Nursing Process –
A simple learning for Nurses
Definition:
A process is a series of steps that follow a logical sequence. The term nursing process is widely accepted to designate a series of steps that the nurse takes in planning and giving nursing care. It provides a logical framework on which the nursing care is based.
It is defined as a systematic problem-solving approach for giving comprehensive nursing care.
It can also be defined as an orderly, systematic way of identifying the client’s problems, making plans to solve them, initiating the plans or assigning others to implement it and evaluating the extent to which the plan was effective in resolving the problems identified.
History – Development of Nursing Process:
Lydia Hall (1955) introduced the term nursing process. Lydia identified three aspects of nursing care: CARE, CURE AND CORE and the three steps of nursing process: OBSERVATION, MINISTRATION OF CARE and VALIDATION.
In 1959, Dorothy Johnson described nursing as fostering the behavioral functioning of the client. She furthered explained that there are three steps of nursing process: ASSESSMENT, DECISION and NURSING ACTION.
In 1961, Ida Lois Orlando explained a three step nursing process: CLIENT’S BEHAVIOUR, NURSE’S REACTION AND NURSE’S ACTIONS. In 1963, Lois Knowles given a five step nursing process using the ‘five Ds’: DISCOVER, DELVE, DECIDE, DO and DISCRIMINATE. The discover and delve steps are relates to assessment phase, decide is the planning stage, do is the implementation stage; discriminate is the evaluation phase of client responses to nursing interventions.
Characteristics of Nursing Process:
It is a framework that enables a nurse to give nursing care to individuals, families and communities.
It is systematic and orderly. Each nursing activity is part of an ordered sequence of activities. The nursing process directs each step of nursing care in a sequentially ordered manner.
It is dynamic. Each step in nursing process flows on to the next step. In some nursing situations, all the stages occur almost simultaneously.
It is interpersonal. Human being is always the heart of nursing. In this nurses are client-centered and not task oriented.
The nursing process encourages nurses to work together to help clients to use their strengths to meet all human needs. This also helps nurses to explore their own strengths and limitations and to grow personally and professionally.
It is outcome-oriented. The client benefit from continuity of care and each nurse’s care moves the clients closer to outcome achievement.
This process is universally applicable in all nursing situations.
This can be used throughout the life span.
Phases of Nursing Process:
The nursing process is a systematic method that helps the client and the nurse to carry out the following:
Assessment in which the need for nursing care is determined.
Nursing diagnosis about actual and potential problems.
Outcome identification and plan of action based on that.
Implementation of planned care.
Evaluation to determine the achievement of planned goal.
Assessment:
It is a deliberate, systematic and logical collection of subjective and objective data that are helpful to identify and define problems of the client, before the nurse proceeds to plan the care. A comprehensive assessment is holistic and includes physical examination, health history, psychological, sociocultural, emotional and spiritual factors that affect the client’s health.
Purpose of Assessment:
Gather data about the client (individual, family or community)
Use the data for diagnosing, identifying outcomes, planning and implementing care.
Reasons for Assessment:
Gather baseline information about the client.
Identify the client’s health status and the ability to manage the problems and need for nursing care.
Decide about the client’s risk for dysfunctions and presence of any dysfunctions.
Identify client’s strengths based on which to plan individualized holistic care.
Bring about positive changes in the client’s health status.
Provide data for diagnosis.
The types of Assessment:
Initial Assessment
Focus Assessment
Time-lapsed Reassessment
Emergency Assessment
Assessment Skills:
Assessment involves recognizing and collecting cues. Cues are pieces of information about a client’s health status and can be overt or covert (subjective or subjective). The clinical skills utilized for assessment include the following:
Observation
Interviewing
Physical Examination
Intuition.
Assessment Activities:
Collection of data is a process of compiling information about the client. Both subjective and objective data are collected.
Subjective data or symptoms or covert cues are the client’s feelings and statements about his or her health problems.
Objective data or signs or overt cues are observable, perceptible and measurable data.
Sources of data: there are two important sources of data collection. Primary source is the client himself and secondary source includes family members or significant others, health source include family members or significant others, health record, laboratory tests and diagnostic procedures, health team members and literature review.
Documenting data systematically record the data collected, which will form a permanent part of the medical record.
Nursing Diagnosis:
This is the second phase of the nursing process. Diagnosis is the clinical act of identifying the problems.
Components of Nursing Diagnosis
Diagnostic label.
Qualifiers.
Definitions.
Defining characteristics.
Risk factors
Related factors
Diagnostic label is the name of the nursing diagnosis. It describes the essence of the problem using as few words as possible. For example, stress incontinence.
Qualifiers are words used to give additional meaning to a nursing diagnosis. Examples: altered, impaired, deficient, excessive, dysfunctional, disturbed, ineffective, decreased, increased, acute, chronic, intermittent.
Definition describes the characteristics of the human response under consideration.
Defining characteristics are major and minor clinical cues that validate the presence of an actual nursing diagnosis.
Risk factors are identifiable intrinsic and extrinsic characteristics of the client. E.g. risk for infection.
Related factors: they describe the conditions, circumstances or etiologies that contribute to the problem. E.g. fluid volume deficit related to vomiting.
Outcome Identification:
Outcome identification refers to and documenting measurable realistic, client-focused goals.
Purpose
Provide individualized care.
Encourage client participation.
Plan realistic and measurable care.
Encourage involvement of support people.
Implementation:
This is the action phase of the nursing process. It is the actual initiation of the plan and documenting of nursing actions. Implementing is mean to carry out, to perform, to intervene or to do something. The nursing activities may be carried out by one nurse or it may be delegated to a group of nurses. Interventions can be independent intervention. i.e. the nurse is licensed to carry out independent or dependent interventions. i.e. those that are carried out under the guidance/order of a physician.
Purpose
Provide technical and therapeutic nursing care required to help the client achieve an optimum level of health.
The activities of Implementation
Reassess the client
Set priorities
Perform nursing interventions.
Document nursing action.
Set Priorities
As the client’s conditions changes, priorities also change. Nursing interventions must be carried out based on the priority needs.
Perform Nursing Interventions
Nurses must carry out the nursing interventions listed in the plan for each client.
Documentation
After implementing the plan, it must be documented in the client’s record.
To carry out the implementation phase successfully, nurses must have the following skills.
Intellectual skills.
Interpersonal skills.
Technical skills.
Evaluation:
Evaluation is the process of determining the extent up to which the goals of nursing care have been attained. It refers to rating, grading and judging.
The nurses will have to use a variety of skills to judge the effectiveness of nursing care. These skills include knowledge of standards of care, normal client responses, and conceptual models of nursing, the ability to monitor the effectiveness of nursing interventions and awareness of clinical research.
Purpose
Gather subjective and objective data to make judgements about the nursing care delivered.
Identify the client’s behavioural responses to nursing interventions.
Make a comparison of client’s behavioural responses and predetermined outcome criteria.
Evaluate the extent of achievement of goals and resolution of problems.
Form a strong basis for the revision of nursing care plan.
Determine the involvement and cooperation of the client and significant others (family, friends, other health team members) in health care decisions.
Decide about the quality of nursing care and the beneficial effects on the client’s health status.
Types of Evaluation
Structure evaluation
Process evaluation
Outcome evaluation
Evaluation can concentrate on the improvement of quality of care given to the clients. Quality improvement means measuring the extent to which standards have been achieved.
Theoretical Basis of Nursing Process:
System theory
Problem-solving process
Decision making process
Information processing theory
Diagnostic reasoning process
