Nursing Process: Ch 5

Nursing Process

• Nursing process is cyclic rather than linear

• Foundation of professional nursing practice

• Framework within which nurses provide care to patients in an organized and effective manner

• Requires critical thinking

  • Allows nurses to collect essential patient data

  • articulate the specific needs of individual patients

  • effectively communicate those needs, realistic patient goals, and customized interventions w/ members of the health care time

Historical Development and Significance of the Nursing Process

• “Nursing process” was first used by Lydia Hall in 1955

• In the late 1950s and early 1960s, other nurses began using the term to
  define the steps used for decision- making while initiating and providing
  patient care.

• In 1973, the American Nurses Association identified five specific steps of the nursing process in its Standards of Clinical Practice.

• Nursing process is used to:

  • assess individuals, families, and communities; diagnose needs; plan attainable goals; identify outcome criteria; implement specific interventions; evaluate degrees of goat attainment

Five steps of the nursing process are:

Assessment

Diagnosis

Planning

Implementation

Evaluation

-Seen as part of outcome identification

Characteristics of the Nursing Process

• Analytical

• Dynamic

• Organized

• Outcome oriented

• Collaborative

• Adaptable

Analytical

Nurses must be able to assess patients accurately and then organize and analyze their findings to provide safe care

• Is the data collection thorough and accurate?

• Are outcomes specific and realistic for the individual patient or group?

• Have all the underlying factors contributing to the patient’s response to illness or group concerns been adequately addressed in the plan of care?

• Could any of the nursing interventions have a negative impact on the patient/group?

• Does each intervention provide for patient-centered care and the safety of the patient?

• Are there new data that necessitate modification of the existing plan of care?

Dynamic

changing over time in response to patients’ needs

-a nurse conducts ongoing assessment as a patients condition changes and modifies the plan of care on the basis of those findings

Organized

Nursing process provides a standardized method of addressing patient needs that is understood by nurses worldwide

Outcome Oriented

Care plans are developed to meet each patient’s goals, not the goals of standardized patient or members of the health care team, including the nurse

Collaborative

Nurses incorporate orders from primary care providers, nursing interventions, and input from others (such as physical therapists, social workers, or respiratory therapists) into a patient’s plan of care to help alleviate patient problems and achieve established patient-centered goals and outcomes

Adaptable

Care plan changes can depend on a variety of concerns, including cost and availability of professionals to implement interventions.

Assessment

is the organized and ongoing appraisal of a patient’s well-being

-Use the Holistic approach

Data collection:

• Primary data

  • Patient interview

• Secondary data

  • Families, friends, etc.

• Subjective data

  • Symptoms

  • Health history

• Objective data: What “I” see

  • Signs

  • Physical examination

  • Laboratory results

  • Diagnostic test results

Holistic approach

Nurses assess the state of a patient’s physical, psychological, emotional, environmental, cultural, and spiritual health

Diagnosis

• Description of what a nurse observes or discovers while assessing a patient or group

• Identifies a problem, potential problem, or opportunity for improvement

Accurate ID of nursing diagnosis occurs:

-Analyzing, validating, and clustering related subjective and objective data

*Nursing diagnoses considers a patient’s response to medical or mental health diagnoses and life situations

Methodology

Differentiate between a medical diagnosis & nursing diagnosis
Cluster assessment data and patient needs

Taxonomies used
• NANDA International, Inc. (NANDA-I)
• International Classification for Nursing Practice (ICNP)
• International Council of Nurses (ICN)
• Clinical Care Classification System (CCC)

Planning

• Prioritizes hypotheses and patient or group nursing diagnoses

• Establishes short and long-term goals

1. patient or group focused

2. realistic

3. measurable

• Choose outcome indicators

• Identifies interventions to address specific goals

Short term goals

-Last less than 1 week

Long term goals

last weeks to months

Outcome Identification

-Involves listing behaviors or observable items that indicate attainment of a goal

ex: The Nursing Outcomes Classification (NOC)

Implementation

Focuses on the initiation of appropriate actions and interventions designed to meet the needs of each patient or group

Interventions must be:

-Independent

-Dependent

-Collaborative

Require indirect or direct care

Evalution

Focuses on the patient or group and the patient’s or group’s response to interventions and goal or outcome attainment

-Must clearly identify the effectiveness of implemented interventions, with the patient or group as its focus

Care Plan Evaluation

• Patient/group goal/outcome attainment?

• Continue?

• Revise/adapt?

• Discontinue?