Nursing Process

NURSING PROCESS
systematic, rational method of planning and providing individualized nursing care Is a problem-solving framework for planning and delivering nursing care to patients and their families

NURSING PROCESS

NURSING PROCESS
A way of thinking as a nurse. A framework of interrelated activities resulting in competent nursing care. Dynamic and cyclical in nature. A scientific, problem-oriented approach to patient care.

Assessing collecting, organizing and communicating / recording client data

Purpose: to establish data base about

the clients response to health concerns or illness and the ability to manage health care needs

Assessment
Activities:
Obtain health hx Perform P.A. Review records, e.g. lab records, other health care records Interview support persons Review literature Validate assessment data

Nursing Process

Assessment

Assessment (Data Collection) = Observation + Interview + Examination

Observation

Interview

Examination

Data Collection process of gathering information about the clients health status
TYPES OF DATA : Subjective symptoms or covert data e.g. itching pain, feelings of worry includes clients sensations, feelings, values, beliefs, attitudes and perception of personal health status and life situations. Problem : Fever subjective cue: Mainit ang pakiramdam ko.

Assessment Let me look at that. Tell me about it.

Types of Data
Objective data signs or overt data; detectable by an observer or can be tested against an accepted standard e.g. discoloration of the skin Problem: fever-objective cue : skin is warm to touch; temp. is 38.9 C/ax

Objective data
Caput medusae

BP reading

SOURCES OF DATA:
Primary source - client (best source of data)

SOURCES OF DATA:
Secondary sources indirect sources e.g. family members, -support people, -client records (medical records, records of therapies by other health professionals and laboratory records), -health care professionals, - literature

METHODS OF DATA COLLECTION:

Observing using the five senses; a conscious deliberate skill that is developed only through effort and with an organized approach

METHODS OF DATA COLLECTION

Interview a planned communication or conversation with a purpose

Interview
Interview 2 approaches:

a. direct interview highly structured and elicit specific information by asking closed questions that call for a specific amount of data.

b. nondirective the nurse allows the client to control the purpose, subject matter and pacing
Requirement: RAPPORT - the understanding between two or more people.

Kinds of interview questions:

Closed questions Open-ended restrictive and questions lead generally require or invite clients to only short answers explore their giving specific thoughts or feelings information; often begin with when, where, who, what, do, does, did

PLANNING THE INTERVIEW AND SETTING:

Time need to be scheduled when the client is comfortable and free of pain Place must have adequate privacy to promote communication Seating arrangement Distance most people feel comfortable 3 to 4 ft apart during an interview

STAGES OF AN INTERVIEW:
Opening sets the tone of the remainder of the interview. a.1. Establish rapport process of creating good will and trust a.2 Orientation explaining the purpose and nature of the interview Body client communicates what he or she thinks, feels, knows and perceives in response to questions from the nurse Closing important in facilitating future interactions.

ASSESSMENT TOOLS: GORDONS FUNCTIONAL HEALTH PATTERN FRAMEWORK

pattern -signifies a sequence of recurring behavior dysfunctional as well as functional behavior to discern emerging patterns.

TYPOLOGY OF 11 FUNCTIONAL HEALTH PATTERNS: 1.Health perception health management pattern: describes clients perceived pattern of health and well-being and how health is managed How does the person describe her/ his current health? What does the person do to improve or maintain her/ his health?

1.Health perception health management pattern: What does the person know about links between lifestyle choices and health? How big a problem is financing health care for this person? Can this person report the names of current medications she/he is taking and their purpose?

1.Health perception health management pattern:

If this person has allergies, what does s/he do to prevent problems? What does this person know about medical problems in the family?

Have there been any important illnesses or injuries in this person's life?

1.Health perception health management pattern:

Nsg. Dx

Ineffective health maintenance Ineffective therapeutic regimen management Ineffective family therapeutic regimen management Ineffective community therapeutic regimen management

1.Health perception health management pattern:

Nsg. Dx

Risk for infection Risk for injury (trauma) Risk for falls

TYPOLOGY OF 11 FUNCTIONAL HEALTH PATTERNS:

2.Nutritional metabolic pattern:

pattern of food and fluid consumption relative to metabolic need and pattern indicators of local nutrient supply Is the person well nourished? How do the person's food choices compare with recommended food intake?

