nursing process handouts

Foundations of Nursing

Nursing Process

Prepared by: Mark Fredderick R. Abejo R.N, M.A.N

Foundations of Nursing Abejo

FOUNDATIONS OF NURSING

Nursing Process

Lecturer: Mark Fredderick R. Abejo R.N, M.A.N

NURSING PROCESS

A systematic, rational method of planning

providing nursing care.

Goal:

1. To identify a client’s healthcare status, and

actual or potential health problems

2. To establish plans to meet the identified needs

3. To deliver specific nursing interventions to

address those needs

I. ASSESSMENT PHASE

The nurse carry out a complete & holistic

nursing assessment of every patient's needs

Utilizes an assessment framework, based on a

nursing model or Waterlow scoring wherein

problems are expressed as either actual or

potential.

Assessing is a systematic and continuous

collection, organization, validation, and

documentation of data (information)

Assessing is a continuous process carried out

during all phases of the nursing process

Nursing assessments focus on a client’s

responses to a health problem

Should include the client’s perceived needs,

health problems, related experience, health

practices, values, and lifestyles

Types of Assessment

Initial Assessment

Problem-focused Assessment

Emergency Assessment

Time-lapsed Reassessment

The assessment process involves four closely related

activities: collecting data, organizing data, validating data,

and documenting data.

A. Collecting Data:

Data collection is the process of gathering

information about a client’s health status. It must be both

systematic and continuous to prevent the omission of

significant data and reflect a client’s changing health

status.

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. Itching, pain, and feelings of worry

are examples of subjective data. It all

includes the client’s sensations, feelings,

values, beliefs, attitudes, and perception of

personal health status and life situation

Objective Data

also referred to as signs or overt data, are

detectable by an observer or can be

measured or tested against an accepted

standard.

They can be seen, heard, felt, or smelled,

and they are obtained by observation or

physical examination.

Primary source is the client

Secondary source is family or anyone else that is not

the client

Methods of Data Collection

Observing

To observe is to gather data by using the sense.

Observation is a conscious, deliberate skill that is

developed through effort and with an organized

approach. It has to aspects: (a) noticing the data

and (b) selecting, organizing, and interpreting the

data.

Interviewing

An interview is a planned communication or a

conversation with purpose, for example, to get or

give information, identify problems of mutual

concern, evaluate change, teach, provide support,

or provide counseling or therapy.

There are two approaches to interviewing:

o Directive interview - Nurse directs

interview, client responds to questions and

has limited chances to discuss concerns.

o Nondirective interview – rapport-building

where the client is in control of the

purpose, subject, and pace.

Questions :

Open-ended – invites client to discover and

explore, elaborate, clarify, or illustrate their

thoughts or feelings. “How have you been

feeling lately?”

Closed-ended – used in directive

interviewing, and are questions that require

a yes or no answer.


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Neutral question – a question that the client

can answer without direction. “Why do you

think you had the operation?”

Leading question – directs the clients

answer. “You’re stressed about surgery

tomorrow, aren’t you?”

Examining

The physical examination or physical assessment

is a systematic data-collection method that uses

observation (i.e., the senses of sight, hearing,

smell, and touch) to detect health problems. To

conduct the examination the nurses uses

techniques of inspection, auscultation, palpation,

and percussion.

B. Organizing Data:

Using a written or computerized format that

organizes the assessment data.

Most schools of nursing and health cause

agencies have developed their own structured

assessment format.

Frameworks:

o Gordon – 11 functional health patterns

o Orem – 8 universal self-care requisites of

humans

o Roy’s adaptation model

o Maslow’s hierarchy of needs

C. Validating Data:

The information gathered during the assessment

phase must be complete, factual, and accurate

because the nursing diagnoses and interventions

are based on this information. Validation is the

act of “double-checking” or verifying data to

confirm that it is accurate and factual.

