Nursing Process The Nursing Process Is Based On A Nursing

NURSING PROCESS The nursing process is based on a nursing theory developed by Ida Jean Orlando. She developed this theory in the late 1950's as she observed nurses in action. From her observations she learned:   

The patient must be the central character Nursing care needs to be directed at improving outcomes for the patient; not about nursing goals The nursing process is an essential part of the nursing care plan. The Five Steps of the Nursing Process

Assessment •

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It is collecting,organizing,validating, and recording data about a client’s health status. Data are obtained from a variety of sources, and are the basis of actions and decisions taken in subsequent phases. Assessment involves taking vital signs, performing a head to toe assessment, listening to the patient's comments and questions about his health status, observing his reactions and interactions with others. It involves asking pertinent questions about his signs and symptoms, and listening carefully to the answers. Once you have collected the data, the process moves on to analysis of the data to determine the health status, the patient's coping mechanisms or lack thereof, his ability to use these mechanisms and to identify his problems related to his health status.

Diagnosis Diagnosing is a process which results in a diagnostic statement or nursing diagnosis. In this phase, the nurse sorts, clusters, and analyzes the data and asks, What are the actual and potential health problems for which the client needs nursing assistance? and “What factors contributed to this problem?” Responses to those questions establish the nursing diagnoses. Nurses only make nursing diagnoses, except in the case of Nurse Practitioners who have been trained and licensed to make medical diagnoses. Once you have identified the patient's problems related to his health status, you formulate a nursing diagnosis for each of them. You will also prioritize the problems in formulating your plan and goals. The nursing diagnoses are categorized by a system commonly referred to as NANDA. The North American Nursing Diagnosis Association (NANDA) has now become an international group who works to classify nursing diagnoses, and to review and accept new diagnoses as needed. In 2000, NANDA adopted the current classification system (known as taxonomy) as Taxonomy II. There are 13 domains which are subdivided into 106 classes and 155 nursing diagnoses. The RN chooses a nursing diagnosis from the NANDA list which most closely describes the patient's problem related to his health status. This might be a current problem or a potential problem which needs to be addressed. It can even be a problem that relates to his family rather than to him alone such as the family's inability to cope with life style changes necessitated by the patient's illness.

Planning

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Setting goals to improve the outcomes for the patient are a primary focus of the nursing process. Based on the nursing diagnoses, what are the expectations for this patient? This not about nursing goals. This is about improving the quality of life for your patient. This is about what your patient needs to do to improve his health status or better cope with his illness. Planning also involves making plans to carry out the necessary interventions to achieve those goals. The product of the planning phase is a written care plan used to coordinate the care provided by all the health team members.

Implementation

ASSESSMENT DATA SUBJECTIVE/ OBJECTIVE Include subjective and objective components. Assess physiological, psychosocial, developmental, cultural and spiritual dimensions. •Subjective Document client's exact words relevant to the diagnosis. "I'm not hungry" •Objective Document data that is measurable, specific, and relevant to the nursing diagnosis.

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weight loss("Weigh t = 48 Kg") anorexia "Lack of subcutaneou s fat" Cachectic appearnace Poor muscle tone Pale conjunctiva and mucous membranes fatigue

NURSING DIAGNOSIS

Use a NANDA diagnosis which has three (3) parts: •Part I: NANDA statement of nursing problem "Alternation in nutrition: Less than body requirements" •Part 2: relating to a nursing etiology: "related to inadequate nutritional intake" •Part 3: manifested by the assessed signs and symptoms: "as manifested/evi denced by low body weight and emaciation."

PLAN OUTCOME CRITERIA (CLIENT CENTERED) State the overall plan as CLIENTcentered, e.g.,: •"The client will..." Relate the plan to the nursing diagnosis: •."have adequate nutritional intake" Indicate a measurable outcome criteria by including time frame/amount/ra nge: •"as evidenced by..."

INTERVENTIONS (NURSE CENTERED)

Make the interventions NURSE centered. Indicate what the nurse will do to assist the client in achieving the outcome criteria, e.g.,

State the principle or scientific rationale for the nursing intervention(s). Include the reference for the rationale.

