REVIEW OF THE REVIEW OF THE NURSING PROCESSNURSING PROCESS

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NovieastariNovieastari, , SKp.,MSNSKp.,MSNDKKD FIK UIDKKD FIK UI

ASSESSMENT

IMPLEMENTATION

EVALUATION

DIAGNOSIS

PLANNING

OVERVIEWOVERVIEWThe nursing process enables the nurse to The nursing process enables the nurse to organize and deliver nursing careorganize and deliver nursing careThe nurse integrates elements of critical thinking The nurse integrates elements of critical thinking to make judgments and take actions based on to make judgments and take actions based on reasonsreasonsThe nursing process is used to identify , The nursing process is used to identify , diagnose, and treat human responses to health diagnose, and treat human responses to health and illness (ANA, 1995)and illness (ANA, 1995)It is a dynamic, continuous process as the It is a dynamic, continuous process as the clientclient’’s need changes need change

Assessment Assessment The nurse must able to review information from The nurse must able to review information from a variety of sources and to make critical a variety of sources and to make critical judgmentsjudgmentsDuring a nursing During a nursing assessment,assessment, the nurse the nurse systematically collects, verifies, analyses, and systematically collects, verifies, analyses, and communicates data about clientcommunicates data about clientThis phase of nursing process includes two This phase of nursing process includes two steps: collection and verification of data from a steps: collection and verification of data from a primary and secondary sources and the analysis primary and secondary sources and the analysis of that data as a basis for nursing diagnosisof that data as a basis for nursing diagnosis

Nursing DiagnosisNursing DiagnosisAfter completing the nursing assessment, the nurse After completing the nursing assessment, the nurse proceeds to the process of forming appropriate nursing proceeds to the process of forming appropriate nursing diagnosisdiagnosisA nursing diagnosis is a clinical judgment about A nursing diagnosis is a clinical judgment about individual, family, or community responses to actual or individual, family, or community responses to actual or potential health problems or life processpotential health problems or life processA nursing diagnosis is a statement that describes the A nursing diagnosis is a statement that describes the clientclient’’s actual or potential response to a health problem s actual or potential response to a health problem that the nurse is licensed and competent to treat itthat the nurse is licensed and competent to treat itNursing diagnosis provide the basis for selection of Nursing diagnosis provide the basis for selection of nursing interventions to achieve outcomes for which nursing interventions to achieve outcomes for which the nurse is accountablethe nurse is accountable

Sources of diagnostic errorSources of diagnostic error

Collecting: Collecting: lack of knowledge or skill, inaccurate data, lack of knowledge or skill, inaccurate data, missing data, disorganizationmissing data, disorganization

Interpreting: Interpreting: inaccurate interpretation of cues, failure to inaccurate interpretation of cues, failure to consider conflicting cues, using unreliable or invalid data, faiconsider conflicting cues, using unreliable or invalid data, failure lure to consider cultural influences or dev. stageto consider cultural influences or dev. stage

Clustering: Clustering: insufficient cluster of cues, premature or early insufficient cluster of cues, premature or early closure, incorrect clusteringclosure, incorrect clustering

Labeling: Labeling: wrong diagnostic label selected, condition is wrong diagnostic label selected, condition is collaborative problem, failure to validate nursing diagnosis witcollaborative problem, failure to validate nursing diagnosis with h client, failure to seek guidanceclient, failure to seek guidance

Avoiding diagnostic errorsAvoiding diagnostic errorsIdentify clientIdentify client’’s response to illnesss response to illnessState NANDA diagnostic statementState NANDA diagnostic statementIdentify an etiology treatable by nursingIdentify an etiology treatable by nursingIdentify a client need associated with a treatment or testIdentify a client need associated with a treatment or testIdentify clientIdentify client’’s response to equipments response to equipmentIdentify clientIdentify client’’s not nurses not nurse’’s problems problemIdentify clientIdentify client’’s problem not interventionss problem not interventionsIdentify clientIdentify client’’s problem not goalss problem not goalsAvoid prejudicial statementsAvoid prejudicial statementsState the etiology legallyState the etiology legallyIdentify a problem and an etiologyIdentify a problem and an etiologyIdentify only one client problem in a diagnostic statementIdentify only one client problem in a diagnostic statement