Cues vs. Inferences:

o Cues – subjective or objective data that can

be directly observed by the nurse, either

what the client says or what the nurse can

see.

o Inferences – nurses interpretations or

conclusions based on the cues. (A nurse

observes the cues that an incision is red,

hot, and swollen; the nurse makes the

inference that the incision is infected.)

- You don’t have to check all data (like

birth dates, height, weight and most lab

studies)

Validating data helps the nurse complete these

tasks:

Ensure that assessment information is

complete.

Ensure that objective and related subjective

data agree.

Obtain additional information that may have

been overlooked.

Differentiate between cues and inferences.

Avoid jumping to conclusions and focusing

in the wrong direction to identify problems.

D. Documenting Data:

To complete the assessment phase, the nurse

records client data. Accurate documentation is

essential and should include all data collected

about the client’s health status.

Data are recorded in a factual manner and not

interpreted by the nurse

o The nurse records the client’s breakfast

intake (objective) as “coffee 240 mL, 1

egg, and 1 slice of toast”

II. DIAGNOSIS PHASE

The term diagnosing refers to the reasoning

process, whereas the term diagnosis is a statement or

conclusion regarding the nature of a phenomenon. The

standardized North American Nursing Diagnosis

Association (NANDA) names for the diagnoses are called

diagnostic labels; and the client’s problem statement,

consisting of the diagnostic label plus etiology (causal

relationship between a problem and its related

Types of Nursing Diagnoses

The five types of nursing diagnoses are actual,

risk, wellness, possible, and syndrome.

An actual diagnosis is a client problem that is

present at the time of the nursing assessment.

Examples are Ineffective Breathing Pattern and

Anxiety. An actual nursing diagnosis is based on

the presence of associated signs and symptoms.

A risk nursing diagnosis is a clinical judgment

that a problem does not exist, but the presence of

risk factors indicates that a problem is likely to

develop unless nurses intervene.

A wellness diagnosis “describes human

responses to levels of wellness in an individual,

family or community that have a readiness for

enhancement”

A possible nursing diagnosis is one in which

evidence about a health problem is incomplete or

unclear. A possible diagnosis requires more data

either to support or to refute it.

Syndrome diagnosis is a diagnosis that is

associated with a cluster of other diagnoses.


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The Diagnostic Process

The diagnostic process uses the critical-thinking

skills of analysis and synthesis.

Critical thinking is a cognitive process during which

a person reviews data and considers explanations

before forming an opinion.

Analysis is the separation into components, that is,

the breaking down of the whole into its parts

. Synthesis is the opposite, that is, the putting

together of parts into the whole. T

he diagnostic has three steps: analyzing data,

identifying health problems, risks, and strengths,

and formulating diagnostic statements.

A. Analyzing Data

In the diagnostic process, analyzing involves the

following steps:

o Compare data against standards (identify

significant cues).

o Cluster cues (generate tentative hypotheses).

Identify gaps and inconsistencies.

B. Identifying Health Problems, Risks, and Strengths.

After data are analyzed, the nurse and client can

together identify strengths and problems. This is

primarily a decision-making process.

Determining problems and risk

After grouping and clustering the data, the nurse

and client together identify problems that support

tentative actual, risk, and possible diagnoses.

In addition, the nurse must determine whether

the client’s problem is a nursing diagnosis,

medical diagnosis, or collaborative problem.

Determining strengths

At this stage, the nurse and client also establish

the client’s strengths, resources, and abilities to

cope.

Most people have a clearer perception of their

problems or weakness than of their strengths and

assets, which they often take for granted.

A client’s strengths can be found in the nursing

assessment record (health, home life, education,

recreation, exercise, work, family and friends,

religious beliefs, and sense of humor).

C. Formulating Diagnostic Statements

Most nursing diagnoses are written as two-part or

three-part statements, but there are variations of

these.

Basic two-part statements

The basic two-part statement includes the

following:

Problem (P): statement of the client’s response.

