EXPLAINING THE NURSING PROCESS

Historical Perspective Hall originated the term nursing process in 1955, and Johnson, Orlando, Weidenbach were among the first to use it to refer to a series of phases describing the practice of nursing. At this time, the nursing process involved only three steps: assessment, planning, and evaluation. In their 1967 book The Nursing Process, Yura and Walsh identified four steps in the nursing process: Assessing, Planning, Implementing and Evaluating. Since then various nurses have described the process of nursing and organized the phases in different ways. The use of the nursing process in clinical practice gained additional legitimacy in 1973 when the phases were included in the ANA Standards of Nursing Practice. It includes the 5 phases of nursing process such as: Assessment, Diagnosis, Planning, Implementation and Evaluation.

THE NURSING PROCESS

The nursing process is the framework for providing professional, quality nursing care. It directs nursing activities for health promotion, health protection, and disease prevention and is used by nurses in every practice setting and specialty. The nursing process provides the basis for critical thinking in nursing (Alfaro-LeFavre, 1998, p. 64). It is a systematic, organized method of planning, and providing quality and individualized nursing care. It is synonymous with the PROBLEM SOLVING APPROACH that directs the nurse and the client to determine the need for nursing care, to plan and implement the care and evaluate the result. It is a G O S H approach (goal-oriented, organized, systematic and humanistic care) for efficient and effective provision of nursing care. The purpose of the nursing process is to identify the clients health status and actual or potential health care problems or needs, to establish plans to meet the identifies need, and to deliver specific nursing interventions to meet those needs. The client may be an individual, a family or a group.

Characteristics of the Nursing Process:

The nursing process has distinctive characteristics that enable the nurse to respond to the changing health status of the client. These characteristics include: 1. The Nursing Process is dynamic and cyclic. Data from each phase provide input into the next phase. Findings from the evaluation feed back into assessment. Hence the nursing process is a regularly repeated event or sequenced of events (a cycle) that is continuously changing (dynamic) rather than staying the same. Each step may be reviewed and revised according to changing client responses to nursing interventions which may necessitate revisions in the plan of care. There is no absolute beginning or end.

2. It is client-centered. The nurse organizes the plan of care according to the client problems rather than nursing goals. The client is motivated and assisted to assume primary responsibility for his own health care. 3. It is an intellectual process. Nurses utilize knowledge in problem solving, decision making and critical thinking as they assess their clients problems, plan their care, i mplement the plan and evaluate the effectiveness of the care they provide. Decision making is involved in every phase in the nursing process. Nurses are not bound by a standard response and may apply their repertoire of skills and knowledge to assist the clients. This facilitates individualization of the nurses plan of care. 4. It is interpersonal and collaborative It requires the nurses to communicate directly and consistently with the clients and the families to meet their needs. It also requires the nurse to collaborate, as member of the health care team, in a joint effort to provide quality care. 5. It is universally acceptable. The process is applicable to any client regardless of age, medical diagnosis, social status, any setting, across specialties and at any point in the illness-wellness continuum. It is used as a framework for nursing care in all types on health care settings, with clients of all age group.

Steps in the Nursing Process

The Nursing Process involves five steps/phases that arent separate entities but overlapping, continuing subprocesses.

1) Assessment -It is the systematic and continuous collection of data which are comprehensive, accurate and
relevant, from various sources. -These data are then organized, validated, recorded in retrievable form, and communicated to concerned individual or groups. -Confidentiality of information obtained from clients should be maintained. Purpose: To establish a data base (all the information about the client): nursing health history physical assessment the physicians history & physical examination results of laboratory & diagnostic tests material from other health personnel

