Nursing Process
Content
The Nursing Process
1
The Nursing Process is ...
“A systematic, rationale method of planning
and providing individualized nursing care.
Its purpose is to identify client’s health
status, actual or potential healthcare
problems or needs, to establish plans to
meet those needs and to deliver specific
nursing interventions to meet those needs”.
(Kozier, 2004)
2
The Nursing Process is ...
The set of activities that professional nurses
perform to determine the needs of the
patient and make a judgment to provide the
care that is needed.
3
Standards of Competent Performance
Formulates nursing diagnosis, through observation and
interpretation of information.
Formulates a care plan in collaboration with the client.
Performs skills essential to the nursing actions to be
taken.
Delegates tasks to subordinates
Evaluates the effectiveness of the care plan
Acts as the client’s advocate.
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Standards of Practice
The collection of data is systematic
Derive nursing diagnosis from data
Plan nursing care including goals
Plan includes priorities and nursing approaches
Nursing actions provide for client participation in
health promotion, maintenance, and restoration
Evaluation of progress or lack of progress
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Problem-Solving & Priority Setting
Priority Setting:
Determine client health values & beliefs
Establish priorities from highest to lowest
Determine urgency or the problem
Problem-Solving:
Once problem is identified, collect data
Analyze the data & identify an action-plan
Implement the plan, observing initial responses
Evaluate the results
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Characteristics of the Nursing
Process
Data from each phase provides input into the next phase.
Client centered.
An adaptation of problem solving and system’s theory.
Decision making is involved in every phase of the nursing process
It is interpersonal and collaborative
Universally acceptable – framework for nursing care in all types of
setting.
Nurses must use a variety of critical-thinking skills to carry out the
nursing process
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Steps of the Nursing Process
Assessment
Diagnosis
Planning
Implementation
Evaluation
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The Nursing Process
Otten/403
9
The
Nursing
Process
Assessment
Phase
Assessment Data
Subjective Data
- The client states “ . . .”
Objective Data
- Vital signs
- Physical assessments
- Previous documentation
Examples of Data
Temp of 102 degree
“I feel tired”
WBC 24,000/mm3
“I need help to walk”
B/P 180/96
“My leg hurts”
Redness and swelling in R ankle
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ASSESSING
Is the systematic and continuous collection,
organization, validation and documentation of
data.
Assessing is a continuous process carried out
during all phases of the nursing process.
All phases of the nursing process depend on the
accurate and complete collection of data.
Assessment vary according to their purpose,
timing, time available, and client status.
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Four types of Assessment
Initial assessment
Problem focused assessment
Emergency assessment
Time-lapsed assessment
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Type of Assessment
Time Performed
Purpose
example
Initial assessment
Performed within
specified time after
admission to a health
care agency
To establish a complete
data base for problem
identification, reference
and future comparison
Nursing admission
assessment
Problem focused
Ongoing process
integrated with
nursing care
To determine the status
of a specific problem
identified in an earlier
assessment.
To identify new or
overlooked problems
- Hourly assessment
of fluid intake and
urinary output
To identify lifethreatening problems
- Rapid assessment
of airway, breathing
status and circulation
(emergency)
- Suicidal tendencies
Emergency
assessment
During any
physiologic or
psychologic crisis of
the client
-The ability to
perform self-care
while assisting to
bathe
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Type
Time
performed
Purpose
Time-lapsed
assessment
Several months To compare the
after initial
client’s current
assessment
status to
baseline data
previously
obtained
Example
Reassessment
of a client’s
functional
health patterns
in a home care
or outpatient
setting or in a
hospital, at shift
change
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Nursing assessment focus on a client’s
responses to a health problem.
It includes:
Perceived needs
Health problems
Related experience
Health practices
Values
lifestyles
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Assessment Activities (Collecting
Data)
DATA
COLLECTION
A process of gathering information about a client’s health status.
It is systematic and continuous (to prevent ommission of
significant data and reflect a client’s changing health status.
DATA BASE is all information about the client, includes the
nursing history, physical examination, physician’s history & PE,
results of laboratory and diagnostic tests material contributed by
other health personnel
Nursing Health History (263)
Functional Health Patterns (Gordon)
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Types of Data
Subjective data
Symptoms or covert data
Apparent only to the person affected and can be described or
verified by him alone
Sensation, feelings, values, beliefs, attitudes, perception of
personal health status and life situation
Objective data
Sign or overt data
Detectable by the observer or can be measured or tested
against an accepted standard.
Seen, hear, felt, or smelled
Obtained by observation or PE
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Sources of Data
Primary source
Client – the best source of data, unless too ill, young
or confused to communicate
Secondary source
Support people (significant others SO)
Client records
Health care professionals
Literature
21
Data Collection Methods
OBSERVING
Use of the senses
Vision, smell, hearing, touch
Has two aspects:
(a)
(b)
Noticing the data
Selecting, organizing and interpreting the data
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INTERVIEWING
Interview is a planned communication or a
conversation with a purpose (to get/ give
information), to identify problems of mutual concern,
evaluate change, teach, provide support, or provide
counseling or therapy.
Nursing health history
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Two approaches to interviewing:
Directive interview
Highly structured and elicits specific information
Nurse establishes the purpose and controls the interview
Client responds but with limited opportunity to ask questions and discuss
concerns
Frequently used to gather and give information when time is limited
Nondirective interview
Or rapport- building interview (rapport is understanding between two
people)
Client control the purpose, matter and pacing
A combination of the two is important during information-gathering
interview.
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INTERVIEW QUESTIONS
Closed questions
in directive interview
Restrictive – require only yes, no, short factual
answers
Begin with when, where, who, what, do (did, does),
is (are, was)
“are you in pain”, “how old are you”
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Open-ended questions
Nondirective interview
Invite clients to discover and explore, elaborate,
clarify or illustrate their thoughts or feelings
Specifies only broad topic to be discussed.
Begin with “how” or “what”
“what brought you to he clinic?”, “how are you feeling
today?”
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Neutral question
Client can answer without direction or pressure from
the nurse
Open-ended, used in nondirective interview
“How do you feel about that?”
Leading question
Usually closed, used in directive interview.
“you’re stressed about surgery tomorrow, aren’t you?
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PLANNING THE INTERVIEW AND
SETTING
BEFORE beginning, review available information
(client’s chart), review agency’s data collection
form, make an interview guide
The following influence the interview:
a.
b.
c.
d.
e.
Time
Place
Seating arrangement
Distance
Language
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TIME
Physically comfortable
Free of pain
Interruptions are minimal
Make the client feel comfortable and unhurried
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PLACE
Well-lighted, well-ventilated, moderate-sized room
Free of noise, movement and interruptions
Encourage communications
Others cannot hear or see (privacy)
SEATING ARRANGEMENT
Equal terms – parties sit in two chairs at right angle to
a desk or table, few feet apart, with no table between
Creates less formal atmosphere
If standing or looking down – if client on bed, makes
intimidating, nurse can sit 45 degree angle to bed
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DISTANCE
Between the interviewer & interviewee should neither
be too small nor too great, because people feel
uncomfortable when talking to someone who is too
close or too far.
Maintaining a distance of 2-3 feet
Some clients require a more or less personal space
depending on their cultural and personal needs.
