired vision, neuromuscular dysfunction, sensory impairment, seizures, and tremors.
The nursing diagnosis is derived from data gathered during the assessment. Health problems or potential health problems are identified and formulated into nursing diagnosis. Nursing Diagnosis is the basis for planning nursing interventions that help prevent, minimize or alleviate specific health issues.A Medical Diagnosis is much different than nursing diagnosis; it is used to define etiology of the disease. It only focuses is on the function and malfunction of a specific organ system. The two are very different.
A Nursing Diagnosis is written in a format called "PES ", developed by NANDA
- "P" stands for PROBLEM
- "E "stands for ETIOLOGY or cause of problem
- "S "stands SIGNS and SYMPTOMS of problem
By using all of the components of the nursing diagnosis, the problem is clearly communicated to everyone involved in the clients care.
- Diagnosis are derived from the assessment data
- Diagnosis is validated with the client.
- Diagnosis is documented to aid in the expected outcomes and plan of care.
The planning phase of the Nursing Process involves the development of a nursing care plan for the client based on the nursing diagnosis. The nursing care plan is a communication tool used by Nurses to care for their clients. Care plans that are kept up to date are vital tools to provide continuity of care, prevent complications and provide for health teaching and discharge planning. Goals should be stated in terms of client outcomes. Each of these nursing sensitive outcomes is labeled, defined and includes criteria for the assessing the status of the outcome over time. Nursing orders are the actions for interventions prescribed to help achieve the stated goals and objectives. When writing nursing orders remember to include:
- How much
- How long
The steps in Nursing Care Planning are:
- Determine priorities from the list of nursing diagnoses.
- Set long-term and short-term goals to determine outcomes of care.
- Develop objectives to reach the goals.
- Write nursing orders to direct care to meet the goals.
- The plan is individualized to the client's condition.
- The plan is developed with the client and significant others if appropriate.
- The plan reflects current nursing practice.
- The plan is documented.
- The plan provides for continuity of care.
Implementation is the actual performance of the nursing interventions identified in the care plan. The implementations are coordinated with other members of the health care team who have direct care of the client. These interventions include, but are not limited to; health teaching, direct client care, medical treatments, medications, and dressing changes. Nurses provide care to achieve established goals of care and then communicate the nursing interventions by documenting and reporting.
Not all interventions are planned. The nurse must use her critical thinking skills to respond to an unexpected crisis.
- Interventions are consistent with the established plan of care.
- Interventions are implemented in a safe and appropriate manner.
- Interventions are documented according to Nursing Standards.
Evaluation is an ongoing process that enables the nurse to determine what progress the patient has made in meeting the goals for care. The outcome criteria provide measures for determining outcomes of care. Please Note that the nurse is not evaluating nursing interventions. In assessing outcomes of care, determine whether goals have been met, partially met, or not met at all. If the goals have not been met, it will be necessary to re-evaluate the plan. The plan may need to be altered. To do this, you will need to do a new assessment.
- Evaluation is systematic and ongoing.
- The client's response to interventions is documented.
- The effectiveness of interventions is evaluated in relation to outcomes.
- Ongoing assessment data are used to revise diagnosis, outcomes, and the plan of care are documented according to nursing standards.
- The client, significant others and the health care providers are involved in the evaluation process, when appropriate.
Purpose of Documentation: Communication
Documentation is fundamentally communication that reflects the client’s perspective on her/his health and well-being, the care provided, the effect of care and the continuity of care. All health care providers need ongoing access to client information to provide safe and effective care and treatment. Effective documentation allows nurses and other care providers to communicate about the care provided and to assist clients to make future care decisions. In addition, documentation provides a legal record of care provided.
You know the old saying, "If it isn’t documented you didn’t DO IT!”
A nurse maintains documentation that is:
- Clear, concise and comprehensive;
- Accurate, true and honest;
- Reflective of observations, not of unfounded conclusions;
- Timely and completed only during or after giving care;
- A complete record of nursing care provided, including assessments, identification of health issues, a plan of care, implementation and evaluation;
- Legible and non-erasable;
- Completed using forms, methods, systems provided or, in independent practice, using practitioner-created forms, methods and systems consistent with these standards.
A nurse’s documentation:
- Includes date and time of the care or the event, and the recording of when it is a late or forgotten entry;
- Identifies who provided the care;
- Contains meaningful information, avoids meaningless phrases such as "good night," "up and about," or "usual day";
- Includes what was observed and avoids statements such as "appears to" and "seems to" when describing observations;
- Includes signatures or initials, and professional designation; and
- Avoids duplication of information in the health record.
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