Etiology (E): factors contributing to or probable

cause of the responses.

Basic three-part statements

The basic three-part nursing diagnosis statement

is called the PES format and includes the

following:

Problem (P): statement of the client’s response.

Etiology (E): factors contributing to or probable

cause of the responses.

Signs and Symptoms (S): defining

characteristics

manifested by the

client.

• Problem Statement describes the client’s

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

• Diagnostic Labels

o Describes the client’s health problem or

response for which nursing therapy is

given.

o Independent function – areas of health care

that are unique to nursing and separate and

distinct from medical management.

o Dependent function- Nurses are obligated

to carry out physician-prescribed therapies

and treatments.


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Differentiating Nursing Diagnoses from Collaborative

Problems

o Collaborative – monitoring the client’s

condition and preventing development of

the potential complication and using

physician-prescribed interventions.

o Nursing Diagnoses – involve the human

response, which vary from one person to

the next.

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

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

4. Use of a procedure instead of a human response

– INCORRECT: Catheterization related to

urinary retention

– CORRECT: Urinary retention related to

perineal swelling

5. Lack of specificity

– INCORRECT: Constipation related to

nutritional intake

– CORRECT: Constipation related to

inadequate dietary bulk and fluid intake

6. Combining two nursing diagnosis

– INCORRECT: Anxiety and fear related to

separation from parents

– CORRECT: Anxiety related to change in

environment and unmet needs

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

8. Use of judgmental/value-laden language

Ineffective airway clearance related to bad habit

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 Is not

A statement of a

patient problem

Actual or potential

Within the scope

of nursing practice

Directive of

nursing

intervention

A medical

diagnosis

A nursing action

A physician order

A therapeutic

treatment

III. PLANNING PHASE

The third phase of the nursing process, in which

the nurse and client develop client goals/desired

outcomes and nursing interventions to prevent,

reduce, or alleviate the client’s health problems.

Planning is a deliberative, systematic phase of

the nursing process that involves decision

making and problem solving. In planning, the

nurse refers to the client’s assessment data and

diagnostic statements for direction in

formulating client’s goals and designing the

nursing interventions required to prevent, reduce,

or eliminate the client’s health problems.

A nursing intervention is “any treatment, based

upon clinical judgment and knowledge that a

nurse performs to enhance patient/client

outcomes”

Types of Planning

Planning begins with the first client contact and

continues until the nurse-client relationship ends, usually

when the client is discharges from the health care agency.

Initial Planning

The nurse perform the admission assessment

usually develops the initial comprehensive plan

of care.

This nurse has the benefit of the client’s body

language as well as some intuitive kinds of

information that are not available solely from the

written database.

Planning should be initiated as soon as possible

after the initial assessment, especially because of

the trend toward shorter hospital stays.


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Ongoing Planning

Is done by all nurses who work with the client.

As nurses obtain new information evaluate the

client’s responses to care, they can individualize

the initial care plan further.

Ongoing planning also occurs at the beginning of

a shift as the nurse plans the care to be given that

day.

Discharge Planning

The process of anticipating and planning for

needs after discharge, is a crucial part of

comprehensive health care and should be

addressed in each client’s care plan.

NURSING CARE PLAN

Types of NCP

Informal Nursing Care Plan

o Strategy for action that exists in the nurse’s

mind.

Formal Nursing Care Plan

o Written or computerized guide for

organizing information

Standardized Nursing Care Plan

o Formal plan that specifies the nursing care

for groups of clients with common needs.

o Not for individuals

o Preprinted guides for the nursing care of a

client who has a need that arises frequently

in the agency.

o Problem -> Goals/desired outcomes ->

Nursing interventions -> Evaluation

Individualized Nursing Care Plan

o Is tailored to meet the unique needs of a

specific client.

- When nurses use the client’s nursing

diagnoses to develop goals and

nursing interventions, the result is a

holistic, individualized plan of case

that will meet the client’s unique

needs.

