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NURSING PROCESS-
• The
nursing process is nursing practice in action. The nursing process is the
framework for providing professional, quality nursing care. It directs nursing
activities for health promotion, health protection, and disease prevention and
is used by nurses in every practice setting and specialty.
HISTORY OF NURSING PROCESS-
• Lydia
Hall first described nursing process in a 1955. In 1967, Yura and Walsh
published the first comprehensive book on nursing process, in which they
described four steps in the nursing process: assessment, planning,
intervention, and evaluation. Gebbie and Lavin (1974) described nursing process
as five step process by adding diagnosis to it.
DEFINITION OF NURSING PROCESS-
• Nursing
process is defined as an orderly , systematic way of identifying the client’s
problems, making plans to solve them, initiating the actions or assigning
others to implement it and evaluating the extent to which the plan was
effective in resolving the problems identified.
CHARACTRISTICS OF NURSING PROCESS-
• Providing
framework- Nursing process is a
framework that enables a nurse to give nursing care to individuals, families
and communities.
• Systematic
and orderly- Each nursing activity
is part of an ordered sequence of activities. The nursing process directs each
step of nursing care in a sequentially ordered manner.
• Cyclic
and Dynamic- Each step in nursing process flows on to the next step. In
some nursing situations, all the stages occur almost simultaneously and some
times in cyclic form.
• Goal
directed and client oriented- The nursing process offers a means for nurses
and patients to work together to identify specific outcomes related to health
promotion, disease and illness prevention, health restoration, and coping with
altered functioning;
• Interpersonal- In Nursing process we have the amount of
interaction that might be necessary between nurses, patients of similar
illnesses and the medical team. It might involve group therapy and / or family
counselling.
• Universally
applicable- This process is
universally standard and no matter what the institution it may be, the process
remains the same. It is like a common nursing language with common nursing
terminology followed universally.
• Scientific
problem solving- Nursing process is
a systematic process which as based on scientific and critical thinking. It
involves scientific methods or problem solving such as problem identification,
data collection, hypothesis formulation,
plan of action, hypothesis testing, interpretation of results, and
evaluation, resulting in conclusion or revision of the study.
STEPS/PHASES OF NURSING PROCESS-
• There
are 5 steps in Nursing Process-
• Assessment
• Diagnosis
• Outcome
identification and planning
• Implementation
• Evaluation
ASSESSMENT-
• Assessment
is the first step in the nursing process and includes collection, verification,
organization, interpretation, and documentation of data. The completeness and
correctness of the information obtained during assessment are directly related
to the accuracy of the Nursing Process.
TYPES OF NURSING ASSESSMENT-
• Nursing
assessments include
• The
comprehensive initial assessment- The initial
assessment is performed shortly after the patient is admitted to a
healthcare agency or service. The purpose of this assessment is to establish a
complete database for problem identification and care planning. The nurse
collects data concerning all aspects of the patient’s health, establishing
priorities for ongoing focused assessments and creating a reference for future
comparison
• The
focused assessment - In a focused assessment, the nurse gathers data
about a specific problem that has already been identified. A focused assessment
may be done during the initial assessment if patient health problems surface,
but it is routinely part of ongoing data collection. Another purpose of the
focused assessment is to identify new or overlooked problems.
• The
emergency assessment- An emergency
assessment to identify life-threatening problems at the time of crisis. For
example choking in the dining room, a bleeding patient brought to the emergency
room with a stab wound, an unresponsive patient in the rehabilitation unit or
sudden collapse of a patient in the ward.
• The
time-lapsed assessment- The time-lapsed
assessment is scheduled to compare a patient’s current status to baseline
data obtained earlier. Time lapsed assessment is done to reassess health status
and to make necessary revisions in the plan of care.
first step in assessment includes
data collection. Data are collected from a variety of sources; however, the
client should be considered the primary source of data. As much information as possible should be
gathered from the client. Secondary sources and include family members, other
health care providers, and medical records
• Two
types of information are collected through the assessment component: subjective
and objective.
• Subjective
data are gathered by interacting with the client and include the client’s
feelings, perceptions, and concerns.
• Objective
data are observable and measurable and are obtained through physical
examination and diagnostic tests.
• Data
Validation is the act of confirming or verifying. The purpose of validating
is to keep data as free from error, bias, and misinterpretation as possible.
Validation is an important part of assessment because invalid information can
lead to inappropriate nursing care. After validation data are recorded and
analyzed.
