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THE NURSING PROCESS

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THE NURSING PROCESS
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THE NURSING PROCESS

  1. 1. ROMMEL LUIS C. ISRAEL III THE NURSING PROCESS
  2. 2. ROMMEL LUIS C. ISRAEL III NURSING PROCESS • It is the cornerstone of the nursing profession • It is essential for the clinical application of knowledge and theory in nursing practice • Synonymous with Problem-solving approach for discussing the health care and nursing care needs of clients
  3. 3. ROMMEL LUIS C. ISRAEL III EVOLUTION • THREE-STEP PROCESS 1. Note observation 2. Administration of care 3. Validation, etc. • FOUR-STEP PROCESS - APIE (Assessment, Planning, Intervention, Evaluation)
  4. 4. ROMMEL LUIS C. ISRAEL III EVOLUTION • FIVE-STEP PROCESS - ADPIE (Assessment, Diagnosis, Planning, Intervention, Evaluation) • SIX-STEP PROCESS - ADOPIE (Assessment, Diagnosis, Outcome Identification, Planning, Intervention, Evaluation)
  5. 5. ROMMEL LUIS C. ISRAEL III THEORISTS ON NURSING PROCESS • LYDIA HALL - She originated the term “nursing process” in 1955 - introduced the 3 steps: a. Note observation b. Administration of care c. Validation
  6. 6. ROMMEL LUIS C. ISRAEL III THEORISTS ON NURSING PROCESS • DOROTHY JOHNSON - She also introduced 3 steps (1959): a. Assessment b. Decision c. Nursing Action
  7. 7. ROMMEL LUIS C. ISRAEL III THEORISTS ON NURSING PROCESS • IDA JEAN ORLANDO - She identified 3 steps (1961): a. Client’s behavior b. Nurse’s reaction c. Nurse’s actions
  8. 8. ROMMEL LUIS C. ISRAEL III THEORISTS ON NURSING PROCESS • YURA AND WALSH - Suggested components (1967): a. Assessing b. Planning c. Intervention d. Evaluation
  9. 9. ROMMEL LUIS C. ISRAEL III THEORISTS ON NURSING PROCESS • KNOWLES - Described nursing process as (1967): a. Discover b. Delve c. Decide d. Do e. Discriminate
  10. 10. ROMMEL LUIS C. ISRAEL III AMERICAN NURSES ASSOCIATION The ANA introduced innovations in the nursing process: • Diagnosis distinguished as separate step of nursing process (1973) • Diagnosis of actual and potential health problems delineated as integral part of the nursing practice (1980)
  11. 11. ROMMEL LUIS C. ISRAEL III AMERICAN NURSES ASSOCIATION The ANA introduced innovations in the nursing process: • Outcome Identification differentiated as a distinct step of the nursing process. The six steps came out (1991): - ADOPIE
  12. 12. ROMMEL LUIS C. ISRAEL III CHARACTERISTICS • ORGANIZED AND SYSTEMATIC - composed of six sequential and integrated steps • HUMANISTIC - The plan of care is developed and implemented with great consideration to the unique needs and concerns of the individual client (individualized; involves aspects of human dignity)
  13. 13. ROMMEL LUIS C. ISRAEL III CHARACTERISTICS • EFFICIENT - Relevant to the need of the client - Promotes client satisfaction and progress • EFFECTIVE - It utilizes resources wisely in terms of human, time, cost resources • GOAL ORIENTED
  14. 14. ROMMEL LUIS C. ISRAEL III CHARACTERISTICS • PROBLEM ORIENTED • Open to accepting new information during its application - flexible to meet client’s needs • Interpersonal (requires the nurse to communicate directly with the client) • Permits creativity among nurses and clients in devising ways to solve the health problems
  15. 15. ROMMEL LUIS C. ISRAEL III CHARACTERISTICS • Cyclycal- interrelated steps • Universal – applicable to individual, family, and community
  16. 16. ROMMEL LUIS C. ISRAEL III THE NURSING PROCESS PHASES: Individual Family Community Evaluation Diagnosis Assessment Implementation Outcome ID Planning
  17. 17. ROMMEL LUIS C. ISRAEL III ASSESSMENT • collecting, validating, organizing, and recording data about the client’s (individual, family, community) health status - Purpose: > to establish a data base
  18. 18. ROMMEL LUIS C. ISRAEL III ASSESSMENT ACTIVITIES: 1. Collection of data - gathering of information about the client - consider the physical, psychological, emotional, socio-cultural and spiritual factors that may affect his status 2. Verifying/validating data - accurate data 3. Organizing data – clustering facts
  19. 19. ROMMEL LUIS C. ISRAEL III ASSESSMENT TYPES OF DATA 1. Subjective data (symptoms) - those that can be described only by the person experiencing it ex: vertigo, pain, tinnitus 2. Objective data (signs) - those that can be observed and measured ex: pallor, diaphoresis
  20. 20. ROMMEL LUIS C. ISRAEL III ASSESSMENT METHODS OF DATA COLLECTION 1. Interview - planned purposeful conversation 2. Observation - use of senses