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ACCEPTED distance in conversation varies with
ethnicity
8-12 in Arab
18 in in US
24 in in Britain
36 in in Japan
Men require more space
Anxiety needs more space
Direct eye contact – increases the need for space
Physical contact is used only for therapeutic purpose
(TOUCH)
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LANGUAGE
Failure to communicate in language the client can
understand is a form of discrimination.
Convert complicated medical terminology into
common English or language for the client.
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STAGES OF INTERVIEW
THE OPENING
Most important part, what is said and done sets the tone for the
remainder of the interview.
Establish rapport
Orientation
THE BODY
The client communicates what she thinks, feels, knows and
perceives in response to nurse’s questions
THE CLOSING
Nurse terminates or ends the interview
Clients may also terminate it (page 268)
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EXAMINING
Physical assessment or physical examination
A systematic collection of data that uses observation
to detect health problems
I-P-P-A approach can be used.
Head-to-toe, body systems approach
the nurse may also focus on a specific problem
identified
Screening examination – or Review of Systems is a
brief review of essential functioning of various body
parts, compared against standard
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ORGANIZING THE DATA
Schools of nursing have developed their own
based on selected theories:
Gordon’s 11 functional health patterns
Orem’s self-care model
Roy’s adaptation model
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VALIDATING THE DATA
Validation is the act of “double-checking” or verifying the
data to confirm that it is accurate and factual.
Ensure assessment is complete
Ensure subjective and objective data agree
Differentiate cue from inference
Avoid jumping to conclusions and focusing in the wrong
direction
Not all data require validation
To collect data accurately, nurses need to be aware of their own
biases, values and beliefs and separate fact from inference,
interpretation and assumption.
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DOCUMENTING THE DATA
To complete the assessment phase, the nurse
records client data
Record subjective data in client’s own words.
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Diagnosis
Phase
A Nursing Diagnosis is ...
A description of the client’s response to a disease
state, process, condition or situation. It is “a
clinical judgment about an individual, family or
community responses to actual/potential health
problems/life processes. Nursing diagnoses
provide the basis for selection of nursing
interventions to achieve desired client outcomes”.
(NANDA, 1990)
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Comparing Nursing & Medical
Diagnoses
Nursing Diagnosis
Describes a response to a
disease process, condition
or situation
Oriented to individual
changes as client changes
Compliments medical
diagnoses
Medical Diagnosis
Describes a specific disease
process
Oriented to pathology & remains
constant
Well defined classification
system
Teaches clients about treatments
Teaches client re self-care
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Advantages & Disadvantages of Nursing
Diagnoses
Advantages:
Provides a common language for nurses
Outcome-oriented
Efficient, Organized , Systematic, and Goal Directed
Disadvantages:
Inconsistently used
Not always formally recognized (by MDs.)
Some problems don’t fit diagnostic statements as
outlined by NANDA
42
Two Types of Nursing Diagnoses
Actual Problems:
Altered Nutrition, less than body requirements
related to poor oral intake as evidenced by weight
loss of 12 lbs. in two weeks.
Potential Problems:
High risk for infection (Potential for) related to
decreased primary defenses.
43
Components of a Nursing Diagnosis
Actual Problem (3 Part Statement)
Diagnostic Label/Statement (Problem Statement):
“ Activity Intolerance” “Impaired Physical Mobility”
(identifies unhealthy responses, what needs change)
Etiology (Contributing Factors)
“… related to _______________”
(identifies factors causing undesirable response)
Defining Characteristics (Manifestations)
“ … as evidenced by __________” (what you see)
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Components of a Nursing Diagnosis
Potential Problems (2 Part Statement)
Diagnostic Label/Statement
Etiology (Contributing Factors)
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Analyzing the Data
Compare data against the standards.
2. Cluster the cues
3. Identify gaps and inconsistencies
1.
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Compare data against standards:
Standard or norm – is a generally accepted
measure, rule, model or pattern.
Example: growth and development patterns, normal
vital signs, laboratory values.
Cue is significant if:
1. Points to negative or positive change in a client’s
health status or pattern.
2. Varies from norms of the client population
3. Indicates a developmental delay
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Clustering cues:
Determine the relatedness of facts and determining
whether any patterns is present.
The nurse may cluster data inductively, or use a
framework, or deductively.
Data clustering involves making inferences about the
data, interpret the meaning by making tentative
diagnostic hypotheses (Table 17-5)
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Example: Using the functional health
pattern
FUNCTIONAL HEALTH
PATTERN
CLIENT CUE
CLUSTERS
INFERENCES
DIAGNOSTIC
STATEMENTS
ACTIVITY / EXERCISE
Difficulty sleeping
because of cough
Disturbed sleep pattern
Disturbed sleep pattern
related to cough, pain,
orthopnea.
“Can’t breathe lying
down”
COGNITIVE/
PERCEPTUAL
Reports pain in the chest Acute pain
especially when
coughing
Acute pain (chest) R/T
cough secondary to
pneumonia
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Identify Gaps and Inconsistencies:
Can be avoided if nurse had a good assessment
Inconsistencies are conflicting data
50
Gordon’s 11 Functional Health Patterns Assessment
Questions
1.Health Perception-Health Management Pattern.
In general, how is the family’s health?
What do you do to stay healthy? Do you drink alcohol or use
tobacco products?
Do you have regular check-ups with your physician and/or
specialists (Pediatrician, Ob/Gyn, Cardiologist, etc.)? Do you
listen to and follow any suggestions made by your health care
providers?2.
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2. Nutritional-Metabolic Pattern.
Describe your Family’s typical daily food intake? Do you consider
your family healthy eaters?.
Describe your family’s typical daily fluid intake? Do you
drink alcohol? .
Does anyone consider themselves over or under weight? Is there
any unexplained weight gain or loss?
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Avoiding errors in diagnostic
reasoning
1.
2.
3.
4.
5.
6.
Verify
Build a good knowledge base and acquire clinical
experience
Have a working knowledge of what is normal
Consult resources
Base diagnoses on patterns – on behavior over time
rather than on an isolated incident
Improve critical thinking skills.
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NCP format
CUES
NURSING
DIAGNOSIS
RATIONALE TO
NURSING
DIAGNOSIS
Subjective
Objective
NANDA
[P-E-S / P-E]
Explain the reason
for the nursing
diagnosis chosen
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Planning
Phase
PLANNING
Is a deliberative, systematic phase of the nursing
process that involves decision making and problem
solving
Refer to the client’s assessment data and diagnostic
statement
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NURSING INTERVENTION
“any treatment, based upon clinical judgment and
knowledge, that a nurse performs to enhance
patient/ client outcomes.” (McCloskey & Bulecheck)
Product is a client care plan
Nurses plan WITH the client. Encourage the clients
to participate.
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TYPES OF PLANNING
Initial planning
From the first client contact until nurse-client relationship ends
(discharge).
