Vous êtes sur la page 1sur 14

1

NURSING PROCESS
Definition:
It is a systematic, client-centered method for structuring the delivery of
nursing care.
Phases:
1. Assessment
2. Diagnosing
3. Planning
4. Implementing
5. Evaluating
Characteristics:
1. It is cyclical and dynamic in nature.
2. It is client-centered.
3. It adapts problem solving.
4. Decision-making is involved in every phase.
5. It is interpersonal and collaborative.
6. It is universally applicable.
7. It uses variety of critical thinking skills.
-----------------------------------

ASSESSMENT
Definition: It is a systematic and continuous collection, organization, validation
and
documentation of data.
Characteristics:
1. It focuses on a clients responses to a health problem.
2. It should include the clients perceived needs, health problems, related
experience, health practices, values and lifestyle.
3. To be most useful, the data collected should be relevant to a particular
health problem.
Activities:
1. Collecting Data
2. Organizing data

3. Validating Data
4. Documenting Data

COLLECTING DATA/ DATA COLLECTION


- process of gathering information about a clients health status
Database/ baseline data- all the information about a client
-which includes:
1.
2.
3.
4.
5.
Purpose:

nursing health history


physical assessment
physicians history
physical examination
results of laboratory and diagnostic tests

THE NURSING HEALTH HISTORY


1. To elicit information about all variables that may effect that clients
health status.
2. To obtain data that help the nurse understand and appreciate the
clients life experiences

3. To initiate a non judgmental, trusting interpersonal relationship with


the client.
Components:
1. Biographic data
2. Chief complaints or reason of visit
3. History of present illness
4. Past history
5. Family history of illness
6. Review of system (ROS)
7. Life style
8. Social data
9. Psychological data
10. Patterns of health care
TYPES OF DATA:
1. Subjective Data
- information given verbally by the patient
- information perceived only by the affected person
- symptoms complained by the patient
example:
Correct:
I feel so nervous
Get out of my room
Sakit akong samad
Incorrect: Patient is anxious
Patient is hostile
Patient has pain
2. Objective data
- are detectable by an observe
- consists of information that is perceptible to the senses
- can be tested against an accepted standard
- factual data observed by the Nurse
example:
Correct: hair combed, make-up applied
drag right leg when walking
tremors of both hands
250 cc dark amber urine

Concise
and
Descriptive
Judgmental
and
Conclusive

Incorrect: neatly- groomed


Improve body image
Patient very afraid
Voided large amount
Sources of Data:
1. Primary- client
2. Secondary- significant others, other health personnel records and
reports
- relevant literature
Data Collection Methods
A. Observation
- occurs whenever the nurse is in contact with the client or support persons
- gather data by using the 5 senses

B. Interviewing

- structured form of communication that the nurse uses to collect data or a


conversation with a purpose
2 Approaches
1. Directive
2. Non- directive
Directive

- structured and elicits specific information


- used to gather and to give information in a limit amount of time

Non-directive
- rapport building interview
- uses open- ended questions, used for problem- solving counseling
and performance appraisal
(Rapport- is an understanding between 2 or more people)
Kinds of Interview Questions:
1. Closed question- used in directive interview, restrictive and generally
require only
short answers- giving specific information
2. Open-ended questions
- non-directive interview
- lead clients to explore their thoughts and feelings
disadvantages. The client may spend time
conveying irrelevant information.
3. Neutral Questions question that the client can answer without
direction or
pressure from the nurse
- is open-ended, and is used in non-directive interviews
4. Leading Questions is usually closed, used in directive interview and
thus directs
clients answer
Some hints to make patient comfortable before beginning the nursing history:
a.
b.
c.
d.

Assess for pain


Offer the patient an opportunity to go to the bathroom or make a call
Offer some beverages is medically permitted
Sit-down- during interview- eye level

Planning the Interview and Setting:


1.
2.
3.
4.
5.