  21. 21. ROMMEL LUIS C. ISRAEL III ASSESSMENT SOURCES OF DATA 1. Primary - patient/client 2. Secondary - Family members, significant others, patient’s record/chart, health care team members, related literature
  22. 22. ROMMEL LUIS C. ISRAEL III DIAGNOSIS • Diagnosing is the clinical act of identifying problems to analyze assessment information and derive meaning from this analysis • Purpose: - to identify the client’s health care needs and to prepare diagnostic statements
  23. 23. ROMMEL LUIS C. ISRAEL III DIAGNOSIS NURSING DIAGNOSIS - a statement of client’s potential or actual alteration of health status - Format: Problem Problem Related Factors Etiology Signs & Symptoms Signs & Symptoms
  24. 24. ROMMEL LUIS C. ISRAEL III DIAGNOSIS ACTIVITIES: 1. Organize cluster or group data 2. Compare data against standards (compare to normal) 3. Analyze data after comparing with standards 4. Identify gaps and inconsistencies in data
  25. 25. ROMMEL LUIS C. ISRAEL III DIAGNOSIS ACTIVITIES: 5. Determine the client’s health rpoblems, health risks and strengths 6. Formulate nursing diagnosis statements Ex: Ineffective airway clearance related to tracheobronchial infection as manifested by weak cough,adventitious breath sounds, and copius
  26. 26. ROMMEL LUIS C. ISRAEL III DIAGNOSIS CLASSIFICATION OF NURSING DIAGNOSIS: 1. HIGH – those that are potentially life- threatening and require immediate action ex: Impaired gas exchange 2. MEDIUM – those that could result in unhealthy consequences such as physical or emotional impairment, but are not life threatening ex: Fatigue, activity intolerance, ineffective coping
  27. 27. ROMMEL LUIS C. ISRAEL III DIAGNOSIS CLASSIFICATION OF NURSING DIAGNOSIS: 3. LOW – it involves problems that usually can be resolved easily with minimal interventions and are unlikely to cause significant dysfunction ex: Hunger in client on NPO Minimal pain on the third day post-op
  28. 28. ROMMEL LUIS C. ISRAEL III OUTCOME IDENTIFICATION • Refers to formulating and documenting measurable, realistic, client-focused goals. • It provides the basis for evaluating nursing diagnosis
  29. 29. ROMMEL LUIS C. ISRAEL III OUTCOME IDENTIFICATION PURPOSES: 1. To provide individualized care 2. To promote client participation 3. To plan care that is realistic and measurable 4. To allow involvement of support people
  30. 30. ROMMEL LUIS C. ISRAEL III OUTCOME IDENTIFICATION ACTIVITIES: 1. Establish priorities 2. Establish client’s goal and outcome criteria
  31. 31. ROMMEL LUIS C. ISRAEL III OUTCOME IDENTIFICATION PRIORITY -is something that takes precedence in position, deemed the most important among several items PRIORITY SETTING is a decision-making process that ranks the order nursing diagnosis in terms of importance to the client
  32. 32. ROMMEL LUIS C. ISRAEL III OUTCOME IDENTIFICATION Factors to consider in establishing priorities: 1. Life-threatening situation should be given the highest priority example: DOB, hemmorhage, suicidal tendencies 2. Principle of ABC’s (1st: Airway, 2nd Breathing, 3rd Circulation)
  33. 33. ROMMEL LUIS C. ISRAEL III OUTCOME IDENTIFICATION Factors to consider in establishing priorities: 3. Maslow’s Hierarchy of needs - physiological needs given priority over psychosocial 4. Consideration of things that are very important to the client - example: pain, anxiety
  34. 34. ROMMEL LUIS C. ISRAEL III OUTCOME IDENTIFICATION Factors to consider in establishing priorities: 5. Clients with unstable conditions should be given priority over those with stable condition 6. Consideration of the amount of time, materials, equipment required to care for clients Example: Post-op dressing before health teaching of patients for discharge
  35. 35. ROMMEL LUIS C. ISRAEL III OUTCOME IDENTIFICATION Factors to consider in establishing priorities: 7. Actual problems take precedence over potential problems 8. Attend to the client before equipment. example: Assess the client first before checking contraptions
  36. 36. ROMMEL LUIS C. ISRAEL III OUTCOME IDENTIFICATION CLIENT’S GOAL AND OUTCOME CRITERIA CLIENT GOAL- an educated guess, made as a “broad statement” about what the client’s state will be after the nursing intervention is carried out.
  37. 37. ROMMEL LUIS C. ISRAEL III OUTCOME IDENTIFICATION 2 TYPES OF GOAL 1. Short-term goal - can be met in a relatively short period (within days or less than a week) 2. Long-term goal - requires more time (several weeks or months)
  38. 38. ROMMEL LUIS C. ISRAEL III OUTCOME IDENTIFICATION OUTCOME CRITERIA - Are specific, measurable, realistic statements of goal attainment, written in a manner that answers the questions: a. Who? b. What actions? c. Under what circumstances? d. How well? e. When?
