The Nursing Process

Mrs. Rosetta G. Herrera St. Rita College of Nursing

The Nursing Process

An organized, systematic and deliberate approach to nursing with the aim of improving standards in nursing care. It uses a structured, holistic, problem-solving approach in partnership with the patient and his family.
Rush S., Fergy S. and Weels D. (1969)

The Nursing Process

The term nursing process came to the UK in the 1970s It is understood as:
A form of documentation A means of organizing work, that is patient allocation it primary nursing An educational tool to help achieve patientcentered nursing A philosophy to help nursing attain professional status by offering an alternative to the medical model

Benefits of Nursing Process

Provides an orderly, systematic and continuous method for planning and providing individualized patient care Enhances nursing efficiency by standardizing nursing practice and preventing duplication of actions Facilitates documentation of care Provides a unity of language for the nursing profession Increases quality of care through the use of deliberate, collaborative actions

Characteristics of the Nursing Process

Within the legal scope of nursing Based on knowledge requiring critical thinking Patient-centered Goal-directed/ results-oriented Prioritized Dynamic as revisions are made depending on health progress of patient

HOLISTIC

The Holistic Nursing Process

Care is geared not only in the diagnosis and treatment of physically and physiologically present illness of the patient, but also on the other aspects of his persona:
Emotional Psychosocial Developmental Spiritual being

Components of the Nursing Process

1. Assessment 2. Diagnosis
5. Evaluation

3. Planning

4. Implementation

All the Components of the Nursing process are considered and conducted using the

Nursing Care Plan

The Nursing Care Plan

A set of actions that the nurse will implement to resolve existing and potential health problems identified through nursing assessment Set of actions are detailed activities that the nurses will undertake. It should be written and shared with all health care personnel to ensure continuity Resolving health problems does not mean eradicating the illness immediately upon delivery of nursing care, but alleviation of patients discomfort, promoting his emotional well-being, that would ultimately lead to improved health condition

Nature of the Nursing Care Plan

Written plan Focuses on clinical care Aids in thorough accurate delivery of care Identify and coordinate resource Organizes nursing information

Purpose of the Nursing Care Plan

It is a legal document Shows accountability (who planned
and implemented the specific nursing care)

Guides the work of others and is a basis for continuity of care

Shows the flow of care from initial assessment to the final evaluation

The NCP should be carried out:

By or under the supervision of the Named Nurse With the agreement oand cooperation of the patient and his family Be evidence based

Characteristics of the NCP

Personalized/ individualized Holistic Based on identifiable health and nursing problem Focuses on actions designed to solve or minimize existing problems
Restorative as well as preventive

With the agreement and cooperation of the patient and his family

1st Component: ASSESSMENT

To successfully assess the status of the patient, the following should be present:
Good communication Systematic approach to data collection Interpretation based on nursing knowledge (Objective) Aesthetics gained through empathy, nurses sensitivity to the patient's needs, personal knowledge (Subjective)

Gathering the Information that You Need

Cue Questions:
Who is this person? How is this person feeling? How does the patient make me feel? How has this affected his and his familys usual life-patterns and roles What is important for this person to make their stay in the hospital comfortable? How does this person view the future and themselves?

Sources of Data
Non verbal Observation
Sight - physical, psychological and social Touch skin temperature, hydration, pulse/BP Sound breath (wheez, stridor) Smell breath, body fluid odor, gangrene

Sources of Data
Verbal Communication
Interview with patient Family members Nursing colleagues Medical colleagues Other members of multidisciplinary team

Sources of Data
Written Records
Chart notations from physician Transfer letter Old notes

Guide to Successful Assessment

Prepare adequately
List down and organize your questions/ observations

Introduce yourself prepare patient Use non-verbal communication Be courteous Use sensitivity, compassion and empathy Use focused questions Listen, clarify when necessary Summarize what they described MAKE NOTES Reflect

2nd Component: PLANNING

The establishment of patient goals/outcomes
Working with client to prevent, reduce or resolve problems To determine related nursing interventions that are most likely to assist in achieving the goals Thisis about improving the quality of life for your patient This is about what your patient needs to do to improve his health status or better cope with his illness

Characteristics of Effective Plans

Determine the problems Establish the risk priorities Addresses the subjective and objective concerns of the patient
Patient goals are well-written Detailed strategies are provided

Purposes and Activities in Planning

Purposes
Direct patient care activities Promote continuity of care Focus charting requirement Allow for delegation of specific activities

Activities
Plan nursing interventions Write the detailed nursing care

Establishing Priorities in the Plan

Because basic needs must be met before a person can focus on higher ones, patient needs may be prioritized using Maslows Hierarchy of Needs:
Physiological Safety Love and belonging Self-esteem Self-actualization

Writing Goals for Each Priority Plan

Purpose of writing goals
Provide individualized care Promote patient participation Plan care that is realistic and measurable Select evidence-based nursing care Communicate the plan of care

Writing Goals
Specific
What is the exact problem with the patient?

Measurable
How can you determine that you have already reached the goals or if there is an improvement?

Attainable
What available resources are there to help you alleviate the patients condition?

Realistic
How will the patient know he has achieved his plans/goals?

Time-bound
when will you implement the action and when will you know that you have achieved your goal? How quickly is the problem likely to change? How soon will you need to re-evaluate the plan?

Sample Goal
Scenario: 74 y/o, M, Temp: 39, BP 130/80, Pulse-80, complains of headache

S - To decrease temperature M - from 39 38 A - sponge and basin is provided, meds are available, room has private CR R - patient has expressed relief from headache T in 4 hours time (2:00pm 6:00 pm)
Goal Statement:
To decrease patients temperature from 39 38 within 4hours time through application of sponge bath and intake of oral medicines prescribed

Kinds of Goals
Long-term
Require a longer period of time Can be for a week or more to resolve

Short term
Usually less than a week For immediate relief of discomfort/illness

Helpful Verbs for Measurable Outcome

Define Prepare Identify Design List Verbalize Describe Choose Explain Select Demonstrate Decrease