Ongoing planning
Done by nurses who work with the client, as nurses obtain new
information (individualize)
To determine if status has changes, set priorities for care during the shift, decide
which problem to focus during the shift, coordinate nurse’s activities, so more than
one can be addressed at each client contact
Discharge planning
Process of anticipating and planning for needs after discharge
Begins at first client contact
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Informal nursing care plan
A strategy for action that exists in the nurse’s mind
Formal nursing care plan
A written or computerized guide that organizes information
about the client’s care
Standardized care plan
A formal plan that specifies the nursing care for groups of
client with common needs (hypertension)
Individualized care plan
Is tailored to meet the unique needs of a specific client
59
Nurses use formal care plan for direction about
what needs to be documented in client’s
progress notes and as a guide for delegating and
assigning staff to care for clients
When nurses use the NURSING DIAGNOSES to
develop goals and nursing interventions, the
result is a holistic, individualized plan of care that
will meet the client’s unique needs
60
Care plans include actions nurses must take to
address the client’s nursing diagnoses and
produce the desired outcomes
BEGIN – upon admission to agency
Constantly updates it throughout the client’s stay
- in response to changes in client’s condition
and evaluations of goal achievement
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During the planning phase:
Nurse decide which client need individualized plans,
standardized plans and routine care
Write individualized desired outcomes and nursing
orders for client problems that require nursing
attention beyond preplanned routine care
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Complete plan of care:
A. Routine care needed to meet basic needs
B. Address the clients nursing diagnoses and
collaborative problems
C. Specify the medical responsibilities in carrying out the
plan of care
Complete plan of care integrates dependent and
independent nursing functions into a meaningful whole
63
STANDING ORDER
A written document about policies, rules, regulations,
or orders regarding client care .
Gives nurses the authority to carry out specific
actions under certain circumstances , often when a
physician is not immediately available
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Concept Map
Page 312 (Ineffective airway clearance)
It is a visual tool in which ideas or data are
enclosed in circles or boxes of some shape and
relationships between these are indicated by
connecting lines or arrows
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Multidisciplinary (Collaborative CP)
Standardized plan that outlines the care required
for clients with common, predictable usually
medical conditions
Also called critical pathways – sequence the
care that must be given on each day during the
projected length of stay for the specific type of
condition
66
Guidelines for Writing NCP
1. date and sign the plan – for evaluation,
review, future planning/ signature demonstrates
accountability
2. use category heading (Cues/ Nursing
Diagnosis) include date for evaluation of each
goal
3. use standardized medical or English symbols
and key words rather than complete sentences
to communicate your ideas
4. be specific (every shift – broad)
67
5. refer to procedure books rather than including
all steps on a written plan
6. tailor the plan to the unique characteristics of
the clients by ensuring that the client’s choices
such as preferences about the times of care and
methods used are included
7. ensure that NCP incorporates preventive and
health maintenance aspects as well as
restorative ones
8. ensure that the plan contains interventions for
ongoing assessment
68
9. include collaborative and coordination
activities in the plan
10. Include plans for client’s discharge and home
care needs.
69
Planning Process
Setting priorities
Establishing client goals/ desired outcomes
Selecting nursing interventions
Writing nursing orders
70
1. SETTING OF PRIORITIES
Priority setting is the process of establishing a
preferential sequence for addressing nursing
diagnosis and interventions (together with the client)
High, Medium, Low priority
Life-threatening problem – high priority
Health threatening – medium priority ( acute illness,
decreased coping)
Arises from normal developmental needs/ or requires
minimal nursing support – low priority
71
Nurses frequently use “Maslow’s Hierarchy of
needs” in prioritizing
Not necessary to resolve all high-priority before
addressing the other problems
Priorities change as client’s responses,
problems, and therapies change
72
Factors to consider when prioritizing
1. Client’s health values and beliefs ….. Resolve
if conflicting with nurse, but in life-threatening
situation, the nurse take the initiative
2. Client’s priorities . . . If conflicting, resolve and
knowledge of the nurse more important
3. Resources available to the nurse and client
4. Urgency of the health problem
5. Medical treatment plan
73
Planning Phase:
Goals & Outcomes
Goals are broad statements about the
effects of nursing interventions on the client
(overall, non-measurable statements)
Outcomes are specific, measurable criteria
used to evaluate whether goals have been
met based on specific nursing interventions
74
Outcome Statements (Criteria)
Outcomes are derived from the diagnosis
Outcomes are measurable/behavioral
Outcomes are realistic compared to the
client’s self-care abilities
Outcomes have a time-frame for completion
Outcomes provide direction for care
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Planning Phase: Interventions
Interventions should be developed
which are consistent with the
established plan of care
Interventions should be implemented in
a safe, appropriate manner based on
sound nursing theory and judgment
76
Planning Phase: Interventions
Interventions should always be
documented in the medical record
Interventions should be realistic for
client, based on abilities and
resources
77
Types of Nursing Interventions
Independent:
Able to be implemented without a physician’s order
Dependent:
Must have or obtain physician’s order to
implement this intervention
Collaborative:
Combination of dependent/independent
nursing intervention
78
Types of Nursing Functions
Independent: functions that are within scope of
nursing practice.
Assessment - history and physical
Nursing diagnosis, which require nursing
interventions
Nursing actions
Referrals to other health members
Evaluation of patient’s responses
79
Types of Nursing Functions
Interdependent: activities that are carried out in
conjunction with other health team members.
RN works with a dietician to help a diabetic patient
control blood sugar.
RN works with PT to help improve patient’s
ambulation.
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Nursing Functions
Dependent: activities performed
based on the physician’s orders
Administration of medication
Carrying out specific treatments
81
Independent? Interdependent? Dependent?
Patient has a B/P of 160/100, the RN
Retakes the B/P; ask the pt what he was doing.
Asks the pt. how he is feeling, notes changes
Checks B/P with the previous B/P readings.
Checks the MD’s order for any related orders.
Gives treatments ordered by the MD.
Monitors effects of medication.
Teaches the pt. relaxation techniques.
82
Focus of Patient Care
Medicine and Nursing
Patient reports, “It feels like my chest is
being crushed”
Observations show facial grimace, SOB
(shortness of breath), and diaphoresis
(perspiring)
83
Focus of Patient Care
Goal of Medicine:
cure, treat disease,
heal physiologic
being
Goal of Nursing:
works with the
whole person
84
Focus of Patient Care
Medical interpretation
of pain: diminished
blood flow from
coronary arteries to
myocardium
Probable Diagnosis:
Myocardial Infarction
Nursing
interpretation: Pain
in the chest
Probable Nursing
Diagnosis: chest
pain related to
cardiac disease
85
Focus of Patient Care
Medical Plan:
dependent functions
Bedrest
Vital Signs q 15 min.
Morphine 2mg IV prn
NTG 1/200 gr SL prn
EKG, O2 at 2L/min
Nursing Plan:
independent functions
Monitor EKG and
dysrhythmia
Assess chest pain
Employ comfort
measures, allow rest
Alleviate anxiety
86
NURSING ORDERS
Instructions for the specific individualized activities the
nurse performs to help the client meet established health
care goals.
Components:
Date
Action verb
Content area
Time element
Signature
Observation orders, prevention orders, treatment orders and
health promotion orders
87
Implementation
Phase
Implementing
Consists of doing and documenting the activities
that are the specific nursing actions needed to
carry out the interventions or nursing orders.
Nurses performs or delegates, then finally
records the activities & resulting client responses
The nurse may act on the client’s behalf, but
professional standards support client & family
participation in all phases of the nursing process
The aim: to make the client independent
89
Implementation Skills (3)
Require cognitive skills
(intellectual skills)
Require interpersonal skills
Require technical skills
90
COGNITIVE SKILLS
Include:
Problem solving
Decision making
Critical thinking
Creativity
These are crucial to SAFE, INTELLIGENT
nursing care
91
INTERPERSONAL SKILLS
ALL of the activities – verbal & nonverbal, people
use when interacting directly with one another.