2.Nutritional metabolic pattern: Nsg. Dx Imbalanced nutrition: more than body requirements Risk for imbalanced nutrition: more than body requirements Imbalanced nutrition: less than body requirements

TYPOLOGY OF 11 FUNCTIONAL HEALTH PATTERNS:

3.Elimination pattern: describes pattern of excretory function ( bowel, bladder and skin) Are the person's excretory functions within the normal range? Does the person have any disease of the digestive system, urinary system or skin?

3.Elimination pattern: Nsg. Dx

Constipation Diarrhea Risk for constipation Bowel incontinence Impaired urinary elimination Functional urinary incontinence

TYPOLOGY OF 11 FUNCTIONAL HEALTH PATTERNS:

4. Activity

exercise pattern :

describes pattern of exercise, activity, leisure and recreation How does the person describe

her/ his weekly pattern of activity and leisure, exercise and recreation? Does the person have any disease that affects her/ his cardiorespiratory system or musculo-

4. Activity exercise pattern : Nsg. Dx

Activity intolerance Risk for activity intolerance Fatigue Deficient diversonal activity Impaired physical mobility

TYPOLOGY OF 11 FUNCTIONAL HEALTH PATTERNS:

5.Cognitive perceptual pattern : describes sensory perceptual and cognitive pattern

-make a quick neurological assessment

TYPOLOGY OF 11 FUNCTIONAL HEALTH PATTERNS:

6.Sleep rest pattern:
describes patterns of sleep, rest and relaxation Describes person's sleep-wake cycle. Does this person appear physically

rested and relaxed?

6.Sleep rest pattern: Nsg. Dx

Disturbed sleep pattern

7.Self perception self concept pattern:

describes self-concept pattern and perceptions of self (body comfort, body image, feeling state)
Is there anything unusual about this person's appearance? Does this person seem comfortable with her/ his appearance?

Describe person's feeling state

7.Self perception self concept pattern:

Nsg. Dx
Fear Anxiety Risk for loneliness Hopelessness Powerlessness Risk for powerlessness Situational low self-esteem Risk for situational low selfesteem Chronic low self-esteem Body image disturbed Disturbed personal identity Risk for violence, selfdirected

TYPOLOGY OF 11 FUNCTIONAL HEALTH PATTERNS:

8.Role relationship pattern :
describes patterns of role engagements and relationships
How does this person describe her/ his

various roles in life? Has, or does this person now have positive role models for these roles?

8.Role relationship pattern :

Which relationships are most

important to this person at present? Is this person currently going though any big changes in role or relationship? What are they?

8.Role relationship pattern : Nsg. Dx

Anticipatory grieving Dysfunctional grieving Risk for dysfunctional grieving Ineffective role performance Social isolation Impaired social interaction Relocation stress syndrome

TYPOLOGY OF 11 FUNCTIONAL HEALTH PATTERNS:

9.Sexuality reproductive pattern:
describes clients patterns of satisfaction

and dissatisfaction with sexuality; describes reproductive pattern

Do you have regular menstruation?

When was the last sexual

intercourse? Sexual activities?

9.Sexuality reproductive pattern:

Nsg. Dx
Sexual dysfunction Rape-trauma syndrome

TYPOLOGY OF 11 FUNCTIONAL HEALTH PATTERNS:

10.Coping stress tolerance pattern:
describes general coping pattern and effectiveness of the pattern in terms of stress tolerance How does this person usually cope with problems? Do these actions help or make things worse? Has this person had any treatment for emotional distress?

10.Coping stress tolerance pattern:

Nsg. Dx.
Ineffective coping Disabled family coping Ineffective community coping Post-trauma syndrome Risk for post-trauma syndrome Risk for suicide

TYPOLOGY OF 11 FUNCTIONAL HEALTH PATTERNS:

11. Value belief pattern:
describes patterns of values, beliefs or goals that guide choices or decisions E.g reads bible everyday

REVIEW OF SYSTEMS
goal : to gather data from the client in each of the major body systems.

General Health. Weight loss, weakness, feelings of fatigue, mood changes, night sweats, or bleeding tendencies?