Activities: A. Collection of data gathering of information about the client includes physical, psychological, emotion, socio-cultural, spiritual factors that may affect clients health status includes past health history of client (allergies, past surgeries, chronic diseases, use of folk healing methods) current/present problems of client (pain, nausea, sleep pattern, religious practices, meds or treatment the client is taking now) Types of Data: a. Subjective Datasymptoms-patient/watcher describes b. Objective Data---signs-can be observed and validated Sources of Data: a. Primary: the patient; is always the best source b. Secondary: everything/everybody else 4 Types of Assessment: a. Initial assessment assessment performed within a specified time on admission Ex: nursing admission assessment b. Problem-focused assessment use to determine status of a specific problem identified in an earlier assessment Ex: problem on urination-assess on fluid intake & urine output hourly c. Emergency assessment rapid assessment done during any physiologic/physiologic crisis of the client to identify life threatening problems. Ex: assessment of a clients airway, breathing status & circulation after a cardiac arrest. d. Time-lapsed assessment reassessment of clients functional health pattern done several months after initial assessment to compare the clients current status to baseline data previously obtained. Methods of Data Collection: a.Observation use to gather data by using the 5 senses and instruments. b. Interview a planned, purposeful conversation/communication with the client to get information, identify problems, evaluate change, to teach, or to provide support or counseling. it is used while taking the nursing history of a client c. Examination systematic data collection to detect health problems using unit of measurements, physical examination techniques (IPPA: Inspection, Palpation, Percussion, Auscultation), interpretation of laboratory results. should be conducted systematically: c.1. Cephalocaudal approach head-to-toe assessment c.2. Body System approach examine all the body system c.3. Review of System approach examine only particular area affected B. Validation of Data the act of double-checking or verifying data to confirm that it is accurate and complete.

Purposes of data validation: a. ensure that data collection is complete b. ensure that objective and subjective data agree c. obtain additional data that may have been overlooked d. avoid jumping to conclusion e. differentiate cues and inferences Cues subjective or objective data observed by the nurse Inferences the nurse interpretation or conclusion based on the cues. C. Organization of Data uses a written or computerized format that organizes assessment data systematically. - Maslows basic needs - Body System Model - Gordons Functional Health Patterns D. Analyze data compare data against standard and identify significant cues. Standard/norm are generally accepted measurements,model, pattern E. Communicate/Record/Document Data nurse records all data collected about the clients health status on retrievable forms data are recorded in a factual manner not as interpreted by the nurse record subjective data in clients word; restating in other words what client says might change its original meaning.

2) Diagnosis
-analyzing and synthesizing data -The nurses uses critical-thinking skills to interpret assessment and formulate diagnostic statements (Nursing Diagnosis) that identify the prioritized clients actual and potential health pro blems and strengths and the factors contributing to the problem. Activities during diagnosis: 1. Compare data against standards 2. Cluster or group data 3. Data analysis after comparing with standards 4. Identify gaps and inconsistencies in data 5. Determine the clients health problems, health risks, strengths 6. Formulate Nursing Diagnosis prioritize nursing diagnosis based on what problem endangers the clients life -Nursing Diagnosis a statement that describes a specific human response to an actual or

potential health problem that requires nursing intervention.

Types of Nursing Diagnosis: a. Actual diagnosis present at the time of nursing assessment b. Risk nursing diagnosis problem doesnt exist yet but the presence of risk factors indicate that a problem is likely to develop unless nurse intervenes. c. Wellness diagnosis client(individual/family) that have readiness for enhancement. d. Possible nursing diagnosis evidence of a health problem is incomplete or unclear. e. Syndrome diagnosis associated with a cluster of other diagnoses.

3)Planning
-steps involves formulation of the nursing care plan wherein nurses work with their client to set goals, outcomes and identify the actions for preventing, correcting or relieving health problems and developing specific nursing interventions for each nursing diagnosis. Purpose: To determine the goals of care and the course of actions to be undertaken during the implementation phase. To promote continuity of care. To focus charting requirements. To allow for delegation of specific activities. Activities: 1. Establish/Set priorities 2. Plan nursing interventions/nursing orders 3. Write a Nursing Care Plan NCP a written summary of the care that a client is to receive. it is the blueprint of the nursing process. Nursing Interventions Independent Nursing Intervention Dependent Nursing Intervention Interdependent/Collaborative

4) Implementation
-is the action stage of the nursing process. -consist of doing and documenting the activities using cognitive, interpersonal and technical skills. -The nurse communicates the plan of care to members of the health team and carries out the interventions as stated in the nursing care plan, or delegates such interventions when indicated. Reassessing the client Determining the nurses need for assistance Implementing the nursing intervention Supervising the delegated care Documenting nursing activities

5)Evaluation
-is a planned, on-going, purposeful activity in which clients and health care professionals determine (a) clients progress towards achievement of goals/outcomes, and (b) the effectiveness of the nursing care plan. -It is an important aspect of the nursing process because conclusions drawn from the evaluation determine whether the nursing interventions should be terminated, continued or changed. -The nurse documents these in the appropriate forms. Activities: 1. Collect data about the clients response. 2. Compare the clients response to goals and outcome criteria. 3. The four possible judgments that may be made are as follows: The goal was completely met, partially met, completely unmet or New problems & nursing diagnosis have developed