•The nurse will..."

EVALUATION

Look at the outcome criteria. State whether the client achieved the outcome criteria, e.g., "The client gained 2 lbs within the past 7 days..."

State frequency/time /amount so any nurse can carry out the plan: 1) Document all food intake for 3 days. 2) Determine and make available client's favorite foods by day 2. 3) Provide oral care before meals.

3.) Improved oral hygiene can enhance appetite and improve oral intake (Ulrich, canale, and Wendell, 1986, p. 570). Reduces unpleasant taste and stimulates appetite (brunner and Suddarth, 1988, p. 878)

4. Offer small, frequent feedings.

4. There may be difficulty in consuming a large meal (Dudek, 1987, p. 398). Small meals are easier to tolerate ( Brunner and Suddarth, 1988, p. 399)

1) the ability to create a balanced meal plan by day (7). 2) gaining 1-2 lbs/wk.

RATIONALE FOR INTERVENTIONS

NOTE: If the outcome criteria was not achieved or only partially achieved, the nurse needs to go back to the beginning, e.g., the "assessment" and make revisions or changes as necessary.

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Setting your plans in motion and delegating responsibilities for each step. Communication is essential to the nursing process. All members of the health care team should be informed of the patient's status and nursing diagnosis, the goals and the plans. They are also responsible to report back to the RN all significant findings and to document their observations and interventions as well as the patient's response and outcomes.

Evaluation Evaluating is assessing the client’s response to nursing interventions and then comparing the response to the goals or outcome criteria written in the planning phase. The nursing process is an ongoing event. Evaluation involves not only analyzing the success of the goals and interventions, but examining the need for adjustments and changes as well. Evaluation leads back to Assessment and the whole process begin again. The evaluation incorporates all input from the entire health care team, including the patient.

DEVELOPING NURSING CARE PLANS WHAT IS A NURSING CARE PLAN? The Nursing Care Plan (also referred to as the client care plan) is a written guide that organizes information about a client’s care into a meaningful whole. It includes the actions nurses must take to address the client’s nursing diagnoses and meet the stated goals. The nurse starts the care plan as soon as the client is admitted to the health care agency and constantly updates it throughout the client’s stay, in response to changes in the client’s condition and evaluations of goal achievement.

1. Nursing Assessment. First level assessment: Subjective and Objective Data Data must support the nursing diagnosis and should include both normal and abnormal assessment values and observations 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.  Subjective data include the client’s sensations, feelings, values, beliefs, attitudes, and perceptions of personal health status and life situation.  Information supplied by family members, significant others, or other health professionals is also considered subjective, if it is based on opinion rather than fact. Objective Data  Also referred to as signs or overt data, are detectable by an observer or can be tested against an accepted standard.  They can be seen, heard, felt, or smelled, and they are obtained by observation or physical examination.  Remove any information that is NOT directly linked to the one Nursing Diagnosis on which you are working.

2. Nursing Diagnosis. Second level assessment: The cause of the problem and all other factors in the patient’s environment that contribute to the problem. Components of Nursing Diagnosis: 1. Problem statement (Diagnostic Label) It describes the client’s health problem or response for which nursing therapy is given.  It describes the client’s health status clearly and concisely in a few words.  All nursing diagnoses must be phrased in NANDA terms and must be chosen from your approved nursing diagnosis list or a nursing care plan text.  Do not make up your own nursing diagnosis.

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Qualifiers are words that have been added to some NANDA labels to give additional meaning to the diagnostic statement; for example: • •

Deficient (inadequate in amount, quality, or degree not sufficient, incomplete) Impaired (made worse, weakened, damaged, reduced, deteriorated)

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Decreased ( lesser in size, amount or degree) Ineffective ( not producing the desired effect) Compromised (to make vulnerable to threat)

2. Etiology (Related factors and Risk factors) It identifies the one or more probable causes of the health problem, gives direction to the required nursing therapy, and enables the nurse to individualize client’s care.  It may include the client’s behaviors, environmental factors, or interaction of the two.  NANDA uses the term related factor to describe the etiology or likely cause of the actual nursing diagnoses.  The term risk factor is used to describe the etiology of high risk (potential) nursing diagnoses, because there are no subjective and objective signs present.