REVIEW OF SYSTEMS
Skin. Skin diseases such as eczema, psoriasis, acne; change in pigmentation; tendency toward bruising; excessive dryness or moisture; jaundice; itching, rashes, hives; change in color or size of moles; or open sores that are slow to heal? Hair. Itchy scalp, loss of hair, excessive body hair? Does the client wear a wig? Nails. color changes, biting, clubbing, splitting?

REVIEW OF SYSTEMS
Head Frequent or severe headaches, fainting, dizziness, accident resulting in unconsciousness

REVIEW OF SYSTEMS
Eyes. Difficulty seeing, eye infection, eye pain, excessive tearing, double vision, blurring, sensitivity to light, cataracts, itching, spots in front of eyes? Does the client wear glasses (for near or far vision) or contact lenses? When was the clients last eye examination?

REVIEW OF SYSTEMS
Ears Any infection, loss of hearing, pain, discharge, ringing in the ears? Does the client wear a hearing aid? Nose. Frequent colds, nosebleeds,

allergies, pain,
tenderness, postnasal drip?

REVIEW OF SYSTEMS
Mouth and throat. Sore gums; bleeding gums; sores, lumps or white spots on the mouth, lips or tongue; toothaches, cavities, difficulty swallowing; voice change or hoarseness? Does the client wear dentures (upper, lower, partial)? When was the clients last dental appointment?

REVIEW OF SYSTEMS
Neck. Pain, swelling, stiffness, limited movements, swollen glands?

Breasts. Nipple discharge, Scaling or cracks around nipples, dimples, lumps, pattern of self breast examination? Last mammogram?

REVIEW OF SYSTEMS
Respiratory system.
Chest pain; cough; shortness of breath; wheezing; coughing up blood; lung disease such as tuberculosis, emphysema, asthma, bronchitis? Has the client ever had a chest x-ray? When? Results?

REVIEW OF SYSTEMS
Cardiovascular system.
Heart disease, palpitations, heart murmur, high blood pressure, anemia, varicose veins, leg swelling or ulcer?

REVIEW OF SYSTEMS
Gastrointestinal system.
Nausea, vomiting, loss of appetite, indigestion, heartburn, bright blood in stools, diarrhea, constipation, abdominal pain; excessive gas, hemorrhoids, rectal pain, colostomy, ileostomy?

REVIEW OF SYSTEMS
Genitourinary system.
Frequency, dribbling, urgency, urination at night, difficulty starting stream, blood in urine, incontinence, pain or burning upon urination, urinary tract infection, sexually transmitted disease such as gonorrhea or syphilis?

REVIEW OF SYSTEMS
Females: Age of menarche, last menstrual period (LMP), duration, amount of flow, regulatory of cycle? Any problems with painful menstruation, bleeding within periods, pain during intercourse, vaginal discharge, vaginal itching, vaginal infection?

REVIEW OF SYSTEMS
Males: Penile discharge, swelling, masses or lesions, difficulty in sexual functioning?

REVIEW OF SYSTEMS
Musculoskeletal system:
Muscular pain, swelling or weakness; joint swelling, soreness, or stiffness; leg cramps; bone defects?

REVIEW OF SYSTEMS
Neurologic system:
Difficulty of walking; unconsciousness; seizures; tremors; paralysis; numbness, tingling; or burning sensations in any body part; weakness on one side of body; speech problems; unclear thinking; changes in emotional state?

REVIEW OF SYSTEMS
Endocrine system: History of goiter; heat or cold; intolerance; diabetes; excessive thirst; excessive eating?

NURSING DIAGNOSIS :
statement of the clients health status clinical judgment about individual, family or community responses to actual and potential health problems / life processes. Purpose: Provides the basis for selections of nursing interventions to achieve outcomes for w/c the nurse is accountable

NURSING DIAGNOSIS :
Eg. Problem : Fever nursing diagnosis : Alteration in thermoregulatory function: or hyperthermia related to inflammatory process

TYPES OF NURSING DIAGNOSES:

Actual Nursing Diagnosis a judgment about the clients response to a health problem w/c is present at the time of nursing assessment Potential Nursing Diagnosis a judgment that a client is more vulnerable to develop the problem in the same / similar situation

