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Nursing Process

The document outlines the nursing process as a systematic method for providing individualized care, consisting of five steps: assessment, diagnosis, planning, implementation, and evaluation. It highlights the evolution of the nursing process, its unique characteristics, and the benefits of its application in promoting quality care and client participation. Additionally, it emphasizes the importance of critical thinking and effective communication in nursing practice.
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0% found this document useful (0 votes)
15 views36 pages

Nursing Process

The document outlines the nursing process as a systematic method for providing individualized care, consisting of five steps: assessment, diagnosis, planning, implementation, and evaluation. It highlights the evolution of the nursing process, its unique characteristics, and the benefits of its application in promoting quality care and client participation. Additionally, it emphasizes the importance of critical thinking and effective communication in nursing practice.
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as PPT, PDF, TXT or read online on Scribd
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Adult Health Nursing I

FN:2303

Sudath Shirley Pathmasiri Warnakulasuriya


RN , RMN ,PGDPC, BScN, MScN ,PhD

Senior Lecturer
University of Colombo
Learning Objectives
1.Describe the historical evolution of the nursing
process.

2.Discuss the nursing process as a therapeutic


framework and describe how it is accepted as a tool for
promoting multidisciplinary collaboration.

3.List and define the five steps of the nursing process.


Learning Objectives
4. Identify theories and philosophies nursing
professionals use in practice to gain an
understanding of the human race.

5. Explain how critical thinking is an important


element of the nursing process.

6. List outstanding characteristics and benefits of the


nursing process.
What is Nursing process ?
Process : A series of planned actions directed
toward a particular result or goal

 Nursing Process
 An organized, systematic method of planning and providing
individualized care to clients

 Can be used any setting where care is provided to clients

 A tool promoting organization and utilization of the steps to


achieve desired outcomes.
Nursing Process
The nursing process is a step-by-step method of
providing care to clients

 Each step, the nurse uses a variety of skills that are


purposeful and promote a systematic, orderly thought
process

The nursing process consists of five steps—


assessment, diagnosis, planning and outcome
identification, implementation, and evaluation
Nursing Process
Unique Characteristics of the Nursing Process
A problem-solving and decision-making method
that is scientifically, as well as philosophically
based .
Cyclic, ongoing, and dynamic
Universally applicable
Client centered
Data are collected and analyzed, and a plan is
formulated and set into motion
Client progress and response to treatment are
continuously monitored and evaluated.
The care plan is revised according to the changing
needs of the client.
Unique Characteristics of the Nursing Process
The ultimate goal is to promote and restore client
wellness, or to maintain the client’s present state of
health or sense of wellness.

The client is continuously monitored for changing


needs, and the plan is evaluated for accuracy
What are the benefits of Nursing process ?
Benefits of application of the nursing process
Promotes improved quality and continuity of care

Promotes and encourages active client participation

Delivery of care and problem solving are

Organized, continuous, and systematic

Time and resources are utilized more efficiently


 Meet expectations of both the health care consumer
and standards of the nursing
profession
Holds all nurses accountable and responsible for
five steps of client care
Benefits of application of the nursing process
Provides individualized care
Provides more effective communication among
nurses and healthcare professionals
Develops a clear and efficient plan of care
Provides personal satisfaction as you see client
achieve goals
Professional growth as you evaluate effectiveness
of your interventions
Evolution of the Nursing Process
In 1955 The term nursing process was coined by Lydia Hall
1950-early 1960 Dorothy Johnson (1959), Ida Orlando (1961),
and Ernestine Wiedenbach (1963) introduced a three-step
nursing process model.
1966 - Virginia Henderson identified the nursing process model
as the same steps used in the scientific method
1973 American Nurses Association (ANA) published Standards
of Clinical Nursing Practice and nursing process gained attention
Publication of Standards gave further legitimacy to the five
phases or steps of the nursing process
North American Nursing Diagnosis Association (NANDA) refines
nursing diagnoses 2 years time
Evolution of the Nursing Process
In 1982 National Council Licensure Examination
(NCLEX) was revised to include the nursing process
concepts as a basis for organization

Joint Commission on Accreditation of Health care


Organizations (JCAHO) launched requirements for
accredited hospitals to use the nursing process

1n 1987 Nursing process was introduced in Sri Lanka


How nurses use nursing process ?
Through the nursing process the nurse utilizes
interpersonal, technical, and intellectual skills

Interpersonal :Communicating, listening, conveying


interest and compassion, and sharing knowledge and
information

Technical: Operation of equipment and performance of


procedures

Intellectual skills: Analyzing, problem solving, critical


thinking, and making judgments.
How nurses use nursing process cont.?

Nurses review, revise, and validate the care plan,


enhancing and promoting quality of care

Recognized to be highly effective in promoting


quality of care
1. Assessment
Provides significant information, assembled to form the
client database
This phase involves several steps:
 Data collection: through interviews, conversations, and
performing physical assessment ( use Varity of sources ? )

 Verification: validating accuracy of data will help prevent


omissions, misunderstanding, and incorrect inferences.

