The Nursing Process

[ابو ليث]

The Nursing Process Introduction A problem-solving method Systematic, goal-directed, flexible, rational approach Ensures consistent, continuous, quality nursing care Provides a basis for professional accountability Input of nurse and patient/family critical The Steps of the Nursing Process are cyclic, overlapping and interrelated: Assess Diagnose Evaluate Plan Implement Step One of the Nursing Process: Assessment: the most critical step Answers the questions: “What is happening?” (actual problem), or “What could happen?” (potential problem) Involves collecting, organizing, and analyzing information/data about the patient Results in Nursing Diagnoses Two parts: Data collection & Data analysis 1. Data Collection: A Holistic Approach Types of data Subjective: “symptoms” that the patient describes; e.g. “I can’t do anything for myself” Objective: signs that can be observed, measured, and verified; e.g. swollen joints Sources of data Primary: the patient; is always the best source Secondary: everything/everybody else Methods of Data Collection Observation Requires practice and skill Systematic, head-to-toe (cephalocaudal) Results in objective, factual information Document exactly what you observe e.g. “Yawned frequently, had dark circles under eyes” NOT “Patient seems tired” Observation results in a General Survey The General Survey: a brief description of patient’s appearance and behavior. 64 year old, well groomed African-American male in acute distress. Awake, alert, and oriented. Approximately 6’, 170lbs. Hair sparse and gray, eyes brown. Sitting on side of bed, holding siderail for support. Verbal responses coherent but halting. Methods of data collection Interview Structured form of communicationPurpose: to provide care specific to this individual’s needs and problems Focus: patient’s perceptions Nurse must: explain purpose of interview, provide comfort and privacy, ensure confidentialityResult: A comprehensive Health History Components of the Health History Demographic data CC: chief complaint HPI: history of present illness PMH: past medical history FMH: family medical history (genogram) ROS: review of systems Psychosocial history Methods of Data Collection Examination Inspect Palpate Percuss Auscultate Nurse must: explain what you are doing, provide privacy, and ask permission before you touch the patient 2. Data Analysis Data review Are data accurate and complete? Data interpretation What are the patient’s actual and/or potential problems? Develop a problem list based on the data Prioritize the patient’s problems Step Two of the Nursing Process Nursing Diagnosis: a statement that describes a specific human response to an actual or potential health problem that requires nursing intervention Written in P E format P = Problem: use North American Nursing Diagnosis Association (NANDA) category [due to or related to] E = Etiology: cause of the problem The Patient A Holistic-Physical-Emotional-Psychosocial-Developmental-Spiritual Being Data Base Medical Diagnosis Nursing Diagnosis Rheumatoid Arthritis Self-care deficit:bathing, related to joint stiffness Step Three of the Nursing Process Plan: to provide consistent, contiuous care that will meet the patient’s unique needs. Includes Patient Goals & Nursing Orders Patient Goals: describe the desired result of nursing care What will the patient (or part of the patient) do to resolve or lessen the problem identified in the nursing diagnosis? By when will this be accomplished? Patient Goals are directly related to the patient’s problem as stated in the nursing diagnosis: One goal should describe resolution of the problem Additional goals should describe steps that contribute to problem resolution Patient Goals can be long term or short term Patient Goals are: Focused on the patient Clear and Concise Observable, Measurable, Realistic: how much? how far? how long? how well? Written with a specific time frame: by when should the goal be accomplished? Determined by the nurse and the patient Mr. H. will perform entire bath unassisted by 4-4-01 Nursing Orders Describe what the nurse will do to help the patient achieve the goals. Nursing Orders must: Focus on nursing actions Describe when and how the nurse will perform nursing actions Include the date & be signed by the nurse 3/30/01 The nurse will assist Mr. H. with bathing qAM until he is able to bathe independently. E. Bruderle, RN Step Four of the Nursing Process Implement: Carry out the care plan Reassess the patient Validate that the care plan is accurate Carry out nurses’ orders Document on patient’s chart Step Five of the Nursing Process Evaluate: Compare the patient’s current status with the stated Patient Goals Were the goals achieved? Why not? Review the nursing process Problem: “I can’t do anything for myself” Nursing Diagnosis: Self care deficit: bathing, related to joint stiffness Patient Goal (resolution): Mr. H. will perform entire bath unassisted by 4-4-00. Patient Goal (contributory): Mr. H. will bathe his upper body unassisted by 4-1-00. Nursing order: 3/30/01 The nurse will assist Mr. H. with bathing q AM until he is able