Planning for Nursing CarePlanning for Nursing Care

The nursing assessment and the formulations of The nursing assessment and the formulations of nursing diagnoses are essential to the planning stepnursing diagnoses are essential to the planning stepPlanning is a category of nursing behaviors in which the Planning is a category of nursing behaviors in which the clientclient--centered goals and expected outcomes are centered goals and expected outcomes are established and nursing interventions are selected to established and nursing interventions are selected to achieve the goals and outcomes of careachieve the goals and outcomes of careDuring planning, priorities are set, in order to help the During planning, priorities are set, in order to help the nurse anticipate and sequence nursing interventions nurse anticipate and sequence nursing interventions when client has multiple problemswhen client has multiple problems

Establishing prioritiesEstablishing priorities

Priority selection is the method the nurse and the client use toPriority selection is the method the nurse and the client use tomutually rank the diagnoses in order of importance based on the mutually rank the diagnoses in order of importance based on the clientclient’’s desires, needs, and safety. For example: s desires, needs, and safety. For example: MaslowMaslow’’sshierarchy of needshierarchy of needsPriorities are classified as high, intermediate, or low, depend Priorities are classified as high, intermediate, or low, depend on on the urgency of the problem, the nature of the treatment the urgency of the problem, the nature of the treatment indicated, and the interactions among the nursing diagnosesindicated, and the interactions among the nursing diagnosesHigh priority: if the nursing diagnoses were untreated, it couldHigh priority: if the nursing diagnoses were untreated, it couldresult in harm to the client or others (include both physiologicresult in harm to the client or others (include both physiological al and psychological dimensions)and psychological dimensions)Intermediate priority: involve the nonIntermediate priority: involve the non--emergent, nonemergent, non--life life threatening needs of clientthreatening needs of clientLow priority: client needs that may not be directly related to aLow priority: client needs that may not be directly related to aspecific illness or prognosisspecific illness or prognosis

Establishing Goals and Expected OutcomesEstablishing Goals and Expected Outcomes

Before delivering any form of nursing care, the nurse Before delivering any form of nursing care, the nurse must decide what the end point of nursing care should must decide what the end point of nursing care should be for the clientbe for the clientIt requires that the nurse critically evaluate the preIt requires that the nurse critically evaluate the pre--established priority diagnoses, the urgency of the established priority diagnoses, the urgency of the problems, and the resources of the client and the health problems, and the resources of the client and the health care delivery systemcare delivery systemGoals and expected outcomes are specific statements Goals and expected outcomes are specific statements used to indicate anticipated client behavior or responses used to indicate anticipated client behavior or responses from nursing carefrom nursing careThe purposes: to provide direction for individualized The purposes: to provide direction for individualized nursing interventions and to set standard of nursing interventions and to set standard of determining the effectiveness of the interventionsdetermining the effectiveness of the interventions

Goals of careGoals of care

A clientA client--centered goal: a specific, measurable objective centered goal: a specific, measurable objective designed to reflect the clientdesigned to reflect the client’’s highest possible level of s highest possible level of wellness and independence in function.wellness and independence in function.It require active involvement by the clientIt require active involvement by the clientGoals should be realistic and based on client needs and Goals should be realistic and based on client needs and resourcesresourcesShortShort--term and longterm and long--term goal could be developed term goal could be developed depend on the nature of the clientdepend on the nature of the client’’s need/problem and s need/problem and the nature of the nursing services providedthe nature of the nursing services provided

Expected outcomesExpected outcomesIt is the specific, stepIt is the specific, step--byby--step objective that leads to attainment step objective that leads to attainment of the goal and the resolution of the etiology for the nursing of the goal and the resolution of the etiology for the nursing diagnosisdiagnosisAn outcome is a measurable change of the clientAn outcome is a measurable change of the client’’s status in s status in response to nursing careresponse to nursing careOutcomes are the desired responses of clientOutcomes are the desired responses of client’’s condition in s condition in physiological, social, emotional, developmental or spiritual physiological, social, emotional, developmental or spiritual dimensionsdimensionsThis change in condition is documented through observable or This change in condition is documented through observable or measurable client responsesmeasurable client responsesThe expected outcomes determine when a specific , clientThe expected outcomes determine when a specific , client--centered goals has been met and later assist in evaluating the centered goals has been met and later assist in evaluating the response to nursing care and resolution of the nursing diagnosisresponse to nursing care and resolution of the nursing diagnosis