 Problem Statement describes the clients health problem or response for which nursing therapy is given Qualifiers added words to give additional meaning to the diagnostic statement Altered change from baseline Impaired made worse, weakened, damaged Decreased smaller in size, amount or degree Ineffective not producing the desired effect Acute severe or of short duration Chronic lasting a long time

COMMON ERRORS IN FORMULATING NURSING DIAGNOSES

1.Using medical diagnosis INCORRECT: Self-care deficit related to stroke CORRECT: Self-care deficit related to neuromuscular impairment 2.Relating the problem to an unchangeable situation

COMMON ERRORS IN FORMULATING NURSING DIAGNOSES

3. Confusing the etiology or signs/symptoms for the problem INCORRECT: Post-operative lung congestion related to bed rest CORRECT: Ineffective airway clearance related to general weakness and immobility

COMMON ERRORS IN FORMULATING NURSING DIAGNOSES

4. Use of a procedure instead of a human response INCORRECT: Catheterization related to urinary retention CORRECT: Urinary retention related to perineal swelling

COMMON ERRORS IN FORMULATING NURSING DIAGNOSES

5. Lack of specificity INCORRECT: Constipation related to nutritional intake CORRECT: Constipation related to inadequate dietary bulk and fluid intake

COMMON ERRORS IN FORMULATING NURSING DIAGNOSES

6. Combining two nursing diagnosis INCORRECT: Anxiety and fear related to separation from parents CORRECT: Anxiety related to change in environment and unmet needs

COMMON ERRORS IN FORMULATING NURSING DIAGNOSES

7. Relating one nursing diagnosis to another INCORRECT: Coping, individual ineffective related to anxiety CORRECT: Anxiety, severe related to change in role functioning and socio-economic status

COMMON ERRORS IN FORMULATING NURSING DIAGNOSES

Use of judgmental/value-laden language Ineffective airway clearance related to bad habit

COMMON ERRORS IN FORMULATING NURSING DIAGNOSES

9. Making assumptions INCORRECT: Risk for altered parenting related to inexperience CORRECT: Deficient knowledge regarding child care issues related to lack of previous experience, unfamiliarity with resources

10.Writing a Legally Inadvisable Statement INCORRECT: Skin integrity related to not being turned every 2 hours CORRECT: Impaired skin integrity related to pressure and altered circulation

A Nursing Diagnosis
Is Not Is A medical diagnosis A statement of a A nursing action patient problem A physician order Actual or potential A therapeutic Within the scope of treatment nursing practice Directive of nursing intervention

Medical Dx vs.Nursing Diagnosis

Myocardial infarction Fear r/t possible recurrence of uncertain outcome Chronic ulcerative colitis Diarrhea r/t dis. process Alteration in nutrition: less than body requirements r/t altered GI absorptions Risk for(Potential) body Cancer of the breast image disturbance if mastectomy is required

Cerebral vascular accident

Self-care deficit: dressing & grooming r/t right sided flaccidity

Etiology (Related/ Risk Factors) the

probable cause of the health problem; may include clients behavior, environmental factors or the interaction of the two; NANDA- related to to describe the etiology or likely cause Example: Activity intolerance related to decreased cardiac output. Ineffective breast-feeding related to firsttime experience Altered bowel elimination; constipation related to insufficient fluid intake.

 Medical Diagnosis made by a physician refers to a pathophysiologic responses that are fairly uniform from one client to another.
Nursing Diagnosis describes the clients physical, sociocultural, psychologic and spiritual responses to an illness or potential health problems; vary among individuals.

Nursing diagnosis
Actual nursing diagnoses
PES approach = Problem + Etiology + Signs/Symptoms Impaired verbal communication r/t cultural differences as manifested by inability to speak English

Nursing diagnosis
Potential nursing diagnosis
PRF approach (risk factor) Potential skin breakdown r/t physical immobilization in total body cast Potential fluid volume deficit r/t diarrhea, age 3 yrs., low oral intake, elevated temperature

 involves decision making and problem solving Planning process includes: A.Setting priorities establishing a preferential order for nursing strategies ; the nurse must consider a variety of factors : 1.Clients health values and beliefs a client may believe that being home with children is more urgent than a health problem. 2.Clients priorities involving the client enhances cooperation between nurse and client 3.Urgency of health problems ABCs of life (airway, breathing, circulation) 4.Medical treatment plan must be congruent with treatment of other health care professionals

PLANNING

PLANNING
should be S-M-A-R-T (specific, measurable, attainable, realistic and time-bound) Example: Problem : Fever subjective cues : Mainit ang pakiramdam ko. objective cues : skin is warm to touch; temp. is 38.9 C nursing diagnosis : Alteration in thermoregulatory function: hyperthermia related to inflammatory process plan : After 4 hours of continuous nursing intervention, patients temperature will decrease from 38.9 C to 37.5C/ ax.