 Organization: categorizing or identifying patterns in data

 Interpretation: formulating initial ideas or impressions

 Documentation: recording or reporting data


Data collection
Subjective data : The client’s communicated
description, perception, feelings, emotions, or
concerns

Objective data : Observable or measurable


information, accumulated through the physical exam,
interview, or results of diagnostic examinations.
Data collection
 Primary Source - Client / Family
 Secondary Source - physical exam, nursing
history, team members, lab reports, diagnostic
tests…..

Assessment interview
 Culturally effective communication skills
 Behavioral observations

 Explore Previous records/data bases

Comprehensive assessment of patient


Step 2: Nursing Diagnosis

Nursing : diagnose and treatment of human


responses to actual or potential health problems” .
[American Nurses Association(ANA), 1980]

 The classification of a disease, condition, or


human response based upon scientific evaluation of
signs and symptoms, patient history, and diagnostic
studies.
Step 2: Nursing Diagnosis cont.
Writing diagnoses
A diagnosis is written in two parts join by the phrase
“related to”
First part: patient's health status

The part of the statement follows by the term “related


to” phrase identifies the physical, psychological,
cultural, spiritual and environmental factors that
cause occurrence of the response .
 The nurse uses critical-thinking and decision-
making skills in developing nursing diagnoses
 A process facilitated by asking questions such as
– What are the actual problems
– What are the possible causes of the problems?
– Is the client at risk for developing other problems;
– if so, what are the factors involved?
– What are the client’s strengths?
– What additional data might be needed to answer these
questions?
– What are possible sources of data collection?
– Are there any identified problems that should be treated in
collaboration with the physician?
– What data are pertinent to collect before contacting the
physician?
Writing diagnoses
Writing method of diagnoses have three components
1. Problem (P),which is the NANDA label

2. Etiology (E) of the problem ,which name the


related factor and is indicated by the phrase “related
to”

3. Sings and symptoms (S),which are the defining


characteristics and are indicated by the phrase “as
manifested by”
Writing diagnoses
Examples
1.Anxiety (P)related to hospitalization(E) as manifested by
statement of nervousness(S) and by crying

2.Bowel incontinence (P) related to loss of sphincter


control (E) as manifested by involuntary passage of stool(S)

3.Fatigue(P) related to side effect(E) of chemotherapy as


manifested by inability(S) to carry out normal daily routine
Step 3: Planning and Outcome Identification
 Involve formulating and documenting the care plan

This task involves several steps:


 1. Prioritizing nursing diagnoses

 2. Identifying short- and long-term goals and


expected outcomes

 3. Determining nursing interventions that will aid


in resolution or prevention of each problem
Step 3: Planning and Outcome Identification cont.
Prioritizing problems :
Decide which nursing diagnoses are most important and
require attention first
 Problems involving life-threatening situations are given
the highest priority
Goals are client centered, which means they focus on
behavior of the client

An expected outcome is a particular expectation involving


steps leading to the fulfillment of a goal

Goals and expected outcomes are used to evaluate the


effectiveness of nursing interventions and the care plan
Step 3: Planning and Outcome Identification cont.
Outcomes are mutually established by nurse and
patients

Both outcomes and nursing interventions are


documented in a written plan of care

Planed nursing interventions are based on evidence


(nursing research and nursing practice guidelines )
Step 4: Implementation
 Involves execution of the nursing care plan

The nurse must continue to assess the client’s


condition before, during, and after each intervention
is carried out
Reporting and documentation of collected data are
important
Both positive and negative responses are reported
and documented
Negative responses to treatment may require
additional intervention
Step 4: Implementation

Types of interventions
Independent ( Nurse initiated )- any action the
nurse can initiate without direct supervision

Dependent ( Physician initiated )-nursing actions


requiring medical orders

Collaborative - nursing actions performed jointly


with other health care team members
Step 4: Implementation
Be aware of the interrelated nature of the
intervention (during one intervention some other
interventions)
Determine the most appropriate intervention based
on health status and treatment .Appropriate
interventions include following
 Directly forming activity for a patient
 Assisting the patient to perform activity
 Supervising the patient while the activity he /she
performing
 Assigning and supervising nursing assistive person to
perform activity
 Teaching the patient and family regarding the care
 Monitoring the patient at risk for potential complications
Step 5: Evaluation
During evaluation (appraisal of results), the nurse determines
if client goals were met, partially met, or not met.
 Deterring whether the plan was effective either to continue
plan ,to revise the plan or terminate the plan

If the goal has been partially met or not met, the nurse
reactivates each step of the nursing process

Data must be collected to determine why the goal was not


achieved and what modifications to the care plan are
necessary.
Step 5: Evaluation

If the outcome have not been accomplished ,nurse


must modify the nursing diagnoses ,outcomes or
the plan
Factors that impede goal attainment:

 Incomplete data gathering during the assessment

 Unrealistic client outcomes

 Nonspecific nursing interventions

 Inadequate time for clients to achieve outcomes


Activity
Describe the role of the patient in the application of
nursing process
Identify the skills that nurse should possess in
application of nursing process
Outline the benefits of nursing process

Tutorial : what is critical thinking ?


 What is involve in critical thinking ?
 How critical thinking influence in making clinical judgment
in patient care
 What are the characteristics of a critical thinker
Reference
Priscilla Le MONE ,Karen BURKE , Gerene
BAULDOFF . (2011).Medical - Surgical nursing : Critical
thinking in patient care (5th edition).Pearson Publication.

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