Effectiveness of nurse’s action depends largely
on the nurse’s ability to communicate with
others.
Nurses use therapeutic communication to
understand the client and in turn be understood.
A nurse also needs to work effectively with
others as a member of the health team
92
Interpersonal skills are necessary for all nursing
activities:
Caring
Comforting
Advocating
Referring
Counseling
Supporting
93
Interpersonal skills also include:
Conveying knowledge, attitudes, feelings, interest,
and appreciation of the client’s cultural values and
lifestyle.
Before nurse’s can be highly skilled in interpersonal
relations – they must have SELF AWARENESS and
SENSITIVITY to others
94
TECHNICAL SKILLS
“Hands-on” skills such as:
Manipulating equipment, giving injections and
bandaging, moving, lifting, and repositioning clients.
also called:
Tasks, procedures, psychomotor skills
Psychomotor skills includes interpersonal component
(like when you communicate with the client)
95
Reassessing the Client
Just before implementing the intervention - Reassess to make sure the intervention is still
needed
“disturbed sleep pattern related to anxiety &
unfamiliar surroundings”
96
Determining the client’s need for
assistance
Reasons:
The nurse is unable to implement the nursing activity
safely alone
Assistance would reduce stress on the client
The nurse lacks the knowledge or skills to implement
a particular nursing activity
97
Guidelines when implementing
nursing actions
Explain to the client what interventions will be
done, what sensations to expect, what the client
is expected to do, and what the expected
outcome is.
Ensure client’s privacy
Coordinate your care – scheduling contacts with
other departments and serving as liaison
98
Base nursing actions on scientific knowledge, nursing
research and professional standards of care
(evidence-based practice)
Aware of the scientific rationale, side effects, complications
Clearly understand the orders to be implemented and
question any that are not understood.
The nurse is responsible for intelligent implementation of
the care plan.
This requires knowledge of each intervention, its purpose in
the client’s plan of care, any contraindications and changes
in the client’s condition that may affect the order.
99
Adapt activities to the individual client.
A client’s beliefs, values, age, health status and
environment are factors that can affect the success of
nursing actions.
Implement safe care
Observe sterile technique, administer the correct dosage
Provide teaching, support and comfort
Independent nursing activities enhance effectiveness of
nursing care plan
Be holistic
Always view the client as a whole
100
Respect the dignity of the client and enhance their selfesteem
Provide privacy, encourage to make their own decisions
Encourage clients to participate actively in implementing
the nursing interventions
Active participation enhances their sense of independence and
control.
However, degree of involvement is related:
To the severity of the illness
Culture
Fear
Understanding of the illness and intervention
101
Supervising delegated care
Nurses ensure that care delegated is according
to the care plan.
Others – communicate their activities to the
nurse by documenting them on the client record,
report verbally, or fill out the written form
102
Documenting nursing activities
The nurse completes the implementing phase by
recording the interventions and client responses in the
nursing progress notes
Nursing care must not be recorded in advance
Nurse may record routine or recurring activities in the client
record at the end of the shift.
In some cases – it should be recorded immediately (like
medications & treatment – for safety )
Nursing activities are communicated verbally and in writing
Nursing activities are also recorded at the change of shift
103
Evaluation
Phase
The Nursing Process
STEP 5
Evaluation—
determining the
client’s progress
monitoring the
client’s response
Otten/403
105
Evaluating
To judge or to appraise
A planned, ongoing, purposeful activity in which clients
and health care professionals determine:
client’s progress toward achievements of goals/outcomes
The effectiveness of the NCP
Important part – because conclusions drawn from the
evaluation determine whether nursing interventions should
be terminated, continued or changed
106
Evaluation is continuous
Done immediately after implementation
At a specified interval
It is continued until the client achieves the health
goals or discharged from nursing care
At discharge – includes the status of goal
achievement
Through evaluating, nurses demonstrate
responsibility and accountability for their actions
Successful evaluation depends on the
effectiveness of the steps that precede it.
107
Process of evaluating client
response
Before evaluation, the nurse identifies the
desired outcomes that will be used to measure
the client goal achievement. (PLANNING step)
Two purposes of desired outcomes:
a.
b.
They establish the kind of evaluation data that
need to be collected
They provide a standard against which the data are
judged
108
5 components of the evaluation process
a.
b.
c.
d.
e.
Collecting data related to the desired outcomes
Comparing the data with outcomes
Relating nursing activities to outcomes
Drawing conclusions about problem status
Continuing, modifying, or terminating nursing
care plan
109
Evaluation Process
Compare the actual to expected outcomes
- Did my client achieve their outcomes?
- If not, determine why outcomes were unmet - Were the
outcomes realistic? Correct problem? Enough time to
achieve outcomes?
If you determine the outcomes to be appropriate, assess
the interventions
-Were the interventions appropriate? Were they completed?
Does the client require other nursing interventions?
If everything looks good, continue with plan of care,
observing for improvement
110
Collect data
Use the clearly stated, precise, measurable desired outcomes –
both objective & subjective data
Compare data with outcomes
Both the nurse and client do this
Three possible conclusions:
The goal was met: client’s response the same as the desired outcome
Goal partially met: either a short term goal was met, but long term goal
not, or desired outcome only partially met
Goal was not met
example: Goal met: Oral intake 300 ml more than output, skin
turgor is good, mucous membrane moist
111
Evaluation checklist – tabel 19-1: page 322
112
Purposes of a Written Care Plan
Provides direction & individualizes client
care
Provides for continuity of care
Provides direction for follow-up &
documentation
Provides assistance in assigning staff
Provides information for reimbursement
113
Mrs. Ida Hubert, 67 y.o.
Admitted to the unit with diagnosis of lung
cancer with bone metastases 3 days ago
Meds: morphine 180 mg daily; Tylenol 650 mg
+Oxycodone 10 mg q6h p.r.n.
Morning report: Mrs. Huber had been restless all
night
114
What assessments would you want to make
in your preparation for her care?
Chart review: Has been taking
narcotics for 2 months; spends
most of her days in bed
115
Assessment of Mrs. Hubert
Patient interview:
Alert and responsive
“Couldn’t sleep or rest; just couldn’t get into a
comfortable position.” Had trouble describing her
discomfort.
Reported decreased appetite, ate 3 small meals/day,
one 8 oz can of supplement. Said she is drinking
very little fluids
116
Assessment of Mrs. Hubert
Measurements:
V.S. were stable
Had active bowel sounds, abdomen non-tender to
palpation, but noted a firm area in LLQ.
Said she had not had a BM since admission (3 days
ago).
What nursing diagnosis might be appropriate for
Mrs. Hubert?
117
Critical Thinking: What is it?
Critical thinking is “making decisions based on
reason, reflection, knowledge and instinct
derived from experience. Critical thinking helps
nurses make patient-care decisions by helping
them to think creatively, and explore new ideas
and alternative ways of solving problems.
(Catalano, 1996)
118
The Critical Thinking Process
Identify the problem
Identifying the underlying beliefs (patient, personal and
other healthcare providers)
Find support for the beliefs (accurate, timely, consistent
literature/research)
Evaluate the situation for possible solutions and weigh
the solutions against the beliefs and values
Present a course of action
119
Comparison of SOAP & Nursing Process Steps
Subjective
Assessment
Objective
Diagnosis
Assessment
Plan
Implementation
Plan
Evaluation
1
The Nursing Process is ...