Time
Place- privacy
Seating arrangement- 45 degree angle to the bed
Distance-3 to 4 ft. apart
Language

Stages of Interview
1. The opening /introduction
steps: a. establishing rapport
b. orienting the interviewee
2. The body
3. The closing

Examination
- major method used in the physical health assessment
- done systematically, according to examiners preference
(head to toe or body systems)
a. Cephalo-caudal- head, neck, thorax, abdomen, and extremities and
ends at the toes
b. Body System approach- respiratory, circulatory, etc.
- datas obtained are measured against norms or standards (ideal
height/weight, temperature, Blood Pressure)
Techniques Used:
1. inspection
2. auscultation
3. palpation
4. percussion
INSPECTION- systematic- head to toe
PALPATION
- the nurse uses the hands and sense of touch to gather data
- used to detect tenderness, temp., texture, vibration, pulsations,
masess
- rules out/confirms suspicious raised during interview and inspection
PERCUSSION- is the tapping of the bodys surface to produce vibration and
sound
- sounds indicates the density of the underlying tissue
tympany-high-pitched-like sound over a hallow organ
dullness-low-pitched,thud-like soun over a dense organ
Technique: place the palmar surface of one hand against the clients body while
tapping with the other.
AUSCULTATION the process of listening to sounds produced by the body
- Systems involved:
Cardiovascular System
Respiratory System
Gastro-intestinal System
- Use: Stethoscope- an instrument that amplifies sounds
produced by i
nternal organs
- nurse uses written
systematically

ORGANIZING DATA
format that organizes

the

assessment

data

Nursing Conceptual Models/Framework which can be used to structure the


nursing admission assessments:
1. Maslows Hierarchy of basic needs
2. Hendersons 14 components of nursing care
3. Gordon;s 11 functional health pattern
4. NANADAs 9 response pattern
VALIDATING DATA
-

information gathered during assessment phase must be complete, factual,


and accurate because the nursing diagnoses and interventions are based on
this information

DOCUMENTING DATA
- to complete the assessment phase, the nurse records the data
----------------------------------------------------

NURSING DIAGNOSIS
- is a clinical Judgment about individual, family or community responses to
Actual or Potential health problems/ life process.
- It provides a basis for selection of nursing interventions to achieve
outcomes for which the N is Accountable
Advantages:
1. Ng Dx facilitates communication among Nurses and other health
team members.
2. Strengthen the Ng. Process and provide Direction for Planning
independent Ng. Actions
3. Health the nurse focus on independent Nursing Actions.
4. Help identify the focus of a Nursing Activity and thus facilitates peer
review and quality assurance program.
5. Facilitate Nursing intervention when a client moves from one hospital
unit to another.
6. They facilitate comprehensive health care by identifying, validating
and responding to specific health problems.
WRITING NURSING DIAGNOSIS
1. ACTUAL NURSING DIAGNOSIS
a. Ng. Dx = PATIENT PROBLEM AND ETIOLOGY
Ex. Impaired skin integrity r/t immobility
Prental role conflict r/t divorce
Impaired verbal r/t cultural
Communication differences
b. Ng. Dx = P + E + S
Impaired skin integrity r/t immobility
Manifested by disruption of skin
Surface over the elbows and coccyx
Prental role conflict r/t divorce as manifested by statement or
unsatisfactory child care during working hours
Impaired verbal r/t cultural differences as Communication manifested
by inability to Speak English.

2. POTENTIAL (High Risk) Ng. PROBLEMS:


HIGH RISK = PROBLEM + RISK FACTOR + NG DX
High risk for skin
r/t
physical immobilization
Breakdown
in totoal body cast
High risk for skin
Fluid vol.
Deficit

r/t

diarrhea, age 3 years, low oral


Intake, temperature

High risk for injury


surgery
3. POSSIBLE NG.DX

r/t

disorientation and division after cataract

Possible sensory- perceptual alteration


Possible nutritional deficit
Possible fluid vol. Deficit
NURSING
Describe an individuals response to a as
Process
Is oriented to the individual
Changes as the clients responses change
throughout

Guides independent Ng.


Activities: planning
of
Intervention and evaluation
by
Is complementary to the MEDICAL Dx
the Ng. Dx
Has no universally accepted classification
System
consist
Consist of two-part
Statement of etiology
When known

MEDICAL DX
Describe a specific do
Is oriented to pathology
Remains

constant

the duration of illness

Guides medical
management, some
which may be carried out
the nurse.
Is complementary to
Has well developed
classification
system
of 2 or 3 words

STEPS OF DIAGNOSE PROCESS


DATA PROCESSING + DETERMINING THE CLIENTS HEALTH
PROBLEMS, HEALTH RISKS AND
STRENGTHS
+ FORMULATION OF
NURSING DIAGNOSE
NG-DX=

1. Organized Data
2. Compare data against standard -------- normal health patterns
-------- normal vital signs
-------- lab values
3. Cluster data