  39. 39. ROMMEL LUIS C. ISRAEL III OUTCOME IDENTIFICATION CHARACTERISTICS OF OUTCOME CRITERIA: Specific Measurable Attainable Realistic Time-framed
  40. 40. ROMMEL LUIS C. ISRAEL III OUTCOME IDENTIFICATION EXAMPLES OF GOALS AND OUTCOME CRITERIA GOAL: The client will report a decreased anxiety level regarding surgery. POSSIBLE OUTCOME CRITERIA: During client teaching, the client discusses fears and concerns regarding surgical procedure. After client teaching, the client realizes decrease anxiety, etc.
  41. 41. ROMMEL LUIS C. ISRAEL III OUTCOME IDENTIFICATION EXAMPLES OF GOALS AND OUTCOME CRITERIA GOAL: The client will mobilize pulmonary secretions. POSSIBLE OUTCOME CRITERIA: After the teaching session, the client demonstrates proper coughing techniques. The client drinks at least six glasses of
  42. 42. ROMMEL LUIS C. ISRAEL III PLANNING • Involves determining beforehand the strategies or course of actions to be taken before implementation of nursing care. • To be effective, involve the client and his family in planning.
  43. 43. ROMMEL LUIS C. ISRAEL III PLANNING PURPOSES: 1. To identify the client’s goal and appropriate nursing interventions 2. To direct client care activities 3. To promote continuity of care 4. To focus charting requirements 5. To allow for delegation of specific activities
  44. 44. ROMMEL LUIS C. ISRAEL III PLANNING WHY PLAN FOR NURSING INTERVENTIONS? “To direct activities to be carried out in the implementation phase”
  45. 45. ROMMEL LUIS C. ISRAEL III PLANNING WHAT IS A NURSING PLAN OF CARE? • It is a written summary of care that the client is to receive • The “Blue Print” of the nursing process • Nursing-centered. Focuses on the treatment of human responses to actual or potential health problems. • It is a step-by-step process
  46. 46. ROMMEL LUIS C. ISRAEL III PLANNING CONSIDERATIONS FOR THE NURSING PLAN OF CARE: 1. Sufficient data to substantiate nursing diagnosis 2. One goal must be stated for each nursing diagnosis 3. Nursing interventions must specially designed to meet the identified goal
  47. 47. ROMMEL LUIS C. ISRAEL III PLANNING CONSIDERATIONS FOR THE NURSING PLAN OF CARE: 4. Outcome criteria must be identified for each goal. 5. Each intervention should be supported by a scientific rationale (justification for carrying out the interventions) 6. Explanation must address whether each goal was completely met, partially met, or completely unmet.
  48. 48. ROMMEL LUIS C. ISRAEL III IMPLEMENTATION • Putting the nursing care plan into action • Purpose: - to carry out planned nursing intervention to help the client attain goal s and achieve optimal level of health.
  49. 49. ROMMEL LUIS C. ISRAEL III IMPLEMENTATION ACTIVITIES: 1. Re-assessing – to ensure prompt attention to emerging problems 2. Set priorities – to determine the order in which nursing interventions are carried out 3. Perform nursing interventions – independent, dependent, or collaborative 4. Record actions – relevant documentation
  50. 50. ROMMEL LUIS C. ISRAEL III IMPLEMENTATION REQUIREMENTS: 1. Knowledge – includes intellectual skills like problem-solving and decision-making. 2. Technical skills – To carry out treatments and procedures 3. Communication skills – use of verbal and non-verbal communication 4. Therapeutic use of self – being willing and being able to care
  51. 51. ROMMEL LUIS C. ISRAEL III EVALUATION • It is assessing the client’s response to nursing interventions and then comparing the response to predetermined standards or outcome criteria • Purpose: - To appraise the extent to which goals and outcome criteria of nursing care have been achieved.
  52. 52. ROMMEL LUIS C. ISRAEL III EVALUATION ACTIVITIES: 1. Collect data about the client’s response 2. Compare the client’s response to goals and outcome criteria 3. The 4 possible judgements: a. The goal was completely met b. The goal was partially unmet c. The goal was completely unmet d. New problems or nursing diagnoses have developed
  53. 53. ROMMEL LUIS C. ISRAEL III EVALUATION ACTIVITIES: 4. Analyze the reasons for the outcomes 5. Modify plan as needed.
  54. 54. ROMMEL LUIS C. ISRAEL III BENEFITS OF THE NURSING PROCESS TO THE CLIENT: • Quality client care – it meets standards of care • Continuity of care • Participation by the clients in their health care
  55. 55. ROMMEL LUIS C. ISRAEL III BENEFITS OF THE NURSING PROCESS TO THE NURSE: • Consistent and systematic nursing education • Job satisfaction • Professional growth • Avoidance of legal action • Meeting professional nursing standards • Meeting standards of accredited hospitals

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