“A systematic, rationale method of planning
and providing individualized nursing care.
Its purpose is to identify client’s health
status, actual or potential healthcare
problems or needs, to establish plans to
meet those needs and to deliver specific
nursing interventions to meet those needs”.
(Kozier, 2004)
2
The Nursing Process is ...
The set of activities that professional nurses
perform to determine the needs of the
patient and make a judgment to provide the
care that is needed.
3
Standards of Competent Performance
Formulates nursing diagnosis, through observation and
interpretation of information.
Formulates a care plan in collaboration with the client.
Performs skills essential to the nursing actions to be
taken.
Delegates tasks to subordinates
Evaluates the effectiveness of the care plan
Acts as the client’s advocate.
4
Standards of Practice
The collection of data is systematic
Derive nursing diagnosis from data
Plan nursing care including goals
Plan includes priorities and nursing approaches
Nursing actions provide for client participation in
health promotion, maintenance, and restoration
Evaluation of progress or lack of progress
5
Problem-Solving & Priority Setting
Priority Setting:
Determine client health values & beliefs
Establish priorities from highest to lowest
Determine urgency or the problem
Problem-Solving:
Once problem is identified, collect data
Analyze the data & identify an action-plan
Implement the plan, observing initial responses
Evaluate the results
6
Characteristics of the Nursing
Process
Data from each phase provides input into the next phase.
Client centered.
An adaptation of problem solving and system’s theory.
Decision making is involved in every phase of the nursing process
It is interpersonal and collaborative
Universally acceptable – framework for nursing care in all types of
setting.
Nurses must use a variety of critical-thinking skills to carry out the
nursing process
7
Steps of the Nursing Process
Assessment
Diagnosis
Planning
Implementation
Evaluation
8
The Nursing Process
Otten/403
9
The
Nursing
Process
Assessment
Phase
Assessment Data
Subjective Data
- The client states “ . . .”
Objective Data
- Vital signs
- Physical assessments
- Previous documentation
Examples of Data
Temp of 102 degree
“I feel tired”
WBC 24,000/mm3
“I need help to walk”
B/P 180/96
“My leg hurts”
Redness and swelling in R ankle
13
ASSESSING
Is the systematic and continuous collection,
organization, validation and documentation of
data.
Assessing is a continuous process carried out
during all phases of the nursing process.
All phases of the nursing process depend on the
accurate and complete collection of data.
Assessment vary according to their purpose,
timing, time available, and client status.
14
Four types of Assessment
Initial assessment
Problem focused assessment
Emergency assessment
Time-lapsed assessment
15
Type of Assessment
Time Performed
Purpose
example
Initial assessment
Performed within
specified time after
admission to a health
care agency
To establish a complete
data base for problem
identification, reference
and future comparison
Nursing admission
assessment
Problem focused
Ongoing process
integrated with
nursing care
To determine the status
of a specific problem
identified in an earlier
assessment.
To identify new or
overlooked problems
- Hourly assessment
of fluid intake and
urinary output
To identify lifethreatening problems
- Rapid assessment
of airway, breathing
status and circulation
(emergency)
- Suicidal tendencies
Emergency
assessment
During any
physiologic or
psychologic crisis of
the client
-The ability to
perform self-care
while assisting to
bathe
16
Type
Time
performed
Purpose
Time-lapsed
assessment
Several months To compare the
after initial
client’s current
assessment
status to
baseline data
previously
obtained
Example
Reassessment
of a client’s
functional
health patterns
in a home care
or outpatient
setting or in a
hospital, at shift
change
17
Nursing assessment focus on a client’s
responses to a health problem.
It includes:
Perceived needs
Health problems
Related experience
Health practices
Values
lifestyles
18
Assessment Activities (Collecting
Data)
DATA
COLLECTION
A process of gathering information about a client’s health status.
It is systematic and continuous (to prevent ommission of
significant data and reflect a client’s changing health status.
DATA BASE is all information about the client, includes the
nursing history, physical examination, physician’s history & PE,
results of laboratory and diagnostic tests material contributed by
other health personnel
Nursing Health History (263)
Functional Health Patterns (Gordon)
19
Types of Data
Subjective data
Symptoms or covert data
Apparent only to the person affected and can be described or
verified by him alone
Sensation, feelings, values, beliefs, attitudes, perception of
personal health status and life situation
Objective data
Sign or overt data
Detectable by the observer or can be measured or tested
against an accepted standard.
Seen, hear, felt, or smelled
Obtained by observation or PE
20
Sources of Data
Primary source
Client – the best source of data, unless too ill, young
or confused to communicate
Secondary source
Support people (significant others SO)
Client records
Health care professionals
Literature
21
Data Collection Methods
OBSERVING
Use of the senses
Vision, smell, hearing, touch
Has two aspects:
(a)
(b)
Noticing the data
Selecting, organizing and interpreting the data
22
INTERVIEWING
Interview is a planned communication or a
conversation with a purpose (to get/ give
information), to identify problems of mutual concern,
evaluate change, teach, provide support, or provide
counseling or therapy.
Nursing health history
23
Two approaches to interviewing:
Directive interview
Highly structured and elicits specific information
Nurse establishes the purpose and controls the interview
Client responds but with limited opportunity to ask questions and discuss
concerns
Frequently used to gather and give information when time is limited
Nondirective interview
Or rapport- building interview (rapport is understanding between two
people)
Client control the purpose, matter and pacing
A combination of the two is important during information-gathering
interview.
24
INTERVIEW QUESTIONS
Closed questions
in directive interview
Restrictive – require only yes, no, short factual
answers
Begin with when, where, who, what, do (did, does),
is (are, was)
“are you in pain”, “how old are you”
25
Open-ended questions
Nondirective interview
Invite clients to discover and explore, elaborate,
clarify or illustrate their thoughts or feelings
Specifies only broad topic to be discussed.
Begin with “how” or “what”
“what brought you to he clinic?”, “how are you feeling
today?”
26
Neutral question
Client can answer without direction or pressure from
the nurse
Open-ended, used in nondirective interview
“How do you feel about that?”
Leading question
Usually closed, used in directive interview.
“you’re stressed about surgery tomorrow, aren’t you?
27
PLANNING THE INTERVIEW AND
SETTING
BEFORE beginning, review available information
(client’s chart), review agency’s data collection
form, make an interview guide
The following influence the interview:
a.
b.
c.
d.
e.
Time
Place
Seating arrangement
Distance
Language
28
TIME
Physically comfortable
Free of pain
Interruptions are minimal
Make the client feel comfortable and unhurried
29
PLACE
Well-lighted, well-ventilated, moderate-sized room
Free of noise, movement and interruptions
Encourage communications
Others cannot hear or see (privacy)
SEATING ARRANGEMENT
Equal terms – parties sit in two chairs at right angle to
a desk or table, few feet apart, with no table between
Creates less formal atmosphere
If standing or looking down – if client on bed, makes
intimidating, nurse can sit 45 degree angle to bed
30
DISTANCE
Between the interviewer & interviewee should neither
be too small nor too great, because people feel
uncomfortable when talking to someone who is too
close or too far.
Maintaining a distance of 2-3 feet
Some clients require a more or less personal space
depending on their cultural and personal needs.