PLANNING
Planning = setting priorities + establishing goals + planning interventions

PLANNING
B. Establish Goals Components of a goal statement Goal statement = pt behavior + criteria of performance + Time + conditions (if needed)

Components of a goal statement

PATIENT BEHAVIOR - an observable activity that the patient will demonstrate (the patient) will void Decrease in ( the patients) BP (the patient) will ambulate (the patient) will report (the patient) will drink

Components of a goal statement

TIME FRAME - a designated time or date when the patient should be able to achieve the behavior
Within the next hour By discharge At the end of this shift By Dec. 25 In 2 months

Components of a goal statement

CONDITIONS
- specific aides which will facilitate the patient
performing a behavior at the level in the criteria and within the specified time frame

With the help of a walker With the use of a wheelchair With the help of the family With the use of medication Using oral analgesics q3-4 hrs Using IM Demerol q3-4 hrs

Planning Process
C. Planning Interventions render continuous tepid sponge bath loosen tight and thick clothing increase fluid intake keep room well ventilated administer antipyretics as indicated/ordered

IMPLEMENTATION / INTERVENTION implement the interventions identified in the plan of care. Cognitive/Intellectual Skills include problem solving, decision making, critical thinking and creative thinking

IMPLEMENTATION / INTERVENTION

Interpersonal skills activities use when communicating directly with one another; include verbal and nonverbal activities; necessary for caring, comforting, referring, counseling and supporting clients;

IMPLEMENTATION / INTERVENTION

Technical /psychomotor skills hands-on skills such as manipulating equipment, giving injections and bandaging, moving, lifting, and repositioning clients; require knowledge and frequently manual dexterity.

The process of implementing: 1.Reassessing the client reassess whether the intervention is still needed Note: even though an order is written on the care plan, the situation or the clients condition may have changed.

The process of implementing:

2.Determining the need for nursing assistance the nurse maybe unable to implement the nursing strategies safely alone

The process of implementing:

3.Implementing nursing strategies nursing activities include caring, communicating, helping, teaching, counseling, acting as a client advocate and change agent, leading and managing.

The process of implementing

4.Communicating nursing actions recording the
interventions along with the client responses in the nursing progress notes.

TYPES OF NURSING ACTIONS:

Independent Nursing Actions an activity that the nurse initiates as a result of the nurses own knowledge and skills Dependent nursing actions activities carried out on the order of the physician, under the physicians supervision or according to specified routines Collaborative nursing actions activities performed either jointly with another member of the health care team or as a result of a joint decision by the nurse and another health care team member

 Problem : Fever subjective cues : Mainit ang pakiramdam ko. objective cues : skin is warm to touch; temp. is 38.9 C nursing diagnosis : Alteration in thermoregulatory function: hyperthermia related to inflammatory process plan : After 4 hours of continuous nursing intervention, patients temperature will decrease from 38.9 C to 37.5C.

Intervention
continuous tepid sponge bath rendered tight and thick clothing loosened fluid intake increased room kept well ventilated antipyretics as indicated/ordered administered

EVALUATION
The evaluation process has 6 components: Identifying the expected outcomes that the nurse will use to measure client goal achievement Collecting data related to the expected outcomes Comparing the data with the expected outcomes and judging whether the goals have been achieved Relating nursing actions to client outcomes Drawing conclusions about problem status Reviewing and modifying the clients care plan determine clients progress toward goal achievement and the effectiveness of NCP

 EVALUATION STATEMENT consist of 2 parts : a conclusion and a supporting data Example : Goal met : After 4 hours of continuous nursing intervention, temperature decreased from 38.9 to 37.4 C/ax