- During planning phase, the nurse must

decide which of the client’s problems

need individualized plans and which

problems can be addressed by

standardized plans and routine care,

and write unique desired outcomes

and nursing interventions for client

problems that require nursing

attention beyond preplanned, routine

care.

Guidelines for writing a Nursing Care Plan

Date and sign the plan

Use category headings “Nursing Diagnoses”

“Goals/Desired Outcomes”

Use standardized medical or English symbols

and key words rather that complete sentences to

communicate your ideas.

Be specific

Refer to procedure books or other sources of info

rather than including all steps on something

Tailor plan to the client: Ask when the best time

is for the client to do interventions

Ensure that the plan incorporates preventive and

health maintenance aspects as well as restorative

ones.

Ensure that the plan contains interventions for

ongoing assessment of the client.

Include collaborative and coordination activities

in the plan

Include plans for the client’s discharge and home

care need

The Planning Process

In the process of developing client care, the

nurse engages in the following activities:

Priority Setting

Is the process of establishing a preferential

sequence for addressing nursing diagnoses and

interventions.

The nurse and client begin planning by deciding

which nursing diagnosis requires attention first,

which second, and so on. Instead of rank-

ordering diagnoses, nurses can group them as

having high, medium, or low priority.

Life-threatening problems such as loss of

respiratory or cardiac function are designated as

high priority.

The nurse must consider a variety of factors

when assigning priorities, including the

following:

Client’s health values and beliefs

Client’s priorities

Resources available to the nurse and client

Urgency of the health problem

Medical treatment plan

Establishing Client Goals/Desired Outcomes

After establishing priorities, the nurse and client

set goals for each nursing diagnosis.

On a care plan the goals/desired outcome

describe, in terms of observable client responses,

what the nurse hopes to achieve by

implementing the nursing interventions.

The term goal and desired outcome are used

interchangeably in this text, except when

discussing and using standardized language.

Selecting Nursing Interventions and Activities

Nursing interventions and activities are the

actions that a nurse performs to achieve client

goals.

The specific interventions chosen should focus

on eliminating or reducing the etiology of the

nursing diagnosis, which is the second clause of

the diagnostic statement.

Types of Nursing Interventions

Independent interventions

Are those activities that nurses 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.


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Dependent interventions Are activities carried out under the physician’s

orders or supervision, or according to specified

routines.

Collaborative interventions Are actions the nurse carries out in collaboration

with other health team members, such as

physical therapist, social workers, dietitians, and

physicians.

Criteria for Choosing Nursing Interventions

The following criteria can help the nurse to choose the

best nursing interventions. The plan must be:

Safe and appropriate for the individual’s age,

health, and condition.

Achievable with the resources available.

Congruent with the client’s values, beliefs, and

culture.

Congruent with other therapies.

Based on nursing knowledge and experience or -

knowledge from relevant sciences.

Within established standards of care as

determined by state laws, professional

associations, and the policies of the institution.

Writing Nursing Order

After choosing the appropriate nursing

interventions, the nurse writes them on the care

plan as nursing orders.

Nursing orders are instructions for the specific

individualized activities the nurse performs to

help the client meet established health care goals.

The term order connotes a sense of

accountability for the nurse who gives the order

and for the nurse who carries it out.

IV. IMPLEMENTATION / INTERVENTION PHASE

The methods by which the goal will be achieved

are also recorded at this stage.

The methods of implementation must be

recorded in an explicit and tangible format in a

way that the patient can understand should he

wish to read it.

Clarity is essential as it will aid communication

between those tasked with carrying out patient

care.

Implementing consists of doing and

documenting the activities that are specific

nursing actions needed to carry out the

interventions that were developed in the planning

step and then concludes the implementing step

by recording nursing activities and the resulting

client responses.

Implementing Skills

To implement the care plan successfully, nurses

need cognitive, interpersonal, and technical

skills.