31
ACCEPTED distance in conversation varies with
ethnicity
8-12 in Arab
18 in in US
24 in in Britain
36 in in Japan
Men require more space
Anxiety needs more space
Direct eye contact – increases the need for space
Physical contact is used only for therapeutic purpose
(TOUCH)
32
LANGUAGE
Failure to communicate in language the client can
understand is a form of discrimination.
Convert complicated medical terminology into
common English or language for the client.
33
STAGES OF INTERVIEW
THE OPENING
Most important part, what is said and done sets the tone for the
remainder of the interview.
Establish rapport
Orientation
THE BODY
The client communicates what she thinks, feels, knows and
perceives in response to nurse’s questions
THE CLOSING
Nurse terminates or ends the interview
Clients may also terminate it (page 268)
34
EXAMINING
Physical assessment or physical examination
A systematic collection of data that uses observation
to detect health problems
I-P-P-A approach can be used.
Head-to-toe, body systems approach
the nurse may also focus on a specific problem
identified
Screening examination – or Review of Systems is a
brief review of essential functioning of various body
parts, compared against standard
35
ORGANIZING THE DATA
Schools of nursing have developed their own
based on selected theories:
Gordon’s 11 functional health patterns
Orem’s self-care model
Roy’s adaptation model
36
VALIDATING THE DATA
Validation is the act of “double-checking” or verifying the
data to confirm that it is accurate and factual.
Ensure assessment is complete
Ensure subjective and objective data agree
Differentiate cue from inference
Avoid jumping to conclusions and focusing in the wrong
direction
Not all data require validation
To collect data accurately, nurses need to be aware of their own
biases, values and beliefs and separate fact from inference,
interpretation and assumption.
37
DOCUMENTING THE DATA
To complete the assessment phase, the nurse
records client data
Record subjective data in client’s own words.
38
Diagnosis
Phase
A Nursing Diagnosis is ...
A description of the client’s response to a disease
state, process, condition or situation. It is “a
clinical judgment about an individual, family or
community responses to actual/potential health
problems/life processes. Nursing diagnoses
provide the basis for selection of nursing
interventions to achieve desired client outcomes”.
(NANDA, 1990)
40
Comparing Nursing & Medical
Diagnoses
Nursing Diagnosis
Describes a response to a
disease process, condition
or situation
Oriented to individual
changes as client changes
Compliments medical
diagnoses
Medical Diagnosis
Describes a specific disease
process
Oriented to pathology & remains
constant
Well defined classification
system
Teaches clients about treatments
Teaches client re self-care
41
Advantages & Disadvantages of Nursing
Diagnoses
Advantages:
Provides a common language for nurses
Outcome-oriented
Efficient, Organized , Systematic, and Goal Directed
Disadvantages:
Inconsistently used
Not always formally recognized (by MDs.)
Some problems don’t fit diagnostic statements as
outlined by NANDA
42
Two Types of Nursing Diagnoses
Actual Problems:
Altered Nutrition, less than body requirements
related to poor oral intake as evidenced by weight
loss of 12 lbs. in two weeks.
Potential Problems:
High risk for infection (Potential for) related to
decreased primary defenses.
43
Components of a Nursing Diagnosis
Actual Problem (3 Part Statement)
Diagnostic Label/Statement (Problem Statement):
“ Activity Intolerance” “Impaired Physical Mobility”
(identifies unhealthy responses, what needs change)
Etiology (Contributing Factors)
“… related to _______________”
(identifies factors causing undesirable response)
Defining Characteristics (Manifestations)
“ … as evidenced by __________” (what you see)
44
Components of a Nursing Diagnosis
Potential Problems (2 Part Statement)
Diagnostic Label/Statement
Etiology (Contributing Factors)
45
Analyzing the Data
Compare data against the standards.
2. Cluster the cues
3. Identify gaps and inconsistencies
1.
46
Compare data against standards:
Standard or norm – is a generally accepted
measure, rule, model or pattern.
Example: growth and development patterns, normal
vital signs, laboratory values.
Cue is significant if:
1. Points to negative or positive change in a client’s
health status or pattern.
2. Varies from norms of the client population
3. Indicates a developmental delay
47
Clustering cues:
Determine the relatedness of facts and determining
whether any patterns is present.
The nurse may cluster data inductively, or use a
framework, or deductively.
Data clustering involves making inferences about the
data, interpret the meaning by making tentative
diagnostic hypotheses (Table 17-5)
48
Example: Using the functional health
pattern
FUNCTIONAL HEALTH
PATTERN
CLIENT CUE
CLUSTERS
INFERENCES
DIAGNOSTIC
STATEMENTS
ACTIVITY / EXERCISE
Difficulty sleeping
because of cough
Disturbed sleep pattern
Disturbed sleep pattern
related to cough, pain,
orthopnea.
“Can’t breathe lying
down”
COGNITIVE/
PERCEPTUAL
Reports pain in the chest Acute pain
especially when
coughing
Acute pain (chest) R/T
cough secondary to
pneumonia
49
Identify Gaps and Inconsistencies:
Can be avoided if nurse had a good assessment
Inconsistencies are conflicting data
50
Gordon’s 11 Functional Health Patterns Assessment
Questions
1.Health Perception-Health Management Pattern.
In general, how is the family’s health?
What do you do to stay healthy? Do you drink alcohol or use
tobacco products?
Do you have regular check-ups with your physician and/or
specialists (Pediatrician, Ob/Gyn, Cardiologist, etc.)? Do you
listen to and follow any suggestions made by your health care
providers?2.
51
2. Nutritional-Metabolic Pattern.
Describe your Family’s typical daily food intake? Do you consider
your family healthy eaters?.
Describe your family’s typical daily fluid intake? Do you
drink alcohol? .
Does anyone consider themselves over or under weight? Is there
any unexplained weight gain or loss?
52
Avoiding errors in diagnostic
reasoning
1.
2.
3.
4.
5.
6.
Verify
Build a good knowledge base and acquire clinical
experience
Have a working knowledge of what is normal
Consult resources
Base diagnoses on patterns – on behavior over time
rather than on an isolated incident
Improve critical thinking skills.
53
NCP format
CUES
NURSING
DIAGNOSIS
RATIONALE TO
NURSING
DIAGNOSIS
Subjective
Objective
NANDA
[P-E-S / P-E]
Explain the reason
for the nursing
diagnosis chosen
54
Planning
Phase
PLANNING
Is a deliberative, systematic phase of the nursing
process that involves decision making and problem
solving
Refer to the client’s assessment data and diagnostic
statement
56
NURSING INTERVENTION
“any treatment, based upon clinical judgment and
knowledge, that a nurse performs to enhance
patient/ client outcomes.” (McCloskey & Bulecheck)
Product is a client care plan
Nurses plan WITH the client. Encourage the clients
to participate.
57
TYPES OF PLANNING
Initial planning
From the first client contact until nurse-client relationship ends
(discharge).