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Comparison of Related Factors and Risk factors

Definition Use as etiology of: Use when signs and symptoms of problems are:

Related factor Factor that is causing or contributing to an actual problem Actual problems Present

Risk factor Factors present that place client at risk for developing a problem that has not yet occured High risk (potential) problems Not present

3. Defining Characteristics   

It is the cluster of signs and symptoms that indicate the presence of a particular diagnostic label. For actual nursing diagnoses, the defining characteristics are the client’s signs and symptoms. For high risk nursing diagnoses, the defining characteristics are the same as the etiology: the risk factors that cause the client to be more than “normally” vulnerable to the problem.

Formulating Diagnostic Statements: The basic format for a diagnostic statement is “Problem related to Etiology.” However, nurses must be able to write one-, two-, three, and four-part diagnostic statements, as well as some variations of each. BASIC TWO-PART STATEMENTS The basic two-part statement is used for actual, high risk, and possible nursing diagnoses. It includes the following:

1. Problem (P) – Statement of the client’s response

2. Etiology (E) – Factors contributing to or probable causes of the responses Problem Impaired skin integrity Constipation

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Related to related to

Etiology Physical immobilization

 Some NANDA labels contain the word related to prolonged laxative use “Specify.” For these, the nurse must add words to indicate the problem more specifically. The format is still a two-part statement, for example,

Noncompliance (specify) Noncompliance (diabetic diet) related to denial of having disease.

 For ease in alphabetizing, many NANDA lists are arranged with qualifying words after the main word. e.g.: 1. Infection, high risk for 2. Cardiac Ouput, decreased

 Avoid writing diagnostic statement in this manner; instead, write them as they would be stated in normal conversation (eg, High risk for infection and Decreased cardiac Output ). BASIC THREE-PART STATEMENTS The basic three-part nursing diagnosis statement is called the PES format and includes 1. Problem (P) – Statement of the client’s response 2. Etiology (E) – Factors contributing to or probable causes of the response 3. Signs and Symptoms (S) - Defining characteristics manifested by the client

 Actual Nursing diagnoses can be documented by using the three-part statement (using related to and as manifested by, or as evidenced by), 

because the signs and symptoms have been identified. However the PES format cannot be used for high risk diagnoses, because the client does not have signs and symptoms of the diagnosis.

Problem

Related to

Etiology

As manifested by

Altered Tissue Perfusion

related to

edema of the operative site

as manifested by

Signs and symptoms paresthesia and decrease in muscle strength

Variations of Basic Formats Variation of the basic one-, two-,and three-part statements include the following:

1. Writing “unknown etiology” when the defining characteristics are present but the nurse does not know the cause of contributing factors.  Noncompliance (medication regimen) related to unknown etiology.

2. Using the phrase “complex factors” when there are too many etiologic factors or when they are too complex to state in brief phrase. 

Decisional conflict/ Chronic self-esteem related to complex factors

3. Using the word “possible” to describe either the problem or the etiology. When the nurse believes more data is needed about the client’s response (problem) or the etiology, the word possible is inserted.  Possible low self-esteem related to loss of job and rejection by family  Altered thought processes possibly related to unfamiliar surroundings

4. Using “secondary to” divide the etiology into two parts, thereby making the statement more descriptive and useful. The part “secondary to” is often a pathophysiologic or disease process, as in  High risk for impaired skin integrity related to decreased peripheral circulation secondary to diabetes.

5. Adding a second part to the general response or NANDA label to make it more precise.  

Impaired physical mobility: inability to walk r/t knee joint stiffness and pain secondary to muscle atrophy Pain: severe headache r/t fear of addiction to narcotics

6. Four-part statements are combination of basic statements and variations 4 and 5.  (1) High risk for impaired skin integrity: (2) pressure sores related to (3) immobility (4) secondary to presence of casts and traction.  (1) Impaired skin integrity: (2) pressure sore on left heel related to (3) immobility (4) as manifested by 2 cmx2cm red, excoriated area on the left heel and inability to move about in bed.