4. Identify gaps & inconsistencies in data


STANDARD/NORM- general accepted rule, model, pattern or measure used in
comparing which must be relevant & reliable
CUE- a piece of information or data that influence decisions
BENEFITS:
A. Client:
1. quality client care
2. continuity of care
3. participation by the client in their health care
B. Nurse:
1. consistent and systematic nursing education
2. job satisfaction
3. professional growth
4. avoidance of legal action
5. meeting professional nursing standards
Characteristics:
1. the NCP focuses on actions which are designed to solve or alleviate an
existing problem.
2. The NCP is a prodcut of a deliberate systematic process.
3. The NCP relates to the future. It utilizes events in the past and what is
happening in the present to determine trends.
4. The NCP revolves around identified healtgh and nursing problem
5. The NCP is a means to an end, not end in itself.
6. Nursing care planning is a continuous process.
DESIRABLE QUALITIE OF NCP
1.
2.
3.
4.
5.

should be based on a clear definition of the problem


is realistic
consistent with the goals and philosophy of the health agency
NCP is drawn with the family
Is best kept in written form

NCP-Importance
1. they individualize care to clients
2. Healps in setting priorities by providing information about the client as well as
the nature of his problems
3. Promotes systematic communication among those involved in the health care
effort
4. Continuity of care facilitated
5. Facilitates the coordination of care
STEPS IN DEVELOPING FNCP:
1.
2.
3.
4.

the
the
the
the

problem definition
goals and objectives of care
plan of intervention
plan for evaluating care

ESTABLISHING GOALS:
Goal - is a general statement of purpose
- it is the end toward which all efforts are directed
S

specific

M
A
R
T

measurable
attainable
realistic
time bounded

DIAGNOSING- is the process of making a clinical judgement (nursing diagnosis)


about a clients potential or actual health problem that nurses are licensed and
able to treat.
PLANNING- inv9olves setting priorities, writing goals, and establishing a written
plan for nursing interventions designed to prevent, resolve or identify problems
or potential problems.
IMPLEMENTING- is carrying out or delegating the nursing interventions
EVALUATING- involves the nurse and the client in determining whether that
clients goals or predetermined outcomes of care have been met
- identifying factors that facilitated or inhibited goal achievement
- and modifying or terminated the care plan accordingly

METHOD DISCHARGE PLANNING


F. Medication
The client will know:
Drug name
What dosage to take and when
Purpose of drug
Effect (s) the drug should have
Symptoms of possible adverse effects, and which ones to report
(repeat for each drug prescribed)
A. ENVIRONMENT
The client will be assured of:
Adequate instruction in necessary homemaking skills
Investigation and correction of any physical hazards in the home
environment
Adequate emotional support
Investigation of sources of economic support
Investigation of transportation means to appointment and/ or
clients
T. Treatment
The client and family will:
Know the purpose of any treatment to be continued at home
Be able to demonstrate correct performance of treatment
H. Health Teaching
The client will:
Describe how his or her disease or condition affects body function
Describe the means necessary to maintain present level of health,
or achive a higher level of health
O. Outpatient Referral/ Observable Signs and Symptoms
The client will:
Know when and where of his or her prescribed diet

Know when and whom to call for medical help


Take home written discharge instructions

D. Diet
The client will be able to:
Describe the purpose of his or her prescribed diet
Plan several typical menus using prescribed diet
PLANNING
Definition- is the process of designing the Ng. Strategies or interventions
required to prevent, reduced opr eliminate those client health problems
identified and validated during the diagnostic phase.
-

the process in which problem solving and decision- making are carried out.

Uses:

1. data obtained during assessing


2. the diagnostic statements that present clients health problem

6 Compaonents of P:
1. setting priorities
2. establishing client goals and outcome criteia
3. planning Ng Strategies
4. writing Ng orders
5. writing the NCP
6. Consulting
I.

Setting Priorities
Determined by the following factors:
1.
2.
3.
4.
5.
6.

II.

clients health values and belief


clients priorities
resource available to the N. and C.
time needed for the nursing strategies
urgency of the health problems
medical treatment plan

Establishing clients goal and criteria


Clients goal- is a desired outcome or change in client behavior in the
direction of the health

Purposes:
1. provide direction of planning nursing intervention
2. provide direction for establishing evaluation
Types of Goals
a. long term- client living at home or having chronic health problems, in NG.
Homes and rehab center.
b. short term- clients requiring short term care
- persons who are frustrated by long term goals
Establishing goals for Fr Ng Dx
Nursing Diagnosis- Impaired Physcial Mobility r/t pain
Client problems- Impaired physical mobility

10

Client goals- client will demonstrate increase in physical

Ng. Dx

- SELF CARE DEFICIT: inability to feed self r/t depression

Client problems

- Self- care deficit: inability to feed self.

