SIX PHASES OF THE NURSING PROCESS 1.

ASSESSMENT - Is collecting, validating, organizing and recording data about the clients health. Purposes: - To establish a data base Activities: A. COLLECTION OF DATA Gathering information about the client, considering the physical, psychological, emotional, socio-cultural, and spiritual factors that may affect his health status. TYPES OF DATA a. Subjective data those that can be described only by the person experiencing it. b. Objective data those that can be observed and measured. METHODS OF COLLECTING DATA a. Interview Planned purposeful conversation b. Observation Use of senses Use of units of measure Physical examination techniques Interpretation of laboratory results SOURCES OF DATA a. Primary Patient/client b. Secondary Family members Significant others Patients record/chart Health team members Related literature B. VERIFYING/VALIDATING DATA C. ORGANIZING DATA 2. DIAGNOSING - It is the process which results to a diagnostic statement or nursing diagnosis. - It is the clinical act of identifying problems. - To diagnose in nursing, it means to analyze assessment information and derive meaning from this analysis. PURPOSES: To identify the clients health care needs and to prepare diagnostic statements.

NURSING DIAGNOSIS - Is a statement of clients potential or actual alteration of health status - It uses the critical-thinking skills of analysis & synthesis - Uses PRS/PES format: P problem R related to factors S signs and symptoms P problem E etiology S signs and symptoms

Activities: - Organize cluster or group data - Compare data against standards - Analyze data after comparing with standards - Identify gaps and inconsistencies in data - Determine the clients health problems, health risks and strengths - Formulate nursing diagnosis statements Comparison of Correct and Incorrect Nursing Diagnosis Correct high risk for ineffective airway clearance related to thick, copious mucus secretions Incorrect high risk for ineffective airway clearance related to pneumonia Correct Incorrect Correct Incorrect high risk for injury related disorientation high risk for injury related to absence of side rails high risk for self-concept disturbance related to the effects of mastectomy mastectomy related to cancer

3. OUTCOME IDENTIFICATION - Refers to formulating and documenting measurable, realistic, client-focused goals. - It provides the basis for evaluating nursing diagnosis. Purposes: - To provide individualized care - To promote client participation - To plan care that is realistic and measurable - To allow involvement of support people Activities: - Establish priorities Priority is something that takes precedence in position, deemed the most important among several items. Priority setting is a decision-making process that ranks the order of nursing diagnosis in terms of importance to the client. - Establishing priorities involves the following: Life threatening situations should be given highest priority. Use the principle of ABCs airway should always be given the highest priority Use Maslows hierarchy of needs Consider something that is very important to the client Clients with unstable condition should be given priority over those with stable condition. Consider the amount of time, materials, equipment required to care for clients Actual problems take precedence over potential concerns Attend to the client before equipment - Nursing diagnoses are classified as high-priority, medium priority, and low priority. High priority are those that are potentially life threatening and require immediate action. Medium priority are those that could result in unhealthy consequences but are not life threatening. Low priority involves problems that usually can be resolved easily with minimal interventions and are unlikely to cause significant dysfunction. - Establish clients goals and outcome criteria Client goal is an educated guess, made as a broad statement about what the clients state will be after the nursing intervention is carried out. Behavioral goal are written to indicate a desired state. They may contain an action verb and a qualifier that indicate the level of performance that needs to be achieved. Qualifier is a description of the parameter for achieving the goal.

Goal may be short term or long term. Short term goal (STG) can be met in a relatively short period. Long term goal (LTG) requires more time Characteristics of well-stated outcome criteria: S specific M measurable A attainable R realistic T time-framed Examples: Goal - The client will report a decreased anxiety level regarding surgery Possible Outcome Criteria During client teaching, the client discusses fears and concerns regarding surgical procedure. After client teaching, the client verbalizes decreased anxiety. The client identifies a support system and strategies to use to reduce stress and anxiety related to the surgical experience.

4. PLANNING - Involves determining beforehand the strategies or course of actions to be taken before implementation of nursing care. PURPOSES: To identify the clients goals and appropriate nursing interventions To direct client care activities To promote continuity of care To focus charting requirements To allow for delegation of specific activities Plan Nursing Intervention To direct activities to be carried out in the implementation phase

Nursing Intervention - Any treatment, based upon clinical judgment and knowledge that a nurse performs to enhance client outcomes. - Used to monitor health status - Prevent, resolve or control a problem - Assist with activities of daily living - Promote optimum health and independence - Nursing intervention are also called nursing orders Nursing Orders are independent, dependent and interdependent activities that nurses carry out to provide client care. PLAN OF CARE - Is a written summary of the care that a client is to receive It is the blueprint of the nursing process. - Is nursing centered. This is essential to identify the scope & depth of the nursing practice. - Focusing on the treatment of human responses to actual or potential health problems - The nurse remains in the nursing practice domain

A step by step process Sufficient data are collected to substantiate nursing diagnosis At least one goal must be stated for each nursing diagnosis Outcome criteria must be identified for each goal Nursing interventions must be specifically designed to meet the identified goal Each intervention should be supported by a specific rationale. The scientific rationale is the justification or reason for carrying out the intervention. Evaluation must address whether each goal was completely met, partially met or completely unmet.

SAMPLE OF NURSING PLAN OF CARE - Nursing diagnosis Risk for injury related to sensory and integrative dysfunction manifested by altered mobility and faulty judgment. - Client goal Client will demonstrate safety habits when performing ADLs and injury prevention. - Client outcome criteria Client uses nurse call light system for assistance for each need to use bathroom immediately after instruction by the nurse. Client demonstrates safety practices in dressing and hygiene. Client uses over the-bed lights, nonskid slippers each time when transferring to chair or out of bed. Client identifies modification for home safety, 12 hours after nurses instruction about home safety.