These skills are distinct from one another; in

practice, however, nurses use them in various

combinations and with different emphasis,

depending on the activity.

Having these skills contributes to the greater

improvement of the nurse's delivery of health

care to the patient, including the patient's level of

health, or health status.

Cognitive or Intellectual Skills Such as analyzing the problem, problem solving,

critical thinking and making judgments

regarding the patient's needs.

Included in these skills are the ability to identify,

differentiate actual and potential health problems

through observation and decision making by

synthesizing nursing knowledge previously

acquired.

Interpersonal Skills Which includes therapeutic communication,

active listening, conveying knowledge and

information, developing trust or rapport-building

with the patient, and ethically obtaining needed

and relevant information from the patient which

is then to be utilized in health problem

formulation and analysis.

Technical Skills Which includes knowledge and skills needed to

properly and safely manipulate and handle

appropriate equipment needed by the patient in

performing medical or diagnostic procedures,

such as vital signs, and medication

administrations.

Process of Implementing

The process of implementing normally includes:

Reassessing the Client

Just before implementing an intervention, the

nurse must reassess the client to make sure the

intervention is still needed.

Even though an order is written on the care plan,

the client’s condition may have changed.

Determining the Nurse’s Need for Assistance

When implementing some nursing interventions,

the nurse may require assistance for one of the

following reasons:

The nurse is unable to implement the

nursing activity safely alone (e.g.,

ambulating an unsteady obese client).

Assistance would reduce stress on the

client (e.g., turning a person who

experiences acute pain when moved).

The nurse lacks the knowledge skills to

implement a particular nursing activity

(e.g., a nurse who is not familiar with a

particular model of traction equipment

needs assistance the first time it is applied).


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Implementing the Nursing Interventions

It is important to explain to the client what

interventions will be done, what sensations to

expect, what the client is expected to do, and

what the expected outcome is.

For many nursing activities it is important to

ensure the client’s privacy, for example by

closing doors, pulling curtains, or draping the

client.

When implementing interventions, nurses should

follow these guidelines:

Base nursing interventions on scientific

knowledge, nursing research, and

professional standards of care whenever

possible.

Clearly understand the orders to be

implemented and question any that are not

understood.

Adapt activities to the individual client.

Implement safe care.

Provide teaching, support, and comfort.

Be holistic.

Respect dignity of the client and enhance

the client’s self-esteem.

Encourage clients to participate actively in

implementing the nursing interventions.

Supervising Delegated Care

If care has been delegated to other health care

personnel, the nurse responsible for the client’s

overall care must ensure that the activities have

been implemented according to the care plan.

Other caregivers may be required to

communicate their activities to the nurse by

documenting them on the client record, reporting

verbally, or filling out a written form.

The nurse validates and responds to any adverse

findings or client responses.

Documenting Nursing Activities

After carrying out the nursing activities, the

nurse completes the implementing phase by

recording the interventions and client responses

in the nursing progress notes.

These are a part of the agency’s permanent

record for the client.

Nursing care must not be recorded in advance

because the nurse may determine on

reassessment of the client that the intervention

should not or cannot be implemented.

V. EVALUATION PHASE

To evaluate is to judge or to appraise.

Evaluating is a planned, ongoing, purposely

activity in which clients and health care

professionals determine

(a) the clients progress toward achievement of

goals/outcomes

(b) the effectiveness of the nursing care plan.

The purpose of this stage is to evaluate progress

toward the goals identified in the previous

stages. If progress towards the goal is slow, or if

regression has occurred, the nurse must change

the plan of care accordingly

Process of Evaluating Client Responses Before evaluation, the nurse identifies the

desired outcomes (indicators) that will be used to

measure client goal achievement

Desired outcomes serve two purposes: they

establish the kind of evaluative data that needed

to be collected and provide a standard against

which the data are judged.