3. Goals and Objectives. Purposes of Goals/Expected outcomes:

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Provide direction for planning nursing interventions that will achieve the desired changes in the client. Ideas for interventions come more easily if the goals state clearly and specifically what the nurse hopes to achieve. • Provide a time span for planned activities. • Serve as criteria for evaluation of client progress. • Enable the client and nurse to determine when the problem has been resolved. Relationship of Goals to the Nursing Diagnoses.  Goals are derived from and relate to the client’s nursing diagnoses-primarily from the first clause (problem).  The problem clause contains the unhealthy response; it states what should change.

 Nursing diagnosis: High risk for fluid volume deficit r/t diarrhea and inadequate intake secondary to nausea.  Goal: After 8 hours of nursing interventions, Client’s fluid balance will be maintained, as evidenced by urinary and stool output in balance with fluid intake, normal skin turgor, and moist mucous membranes  Rule: for every nursing diagnosis, the nurse must write at least one outcome criterion that, when achieved, directly demonstrates resolution of the problem clause. When developing outcome criteria, ask the following questions: 1. What is the problem clause? 2. What is the opposite, healthy response? 3. How will the client look like or behave if the healthy response is achieved? (What will I be able to see, hear, palpate, smell, or otherwise observe with my senses?) 4. What must the client do and how well must the client do it to demonstrate problem resolution or to demonstrate the capability of resolving the problem? Characteristics of Well-Stated Goals: • • • • • • •

Expected outcomes are derived primarily from the first clause of the nursing diagnosis. Their achievement demonstrates problem resolution or prevention. The expected outcome is possible to achieve. The expected outcome is stated in terms of client responses rather than nursing activities. Each expected outcome is specific and concrete, to facilitate measurement. Each expected outcome is measurable, that is outcome can be seen, heard, felt, or measured by another person. The goal is valued by the client and family. The goal is compatible with the therapies of other professionals.

4. NURSING INTERVENTIONS WITH SCIENTIFIC RATIONALE 4.1. Immediately following each goal that you write, list specific nursing actions you used to work toward that goal. 4.2. Nursing actions must be specific, not global, appropriate, and without important omissions. In most cases several interventions are needed to achieve any one goal. 4.3 4.4 4.5

If your idea to use a nursing action comes from a Care Plan book or other source, cite the source. After each nursing action give the scientific rationale for selecting the action. Cite your source for this rationale. Sources might include a book, lecture, discussion with a health professional or media source. Rationale must be logical and relevant.  Interventions should be prioritized and specific to the patient.  Interventions should be obtained from professional nursing care plan resources or your medical surgical nursing book.  Adapt standardized care plan interventions to your patient. Include only those interventions that relate to your specific patient.  You should have a minimum of seven interventions for your identified priority problems.

Types of Nursing Strategies/Interventions:

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ii. iii.

Independent interventions- are those activities that 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. Dependent interventions- are those activities carried out under the physician’s orders or supervision, or according to specified routines.  Medical orders commonly include orders for medication, intravenous therapy, diagnostic tests, treatments, diet, and activity. Collaborative intervention- are actions the nurse carries out in collaboration with other health team members, such as physical therapists, social workers, dieticians, and physicians.  For example, the doctor might order for physical therapy to teach the patient crutch-walking. The nurse assists with crutchwalking and collaborates with the physical therapist to evaluate the client’s progress.

5. EVALUATION • • •

An evaluation statement consists of two parts: a conclusion and supporting data The conclusion is a statement that the goal/expected outcome was met, partially met, or not met. The supporting data are the list of client responses that supports the conclusion, for example:  After 8 hours of nursing interventions, Goals were met; oral intake 300 ml more than output; skin turgor good; mucous membranes moist

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Use the measures you designated for goal achievement to state your client's degree of success. (For example: "the client evaluated her anxiety as 4 on a 10-point scale." Draw conclusions on the interventions used related to the outcome. (For example: "Helping the client to talk about her feelings reduced her sense of isolation.")

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F.T.Santiago,RN.,MN.