Client goals

- client will perform self feeding

OUTCOME CRITERIA:
4 purposes:
1. provide direction for nursing intervention
2. provide a time spab for planned activities
3. serve as criteria for evaluation of progress toward goal achievement
COMPONENTS OF OUTCOME CRITERIA:
1.
2.
3.
4.

subject
verb
condition or modifier
criterion
SUBJECT

VERB

Standard
Client
Client

Drinks
List

Client

Identifies

Client

States

Cleint

Identifies

CONDITION
100 ml of fluid
Three hazards of
Smoking
Advance of
Immunization
The purpose of his
medication
Importance of
eating right kind
of food

DESIRED
PERFORMANCE
Q 4 hours
(three)
On the next visit
Before discharge
On the next visit

GUIDELINES:
1. Write goals and outcome criteria in term of client behavior- focus on the client
not nursing action.
2. Avoid statement that short and enable, facilitate, allow, let, permit followed
by the word client
3. Make sure the goal statement is appropriate for the NG. Dx and those
outcome criteria are appropriate for goal
4. Make sure the client considers the goals important and values them.
5. Ensure that the (goals) (client) goals and outcome criteria are compatible with
the word and therapies of other professionals
6. Make sure that each goals is derived from only on NG Dz
7. When writing outcome criteia, use observable, measurable terms (smart)
III.

PLANNING NG STRATEGIES:
1. generating alternative nursing strategies
a. brainstorming
b. Hypothesizing
c. Extrapolating
2. considering the consequences of each strategies
3. choosing nursing strategies

IV.

WRITING NURSING ORDERS:

11

5 components:
1. date
2. action verb
3. time element
4. signature
Relationship of OC Vs CG
1. OC- outcome criteria are derived from and relate to the client goals CG from
1st clause of the Ng Dx
Ng Dx- POTENTIAL IMPIARED SKIN INTERITY r/t imposed bed rest.
Client goal- maintain intact ski, particular over bony prominence
Outcome Criteria- demonstrate correct techniques for positioning and
turning
Note: 3-6 outcome criteia are neede to each goal
Characteristics of a well stated outcome criteria:
1. each outcome criteria related to the established goals
2. the outcome stated in the criteria is possible to achieve
3. each criteria is a specific and concrete as possible, to facilitate
measurement
4. each criteria is appraisable or measurable
V.

WRITING NCP

NCP- is a guide that organizes information about a Clients health into a


meaningful whole
Format: 4 columns or categories
1.
2.
3.
4.

Ng. Dx or problem list


Goals
Ng. Strategies/ interventions/ orders
Outcome or evaluation criteria

Ng. Dx
Fears r/t cardiac
catherterization,
possible
heart
surgery and its
outcome

Goals
Experience
increased
emotional comfort
and feelings of
control

Ng. Orders
Establish
a
trusting
relationship
with
the
client
and
family to express
feelings
and
concern
discuss
the cardiac cath
procedure
and
what is expected
of him before and
after
the
procedure

CONSULTING- is deliberating between 2 people


7 steps:
1. identify the problem

Outcome criteria
Verbalizes
specified concerns
communicate
thoughts clearly
and logically facial
expressions, voice
tone, and body
posture
correcpond to
verbal expressions
and increased
emotional comfort
after instruction,
describe cath
procedure and
what is expected
of him.

12

2.
3.
4.
5.
6.

collect pertinent data about the client


select the consultant
communicate the problem
discuss the recommendation with the consultant
include the recommendations in the clients NCP