DIAGNOSIS-
• The
second step in the nursing process is the formulation of the list of nursing
diagnosis. A nursing diagnosis focuses on an individual, family, or community
response to actual or potential health problems. An actual nursing diagnosis
indicates that a problem exists and is composed of the diagnostic label,
related factors, and signs and symptoms.
An example of an actual diagnosis is impaired skin integrity related to
prolonged pressure on bony prominence
• A
risk nursing diagnosis (potential problem) indicates that a problem does not
yet exist, but special risk factors are present. A risk diagnosis is composed
of the diagnostic label preceded by the phrase ‘‘risk for,’’ with the specific
risk factors listed. An example of a risk diagnosis is risk for impaired skin
integrity related to inability to turn self from side to side in bed.
OUTCOME IDENTIFICATION AND PLANNING-
planning is a framework on which scientific nursing practice
is based. The four critical elements of planning include:
• Establishing
priorities
• Setting
goals and developing expected outcomes
• Planning
nursing interventions
• Documenting
(Writing Nursing care Plan)
• Establishing
priorities- When an individual client has more than one diagnosis, the
nurse and client need to establish priorities to identify which nursing
diagnosis will be addressed initially in the plan of care. One of the most
common methods of setting priorities is the consideration of Maslow’s hierarchy
of needs, which requires that a life-threatening diagnosis be given more
urgency than a non–life-threatening diagnosis.
• Setting
goals and developing expected outcomes- After formulating nursing diagnoses,
and establishing priorities, the nurse sets goals and identifies and
establishes expected outcomes for each nursing diagnosis. Goals should be
established to meet the immediate, as well as long-term prevention and
rehabilitation, needs of the client.
• Planning
nursing interventions - A nursing
intervention is an action performed by a nurse that helps the client to achieve
the results specified in the goals and expected outcomes. These actions are
based on scientific principles and knowledge from nursing, behavioral, and
physical sciences. It is important to identify as many nursing interventions as
possible so that if one proves to be unsuitable, others are readily available.
• Documenting
(Writing Nursing care Plan) – After careful planning all the detail in
written in a format known as nursing
care plan. There are a lot of formats used for writing nursing care plan. They
vary from institution to institution . Number of columns may be different but
basic information is more or less same. Here we are going to discuss a 5 column
nursing care plan which can be used in every setting.
IMPLEMENTATION-
• During
the implementation step of the nursing process, nursing actions planned
in the previous step are carried out. The purpose of implementation is to
assist the patient in achieving valued health outcomes: promote health, prevent
disease and illness, restore health, and facilitate coping with altered
functioning.
• The
plan of care is best implemented when patients who are able and willing to
participate have maximum opportunities to provide self-care. Family members and
other support people, as well as other healthcare professionals, may also be
involved in successfully implementing the plan of care
• The
implementation phase of the nursing process requires cognitive (intellectual),
psychomotor (technical), and interpersonal communication skills.
• Nurses
perform a variety of activities that are designed to assist clients in meeting
needs.
• Nursing implementation activities include:
• Ongoing
assessment- Because a client’s condition can change rapidly, or new data
may become available, ongoing assessment is necessary to validate the relevance
of proposed interventions.
• Establishment
of priorities- Priorities are based on
severity of the problems that are deemed most important by the nurse,
client, family, or significant others.
• Allocation
of resources- Whereas some interventions are complex and require the
knowledge and skills of a registered nurse, other interventions are relatively
simple and can be delegated to assistive personnel.
• Initiation
of nursing interventions- Interventions can be implemented on the basis of
standing orders or protocols. A standing order is a standardized intervention
written, approved, and signed by a prescribing practitioner
• Nursing
interventions include:
• Assisting
with activities of daily living (ADL)
• Delivering
skilled therapeutic interventions
• Monitoring
and surveillance of response to care
• Teaching
• Discharge
planning
• Documentation
of interventions- Communication concerning implementation of interventions
must be provided through written documentation and should also be verbally
conveyed when responsibility of the client’s care is transferred to another
nurse. The nurse is legally required to record all interventions and
observations related to the client’s response to treatment.
EVALUATION-
• Evaluation
is the fifth step in the nursing process and involves determining whether the
client goals have been met, have been partially met, or have not been met. Even
though it is the final phase of the nursing process, evaluation is an ongoing
part of daily nursing activities. Steps in evaluation includes-
• Establishing
standards.
• Collecting data.
• Determining achievement of goal.
• Relating nursing actions to client’s health
status.
• Judging the value of nursing interventions.
• Reassessing the client’s status.
• Modifying the plan of care (Re-planning)
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