Ongoing planning
Done by nurses who work with the client, as nurses obtain new
information (individualize)
To determine if status has changes, set priorities for care during the shift, decide
which problem to focus during the shift, coordinate nurse’s activities, so more than
one can be addressed at each client contact
Discharge planning
Process of anticipating and planning for needs after discharge
Begins at first client contact
58
Informal nursing care plan
A strategy for action that exists in the nurse’s mind
Formal nursing care plan
A written or computerized guide that organizes information
about the client’s care
Standardized care plan
A formal plan that specifies the nursing care for groups of
client with common needs (hypertension)
Individualized care plan
Is tailored to meet the unique needs of a specific client
59
Nurses use formal care plan for direction about
what needs to be documented in client’s
progress notes and as a guide for delegating and
assigning staff to care for clients
When nurses use the NURSING DIAGNOSES to
develop goals and nursing interventions, the
result is a holistic, individualized plan of care that
will meet the client’s unique needs
60
Care plans include actions nurses must take to
address the client’s nursing diagnoses and
produce the desired outcomes
BEGIN – upon admission to agency
Constantly updates it throughout the client’s stay
- in response to changes in client’s condition
and evaluations of goal achievement
61
During the planning phase:
Nurse decide which client need individualized plans,
standardized plans and routine care
Write individualized desired outcomes and nursing
orders for client problems that require nursing
attention beyond preplanned routine care
62
Complete plan of care:
A. Routine care needed to meet basic needs
B. Address the clients nursing diagnoses and
collaborative problems
C. Specify the medical responsibilities in carrying out the
plan of care
Complete plan of care integrates dependent and
independent nursing functions into a meaningful whole
63
STANDING ORDER
A written document about policies, rules, regulations,
or orders regarding client care .
Gives nurses the authority to carry out specific
actions under certain circumstances , often when a
physician is not immediately available
64
Concept Map
Page 312 (Ineffective airway clearance)
It is a visual tool in which ideas or data are
enclosed in circles or boxes of some shape and
relationships between these are indicated by
connecting lines or arrows
65
Multidisciplinary (Collaborative CP)
Standardized plan that outlines the care required
for clients with common, predictable usually
medical conditions
Also called critical pathways – sequence the
care that must be given on each day during the
projected length of stay for the specific type of
condition
66
Guidelines for Writing NCP
1. date and sign the plan – for evaluation,
review, future planning/ signature demonstrates
accountability
2. use category heading (Cues/ Nursing
Diagnosis) include date for evaluation of each
goal
3. use standardized medical or English symbols
and key words rather than complete sentences
to communicate your ideas
4. be specific (every shift – broad)
67
5. refer to procedure books rather than including
all steps on a written plan
6. tailor the plan to the unique characteristics of
the clients by ensuring that the client’s choices
such as preferences about the times of care and
methods used are included
7. ensure that NCP incorporates preventive and
health maintenance aspects as well as
restorative ones
8. ensure that the plan contains interventions for
ongoing assessment
68
9. include collaborative and coordination
activities in the plan
10. Include plans for client’s discharge and home
care needs.
69
Planning Process
Setting priorities
Establishing client goals/ desired outcomes
Selecting nursing interventions
Writing nursing orders
70
1. SETTING OF PRIORITIES
Priority setting is the process of establishing a
preferential sequence for addressing nursing
diagnosis and interventions (together with the client)
High, Medium, Low priority
Life-threatening problem – high priority
Health threatening – medium priority ( acute illness,
decreased coping)
Arises from normal developmental needs/ or requires
minimal nursing support – low priority
71
Nurses frequently use “Maslow’s Hierarchy of
needs” in prioritizing
Not necessary to resolve all high-priority before
addressing the other problems
Priorities change as client’s responses,
problems, and therapies change
72
Factors to consider when prioritizing
1. Client’s health values and beliefs ….. Resolve
if conflicting with nurse, but in life-threatening
situation, the nurse take the initiative
2. Client’s priorities . . . If conflicting, resolve and
knowledge of the nurse more important
3. Resources available to the nurse and client
4. Urgency of the health problem
5. Medical treatment plan
73
Planning Phase:
Goals & Outcomes
Goals are broad statements about the
effects of nursing interventions on the client
(overall, non-measurable statements)
Outcomes are specific, measurable criteria
used to evaluate whether goals have been
met based on specific nursing interventions
74
Outcome Statements (Criteria)
Outcomes are derived from the diagnosis
Outcomes are measurable/behavioral
Outcomes are realistic compared to the
client’s self-care abilities
Outcomes have a time-frame for completion
Outcomes provide direction for care
75
Planning Phase: Interventions
Interventions should be developed
which are consistent with the
established plan of care
Interventions should be implemented in
a safe, appropriate manner based on
sound nursing theory and judgment
76
Planning Phase: Interventions
Interventions should always be
documented in the medical record
Interventions should be realistic for
client, based on abilities and
resources
77
Types of Nursing Interventions
Independent:
Able to be implemented without a physician’s order
Dependent:
Must have or obtain physician’s order to
implement this intervention
Collaborative:
Combination of dependent/independent
nursing intervention
78
Types of Nursing Functions
Independent: functions that are within scope of
nursing practice.
Assessment - history and physical
Nursing diagnosis, which require nursing
interventions
Nursing actions
Referrals to other health members
Evaluation of patient’s responses
79
Types of Nursing Functions
Interdependent: activities that are carried out in
conjunction with other health team members.
RN works with a dietician to help a diabetic patient
control blood sugar.
RN works with PT to help improve patient’s
ambulation.
80
Nursing Functions
Dependent: activities performed
based on the physician’s orders
Administration of medication
Carrying out specific treatments
81
Independent? Interdependent? Dependent?
Patient has a B/P of 160/100, the RN
Retakes the B/P; ask the pt what he was doing.
Asks the pt. how he is feeling, notes changes
Checks B/P with the previous B/P readings.
Checks the MD’s order for any related orders.
Gives treatments ordered by the MD.
Monitors effects of medication.
Teaches the pt. relaxation techniques.
82
Focus of Patient Care
Medicine and Nursing
Patient reports, “It feels like my chest is
being crushed”
Observations show facial grimace, SOB
(shortness of breath), and diaphoresis
(perspiring)
83
Focus of Patient Care
Goal of Medicine:
cure, treat disease,
heal physiologic
being
Goal of Nursing:
works with the
whole person
84
Focus of Patient Care
Medical interpretation
of pain: diminished
blood flow from
coronary arteries to
myocardium
Probable Diagnosis:
Myocardial Infarction
Nursing
interpretation: Pain
in the chest
Probable Nursing
Diagnosis: chest
pain related to
cardiac disease
85
Focus of Patient Care
Medical Plan:
dependent functions
Bedrest
Vital Signs q 15 min.
Morphine 2mg IV prn
NTG 1/200 gr SL prn
EKG, O2 at 2L/min
Nursing Plan:
independent functions
Monitor EKG and
dysrhythmia
Assess chest pain
Employ comfort
measures, allow rest
Alleviate anxiety
86
NURSING ORDERS
Instructions for the specific individualized activities the
nurse performs to help the client meet established health
care goals.
Components:
Date
Action verb
Content area
Time element
Signature
Observation orders, prevention orders, treatment orders and
health promotion orders
87
Implementation
Phase
Implementing
Consists of doing and documenting the activities
that are the specific nursing actions needed to
carry out the interventions or nursing orders.
Nurses performs or delegates, then finally
records the activities & resulting client responses
The nurse may act on the client’s behalf, but
professional standards support client & family
participation in all phases of the nursing process
The aim: to make the client independent
89
Implementation Skills (3)
Require cognitive skills
(intellectual skills)
Require interpersonal skills
Require technical skills
90
COGNITIVE SKILLS
Include:
Problem solving
Decision making
Critical thinking
Creativity
These are crucial to SAFE, INTELLIGENT
nursing care
91
INTERPERSONAL SKILLS
ALL of the activities – verbal & nonverbal, people
use when interacting directly with one another.