Guidelines for writing goals and Guidelines for writing goals and expected outcomeexpected outcome

ClientClient--centered factorscentered factorsSingular factorsSingular factorsObservable factorsObservable factorsMeasurable factorsMeasurable factorsTimeTime--limited factorslimited factorsMutual factorsMutual factorsRealistic factorsRealistic factors

NDxNDx: : Altered peripheral tissue perfusion Altered peripheral tissue perfusion related to postoperative venous status and risk related to postoperative venous status and risk for for thrombophlebitisthrombophlebitisGoalsGoals: : client will maintain adequate tissue client will maintain adequate tissue perfusion by dischargeperfusion by dischargeExpected outcomes:Expected outcomes:--

client will perform active range of motion exercises client will perform active range of motion exercises

every 2 hours while restricted to bedevery 2 hours while restricted to bed--

clientclient’’s toes remain warm, dry with capillary refill of s toes remain warm, dry with capillary refill of <<

2 seconds2 seconds--

client increases ambulation by 15 meters every dayclient increases ambulation by 15 meters every day

Nursing InterventionsNursing InterventionsTypes of interventions:Types of interventions:--

nursenurse--initiated interventionsinitiated interventions

--

physicianphysician--initiated interventionsinitiated interventions--

collaborative interventionscollaborative interventions

Choosing nursing interventions based on: Choosing nursing interventions based on: 1)1)

Characteristic of nursing diagnoses, Characteristic of nursing diagnoses, 2)2)

expected outcome, expected outcome, 3)3)

research base,research base,4)4)

feasibility, feasibility, 5)5)

acceptability to the client,acceptability to the client,6)6)

competencies of the nursecompetencies of the nurse

Planning nursing carePlanning nursing care

Care plans in various setting:Care plans in various setting:--

institutional care plansinstitutional care plans

--

computerized care planscomputerized care plans--

student care plansstudent care plans

--

care plans for communitycare plans for community--based settingsbased settings--

critical pathways to develop integrated care critical pathways to develop integrated care

plans for clientsplans for clients

Writing the nursing care planWriting the nursing care plan

What is the intervention?What is the intervention?When should the intervention be implemented?When should the intervention be implemented?How should the intervention be performed?How should the intervention be performed?Who should be involved in each aspect of Who should be involved in each aspect of intervention?intervention?

See table 16.5See table 16.5

Implementation processImplementation processReassessing the clientReassessing the clientReviewing and revising the existing nursing care Reviewing and revising the existing nursing care planplanOrganizing resources and care delivery Organizing resources and care delivery (personnel, equipment, environment, client, (personnel, equipment, environment, client, anticipating and preventing complications), anticipating and preventing complications), identifying areas of assistance)identifying areas of assistance)Implementing nursing interventions (cognitive, Implementing nursing interventions (cognitive, interpersonal, psychomotor skills)interpersonal, psychomotor skills)

Implementation methodsImplementation methods

Assisting with daily living activitiesAssisting with daily living activitiesCounselingCounselingTeaching Teaching Providing direct nursing careProviding direct nursing careCompensation for adverse reactionsCompensation for adverse reactionsDelegating, supervising and evaluating the work Delegating, supervising and evaluating the work of other staff membersof other staff members

EvaluationEvaluation

It is important to evaluate each client according to the It is important to evaluate each client according to the level of wellness or recovery level of wellness or recovery The nurse evaluates whether the clientThe nurse evaluates whether the client’’s behaviors or s behaviors or responses reflect a reversal or improvement in a responses reflect a reversal or improvement in a nursing diagnosis or in maintenance of a healthy statenursing diagnosis or in maintenance of a healthy stateIt measures the clientIt measures the client’’s response to nursing actions and s response to nursing actions and the clientthe client’’s progress toward achieving goalss progress toward achieving goalsData are collected on an ongoing basis to measure Data are collected on an ongoing basis to measure changes in functioning, in daily living, and in availability changes in functioning, in daily living, and in availability or use of external resourcesor use of external resources