Discharge Planning- the process of anticipating and planning for needs after
discharge form a Hospital or other facility.
IMPLEMENTING- Intervening
- putting the nursing strategies listed in the hrsing care plan into action
by: Belucheck and Mc Closkey
Nursing Intervention- an autonomous action based on scientific rationale that is
executed to benefit the client in a predicted way related to the Nursing diagnosis
and stated goals.
TYPES OF NURSING ACTIONS:
1. Independent Nursing Action- an activity that the nurse initiates as a result
of the nurses own knowledge and skill autonomous nursing practice.
Taxonomy- is a set of classification that are ordered and arranged on the
basis of a single principle or consistent set of principle.
2. Dependent Nursing Action- are those activities carried out in the order of
the physician, under the physicians supervision or according to specified
routines.
3. Interdependent Interventions- is completed with our without a physicians
order or is written at a nurse suggestion
COLLABORATION- a ture partnership, in which power on both sides in valued
by both, with recognition and acceptance of separate and combined spheres
of activity and responsibility, mutual safe guarding of legitimate interests of
each party and a commonality of goals that is recognized by both parties.
PROTOCOLS- is a written plan specifying the procedure to be followed in a
particular situation.
STANDING ORDER- is a written document about policies, rules, regulations
or orders regarding client care.
6 COMPONENTS OF IMPLEMENTING
1. Reassessing the client
- focuses on more specific needs
- N- determine whether planned nursing strategies are appropriate for the
client.
2. Validating the NCP
N reviews the NCP in 4 areas:
a. safety
b. appropriateness
c. effectiveness
d. individualize nursing care
to validate the plan- to request another appropriate professional and patient
iif possible to give plan approved or implementation
3. Determining the Needs for Assistance
2 Reasons:
a. the N unable to implement the nursing strategies safety alone

13

b. the N lack the knowledge or skills to implement a particular nursing


activity
4. Implementing Nursing Strategies
- to help the client meet his/her health goals
4 Areas of Nursing Practice
a. health promotion
b. health maintenance
c. health restoration
d. care of the dying
6 Important Consideration for Implementing
1.
2.
3.
4.
5.
6.

The clients individuality


The clients need for involvement
Prevention of Complication
Preservation of bodys defenses
Provision of comfort and support to the client
Accurate and careful implementation of all nursing activities

5. Communicating Nursing Actions:


Written and Verbal
IMPLEMENTING ACTIVITIES:
3 important skills:
a. cognitive (intellectual skills)
b. interpersonal skills
c. technical skills

IMPLEMENTING ACTIVITIES
1. Caring
2. Communicating
3. Helping
4. Teaching
5. Counseling
6. Client advocate
GUIDELINES FOR IMPLEMENTING NURSING STRATEGIES
1. Nursing action are based on scientific knowledge
2. Nursing actions resulting from a physicians order must be understood by the
N
3. Nursing actions are adapted to the individual
4. Nursing actions should always be safe
5. Nursing actions often require teaching, supportive and comfort components
6. Nursing actions should be holistic
7. Nursing action should respect the dignity of the client and enhance clients
self-esteem
8. The clients active participation in implementing nursing actions should be
encouraged as health permits.
EVALUATING
To evaluate- to identify whether or to what degree to clients goals have been
met
6 Components
1. Identifying Outcome Criteria
2 purposes

14

a. establish the kind of evaluation data that need to bo collected


b. provide a standard against which data are judged
2. Collecting Data
- observation
- direct communication
- purposeful listening/ reports
3. Judging Goal Achievement
4. relating Nursing Action to Client Outcomes
5. Reexamining the clients care plan
- database
- diagnostic statement
- goal statements
- nursing strategies
6. Modifying the care plan
3 alternative on how well a goal was met
a. Goal met- if the patient was able to demonstrate the behavior by the
specific time on date
b. Goal Partially Met- if the patient was able to demonstrate the behavior but
not as well as the N had specified in the goal statement
c. Goal Not Met- if the patient was unable or willing to perform the behavior
at all
Example:
Nursing Diagnosis- Activity intolerance related to prolonged bed rest
Goal Statement- Patient will walk length of hall and abck by 7/29\
Goal Evaluation- (done on 7/29 or earlier)
Goal Achieved- Patient walked length of hall but not too tired to walk back
Goal partially achieved- Patient walked length of hall but too tired to walk back
Goal not Achieved- Patient refused to walk
Goal Not Achieved- Patient unable to bear his own weight
EVALUATING QUALITY OF NURSING CARE
-

is essential part of professional accountability


other terms: QUALITY ASSESSMENT- examination of services
QUALITY ASSURANCE- implies that efforts are made to evaluate
and ensure quality health care

APPROACHES TO QUALITY EVALAUTION


1. the structure to which client care takes place
2. The process of care- activity of the nurse
How:
- talking with the client
- auditing clients record
- observing the nursing activities
3. Outcomes of care- clients change in behavior toward goal achievement prior
to discharge (concurrent audit)
- client record- reviewed (retrospective audit)
TOOLS AND METHODS USED:
Steps:
1. Defining and clarifying the nature of nursing
2. Deciding what approach to take
3. Developing standards and criteria
4. Testing criteria