Effectiveness of nurse’s action depends largely
on the nurse’s ability to communicate with
others.
Nurses use therapeutic communication to
understand the client and in turn be understood.
A nurse also needs to work effectively with
others as a member of the health team
92
Interpersonal skills are necessary for all nursing
activities:
Caring
Comforting
Advocating
Referring
Counseling
Supporting
93
Interpersonal skills also include:
Conveying knowledge, attitudes, feelings, interest,
and appreciation of the client’s cultural values and
lifestyle.
Before nurse’s can be highly skilled in interpersonal
relations – they must have SELF AWARENESS and
SENSITIVITY to others
94
TECHNICAL SKILLS
“Hands-on” skills such as:
Manipulating equipment, giving injections and
bandaging, moving, lifting, and repositioning clients.
also called:
Tasks, procedures, psychomotor skills
Psychomotor skills includes interpersonal component
(like when you communicate with the client)
95
Reassessing the Client
Just before implementing the intervention - Reassess to make sure the intervention is still
needed
“disturbed sleep pattern related to anxiety &
unfamiliar surroundings”
96
Determining the client’s need for
assistance
Reasons:
The nurse is unable to implement the nursing activity
safely alone
Assistance would reduce stress on the client
The nurse lacks the knowledge or skills to implement
a particular nursing activity
97
Guidelines when implementing
nursing actions
Explain to the client what interventions will be
done, what sensations to expect, what the client
is expected to do, and what the expected
outcome is.
Ensure client’s privacy
Coordinate your care – scheduling contacts with
other departments and serving as liaison
98
Base nursing actions on scientific knowledge, nursing
research and professional standards of care
(evidence-based practice)
Aware of the scientific rationale, side effects, complications
Clearly understand the orders to be implemented and
question any that are not understood.
The nurse is responsible for intelligent implementation of
the care plan.
This requires knowledge of each intervention, its purpose in
the client’s plan of care, any contraindications and changes
in the client’s condition that may affect the order.
99
Adapt activities to the individual client.
A client’s beliefs, values, age, health status and
environment are factors that can affect the success of
nursing actions.
Implement safe care
Observe sterile technique, administer the correct dosage
Provide teaching, support and comfort
Independent nursing activities enhance effectiveness of
nursing care plan
Be holistic
Always view the client as a whole
100
Respect the dignity of the client and enhance their selfesteem
Provide privacy, encourage to make their own decisions
Encourage clients to participate actively in implementing
the nursing interventions
Active participation enhances their sense of independence and
control.
However, degree of involvement is related:
To the severity of the illness
Culture
Fear
Understanding of the illness and intervention
101
Supervising delegated care
Nurses ensure that care delegated is according
to the care plan.
Others – communicate their activities to the
nurse by documenting them on the client record,
report verbally, or fill out the written form
102
Documenting nursing activities
The nurse completes the implementing phase by
recording the interventions and client responses in the
nursing progress notes
Nursing care must not be recorded in advance
Nurse may record routine or recurring activities in the client
record at the end of the shift.
In some cases – it should be recorded immediately (like
medications & treatment – for safety )
Nursing activities are communicated verbally and in writing
Nursing activities are also recorded at the change of shift
103
Evaluation
Phase
The Nursing Process
STEP 5
Evaluation—
determining the
client’s progress
monitoring the
client’s response
Otten/403
105
Evaluating
To judge or to appraise
A planned, ongoing, purposeful activity in which clients
and health care professionals determine:
client’s progress toward achievements of goals/outcomes
The effectiveness of the NCP
Important part – because conclusions drawn from the
evaluation determine whether nursing interventions should
be terminated, continued or changed
106
Evaluation is continuous
Done immediately after implementation
At a specified interval
It is continued until the client achieves the health
goals or discharged from nursing care
At discharge – includes the status of goal
achievement
Through evaluating, nurses demonstrate
responsibility and accountability for their actions
Successful evaluation depends on the
effectiveness of the steps that precede it.
107
Process of evaluating client
response
Before evaluation, the nurse identifies the
desired outcomes that will be used to measure
the client goal achievement. (PLANNING step)
Two purposes of desired outcomes:
a.
b.
They establish the kind of evaluation data that
need to be collected
They provide a standard against which the data are
judged
108
5 components of the evaluation process
a.
b.
c.
d.
e.
Collecting data related to the desired outcomes
Comparing the data with outcomes
Relating nursing activities to outcomes
Drawing conclusions about problem status
Continuing, modifying, or terminating nursing
care plan
109
Evaluation Process
Compare the actual to expected outcomes
- Did my client achieve their outcomes?
- If not, determine why outcomes were unmet - Were the
outcomes realistic? Correct problem? Enough time to
achieve outcomes?
If you determine the outcomes to be appropriate, assess
the interventions
-Were the interventions appropriate? Were they completed?
Does the client require other nursing interventions?
If everything looks good, continue with plan of care,
observing for improvement
110
Collect data
Use the clearly stated, precise, measurable desired outcomes –
both objective & subjective data
Compare data with outcomes
Both the nurse and client do this
Three possible conclusions:
The goal was met: client’s response the same as the desired outcome
Goal partially met: either a short term goal was met, but long term goal
not, or desired outcome only partially met
Goal was not met
example: Goal met: Oral intake 300 ml more than output, skin
turgor is good, mucous membrane moist
111
Evaluation checklist – tabel 19-1: page 322
112
Purposes of a Written Care Plan
Provides direction & individualizes client
care
Provides for continuity of care
Provides direction for follow-up &
documentation
Provides assistance in assigning staff
Provides information for reimbursement
113
Mrs. Ida Hubert, 67 y.o.
Admitted to the unit with diagnosis of lung
cancer with bone metastases 3 days ago
Meds: morphine 180 mg daily; Tylenol 650 mg
+Oxycodone 10 mg q6h p.r.n.
Morning report: Mrs. Huber had been restless all
night
114
What assessments would you want to make
in your preparation for her care?
Chart review: Has been taking
narcotics for 2 months; spends
most of her days in bed
115
Assessment of Mrs. Hubert
Patient interview:
Alert and responsive
“Couldn’t sleep or rest; just couldn’t get into a
comfortable position.” Had trouble describing her
discomfort.
Reported decreased appetite, ate 3 small meals/day,
one 8 oz can of supplement. Said she is drinking
very little fluids
116
Assessment of Mrs. Hubert
Measurements:
V.S. were stable
Had active bowel sounds, abdomen non-tender to
palpation, but noted a firm area in LLQ.
Said she had not had a BM since admission (3 days
ago).
What nursing diagnosis might be appropriate for
Mrs. Hubert?
117
Critical Thinking: What is it?
Critical thinking is “making decisions based on
reason, reflection, knowledge and instinct
derived from experience. Critical thinking helps
nurses make patient-care decisions by helping
them to think creatively, and explore new ideas
and alternative ways of solving problems.
(Catalano, 1996)
118
The Critical Thinking Process
Identify the problem
Identifying the underlying beliefs (patient, personal and
other healthcare providers)
Find support for the beliefs (accurate, timely, consistent
literature/research)
Evaluate the situation for possible solutions and weigh
the solutions against the beliefs and values
Present a course of action
119
Comparison of SOAP & Nursing Process Steps
Subjective
Assessment
Objective
Diagnosis
Assessment
Plan
Implementation
Plan
Evaluation