Evaluation of goal attainmentEvaluation of goal attainment

The purpose of nursing care is to assist the The purpose of nursing care is to assist the client in resolving the actual health problems, client in resolving the actual health problems, preventing the occurrence of potential preventing the occurrence of potential problems, and maintaining a healthy state. problems, and maintaining a healthy state. Evaluation of the goals of care determines Evaluation of the goals of care determines whether this purpose was accomplished.whether this purpose was accomplished.The nurse matches the clientThe nurse matches the client’’s behavior pr s behavior pr physiological response with the behavior or physiological response with the behavior or response specified in the goalresponse specified in the goal

Steps to evaluate Steps to evaluate

Examine the goal statement to identify the exact Examine the goal statement to identify the exact desired client behavior or responsedesired client behavior or responseAssess the client for presence of the behavior or Assess the client for presence of the behavior or responseresponseCompare the established outcome criteria with the Compare the established outcome criteria with the behavior or responsebehavior or responseJudge the degree of agreement between outcome Judge the degree of agreement between outcome criteria and the behavior or responsecriteria and the behavior or responseIf there is no agreement between the outcome criteria If there is no agreement between the outcome criteria and the behavior or response, what is/are the barriers? and the behavior or response, what is/are the barriers? Why did they not agree?Why did they not agree?

The degrees of goal attainment:The degrees of goal attainment:--

if the clientif the client’’s response matches or exceeds the s response matches or exceeds the

outcome criteria, the goal is metoutcome criteria, the goal is met--

if the clientif the client’’s behavior begins to show changes but s behavior begins to show changes but

does not yet meet the criteria, the goal is partially metdoes not yet meet the criteria, the goal is partially met--

if there is no progress, the goal is not metif there is no progress, the goal is not met

Discontinuing a care planDiscontinuing a care planModifying a care planModifying a care plan

ReferencesReferencesCraven, F.R. & Craven, F.R. & HirnleHirnle, J.C. (2007). , J.C. (2007). Fundamentals of Nursing: Fundamentals of Nursing: Human Health & FunctionHuman Health & Function. 5th Ed. Philadelphia: . 5th Ed. Philadelphia: LippincottLippincott, , Williams & Wilkins.Williams & Wilkins.Crisp, J. & Taylor, C. (2001). Crisp, J. & Taylor, C. (2001). Potter & PerryPotter & Perry’’s Fundamentals of s Fundamentals of NursingNursing, Sidney: , Sidney: MosbyMosby..KozierKozier, B., , B., ErbErb, , G.,BermanG.,Berman, A.J., & Snyder. (2004). , A.J., & Snyder. (2004). Fundamentals of Nursing: Concepts, Process, and Practice. 7th EdFundamentals of Nursing: Concepts, Process, and Practice. 7th Ed.. New New Jersey: Pearson Education, Inc.Jersey: Pearson Education, Inc.Mc Farland, G.K. & Mc Farlane, E.A. (1997). Mc Farland, G.K. & Mc Farlane, E.A. (1997). Nursing Diagnosis Nursing Diagnosis & Intervention: Planning for Patient Care. 3rd Ed.& Intervention: Planning for Patient Care. 3rd Ed. St. Louis: St. Louis: MosbyMosby..Potter, P.A. & Potter, P.A. & Perry,A.GPerry,A.G. (1997). . (1997). Fundamentals of Nursing: Fundamentals of Nursing: Concepts, Process, and Practice. 4th Ed. Concepts, Process, and Practice. 4th Ed. St. Louis: St. Louis: MosbyMosby. . Rubenfeld, M.G. & Scheffer, B.K. (1999). Rubenfeld, M.G. & Scheffer, B.K. (1999). Critical Thinking in Critical Thinking in Nursing: An Alternative Approach, 2nd Ed.Nursing: An Alternative Approach, 2nd Ed. Philadelphia: Philadelphia: LippincottLippincott....StonnerStonner, M.S. (1999). , M.S. (1999). Critical Thinking Activities for NursingCritical Thinking Activities for Nursing, , Philadelphia: Philadelphia: LippincottLippincott..