The evaluation process has five components:

Collecting Data Using the clearly stated, precise, and measurable

desired outcomes as a guide, the nurse collects

data so that conclusions can be drawn about

whether the goals have been met.

It is usually necessary to collect both objective

and subjective data.

Comparing Data with Outcomes If the first two parts of the evaluation process

have been carried out effectively, it is relatively

simple to determine whether a desired outcome

has been met.

Both the nurse and the client play an active role

in comparing client’s actual responses with the

desired outcomes.

After determining whether a goal has been met,

the nurse writes an evaluative statement (either

on the care plan or in the nurse’s notes).

An evaluation statement consists of two parts: a

conclusion (is a statement that the goal/desired

outcomes was met, partially met, or not met),

and supporting data (are the list of client

responses that support the conclusion).

Relating Nursing Activities to Outcomes The third aspect of the evaluating process is

determining whether the nursing activities had

any relation to the outcomes.

It should never be assumed that a nursing

activity was the cause of or the only factor in

meeting, partially meeting, or not meeting a goal.

Drawing Conclusions about Problem Status The nurse uses the judgments about goal

achievement to determine whether the care plan

was effective in resolving, reducing, or

preventing client problems.

When goals have been met, the nurse can draw

one of the following conclusions about the status

of the client’s problem:

The actual problem stated in the nursing

diagnosis has been resolved; or potential

problem is being prevented and the risk factors

no longer exist.


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In these instances, the nurse documents that the

goals have been met and discontinues the care

for the problem.

The potential problem stated in the nursing

diagnosis is being prevented, but the risk

factors are still present. In this case, the

nurse keeps the problem on the care plan.

The actual problem still exists even though

some goals are being met. The nursing

interventions must be continued.

Continuing, Modifying, and Terminating the Nursing

Care Plan After drawing conclusions about the status of the

client’s problems, the nurse modifies the care

plan as indicated.

Depending on the agency, modifications may be

made by drawing a line through proportions of

the care plan, or marking portions using a

highlighting pen, or writing “Discontinued”

(dc’d) and the date.

Whether or not goals were met, a number of

decisions need to be made about continuing,

modifying, or terminating nursing care for each

problem.

Before making individual modifications, the

nurse must first determine why the plan as a

whole was not completely effective.

This requires a review of the entire care plan and

a critique of the nursing process steps involved

in its development for a checklist to use when

reviewing a care plan.

Evaluating the Quality of Nursing Care In addition to evaluating goal achievement for

individual clients, nurses are also involved in

evaluating and modifying the overall quality of

care given to groups of clients.

This is an essential part of professional

accountability.

Quality Assurance A quality-assurance (QA) program is an

ongoing, systematic process designed to evaluate

and promote excellence in the health care

provided to clients.

Quality assurance frequently refers to evaluation

of the level of care provided in a health care

agency, but it may be limited to the evaluation of

the performance of one nurse or more broadly

involve the evaluation of the quality of the care

in an agency, or even in a country.

It consists of three components of care:

The structure evaluation (focuses on the

setting in which care is given. It answers this

question: what effect does the setting have

on the quality of care?),

The process evaluation (focuses on how

the care was given. It answers question such

as these: Is the care relevant to the client’s

needs? Is the care appropriate, complete and

timely?),

Outcome evaluation (focuses on

demonstrable changes in the client’s health

status as a result of nursing care. Outcome

criteria are written in terms of client

responses or health status.

Quality Improvement Quality improvement (QI) is also known as

continuous quality improvement (CQI), total

quality management (TQM), performance

improvement (PI), or persistent quality

improvement (PQI)

Nursing Audit An audit means the examination or review of

records.

A retrospective audit is the evaluation of a

client’s record after discharge from an agency.

Retrospective means “relating to past events”.

These evaluations use interviewing, direct

observation of nursing care, and review of

clinical records to determine whether specific

evaluative criteria have been met.

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