nursing process application1

8/10/2019 Nursing Process Application1

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The nursing process is oftendefined as the application ofcritical thinking to client careactivities .

NURSING PROCESS

APPLICATION


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The purpose of the nursing process is to

provide care for clients that is individualized,

holistic, effective, and efficient.

It directs nursing activities for healthpromotion, health protection, and diseaseprevention and is used by nurses in everypractice setting and specialty. The nursingprocess provides the basis for criticalthinking in nursing


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Thinking Ways

Ritual.

Random.

Appreciative.

Critical.


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RITUAL THINKING

Underlies the development of habits

actions we perform so often, that we do

them automatically, without conscious

decisions.


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RANDOM THINKING

Is the free association of ideas at the

unconscious level that can lead to

impulsive implementation of the first

problem solving solution.


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APPROCIATIVE

THINKING Reflects awareness of human values and

respect for clients individual needs.


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CRITICAL THINKING

Is based on the scientific method i.e.

deliberate and systemic use of rational

informed thought process in problem

finding and problem solving.


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STEPS OF NURSING

PROCESSNursing process involves five steps which

include assessment, nursing diagnosis,

planning, implementation and evaluation.


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ASSESSMENT

Is the first phase in the nursing process and

has two sub phases which include data

collection and data analysis or synthesis.


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Assessment consist of the systematic and

orderly collections and analysis of data about

the health status of the patient to making the

nursing diagnosis.

Incorrect or insufficiency assessment leading

to false diagnosis.


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ASSESSMENT

GUIDLINES Biographical data.

Health historyincluding family

members. Subjective and

objective data (physical exam,medical diagnosis,medical problem,diagnostic studiesresult.)

Social, cultural andenvironmentaldata.

Behaviours riskslead to potentialproblem.

Traditionallynursing usedmedicalassessmentframework for thecollection &organization ofdata.


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Subjective Data

Subjective data are data from the clients point ofview and include feelings, perceptions, andconcerns. The method of collecting subjectiveinformation is primarily the interview. Using

therapeutic interviewing techniques, the nursecollects data that will begin to build the clientdatabase. Examples of subjective informationinclude such statements as:

I drink only coffee for breakfast.

I have had pains in my legs for three days now.

I go to sleep easily each night, but I wake up abouttwo hours later and cannot go back to sleep until itis time to get up in the morning.


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Objective Data

Objective data are observable andmeasurable data that are obtained throughboth standard assessment techniques

performed during the physical examinationand diagnostic tests. The primary methodof collecting objective information is thephysical examination, which providesinformation about the function of body

systems.


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Examples of objective

information include:

T 98.6F, P 100, R 12, B/P 130/76

Bowel sounds auscultated in all fourquadrants

Gait slow, shuffling, and unsteady

This objective information may add to orvalidate subjective information. Validationis a critical step in data collection to avoidomissions, prevent misunderstandings, and

avoid incorrect inferences andconclusions.


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Diagnosis

The second step in the nursing processinvolves further analysis (breaking thewhole down into parts that can beexamined) and synthesis (putting datatogether in a new way) of the data thathave been collected. Formulation of the

list of nursing diagnoses is the outcome ofthis process. According to the NorthAmerican Nursing Diagnosis Association(NANDA) a nursing diagnosis is a clinicaljudgment about individual, family, or

community responses to actual orpotential health problems/life processes.Nursing diagnoses provide the basis forselection of nursing interventions toachieve outcomes for which the nurse isaccountable.


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The nurse uses critical-thinking and decision-makingskills in developing nursing diagnoses. This process isfacilitated by asking questions such as:

Are there problems here?

If so, what are the specific problems?

What are some possible causes for the problems?

Is there a situation involving risk factors?

What are the risk factors?

Is there a situation in which a problem can develop if

preventive measures are not taken?Has the client indicated a desire for a higher level of

wellness in a particular area of function?

What are the clients strengths?

What data are available to answer these questions?

Are more data needed to answer the question?If so, what are some possible sources of the data that

are needed?


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Comparison of Medical Diagnoses

and Nursing Diagnoses


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Types of Nursing

Diagnoses


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Outcome Identification

and Planning

Planning is the third step of the nursing

process and includes the formulation of

guidelines that establish the proposed

course of nursing action in the resolutionof nursing diagnoses and the development

of the client's plan of care.


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The planning phase involves several

tasks:

The list of nursing diagnoses is

prioritized.

Client-centered long- and short-term

goals and outcomes are identified andwritten.

Specific interventions are developed.

The entire plan of care is recorded in

the clients record.


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Expected outcomes are specific objectives related to thegoals and are used to evaluate the nursinginterventions.

They must be measurable, have a time limit, and berealistic. Once goals and expected outcomes havebeen established, nursing interventions are plannedthat enable the client to reach the goals.

Consider, for example, two outcomes:

The patients shortness of breath will improve.

The patient will be less short of breath within 15minutes

as evidenced by patient rating the shortness of breath at

less than 3 on a scale of 1 to 10, respiratory ratebetween

16 and 20, and relaxed appearance.


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Establishing Goals

After the priorities of the nursingdiagnoses and expected outcomeshave been established, the

immediate, intermediate, and long-term goals and the nursing actionsappropriate for attaining the goalsare identified. The patient and his or

her family are included inestablishing goals for the nursingactions.


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For example, goals for a patient with diabetesand a nursing diagnosis of deficientknowledge related to the prescribed diet may

be stated as follows: Immediate goal: Demonstrates oral intake

and tolerance of 1500-calorie diabetic dietspaced in three meals and one snack per day.

Intermediate goal: Plans meals for 1 week

based on diabetic exchange list. Long-term goal: Adheres to prescribed

diabetic diet.


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IMPLEMENT TION

The fourth step in the nursing process isimplementation.

Implementation involves the execution of thenursing

plan of care derived during the planningphase.When implementing the plan of care, theactions listed as interventions areperformed. The patients response to

each intervention is noted and documented.This documentation provides the basis forevaluation and revision of the plan of care.


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The plan of nursing care serves as the basis forimplementation:

The immediate, intermediate, and long-termgoals are used as a focus for the

implementation of the designated nursinginterventions.

While implementing nursing care, the nursecontinually assesses the patient and his orher response to the nursing care.

Revisions are made in the plan of care as thepatients condition, problems, and responseschange and when reassignment of prioritiesis required.

Implementation includes direct or indirect

execution of theplanned interventions. It is focused on resolvingthe patients nursing diagnoses andcollaborative problems and achievingexpected outcomes, thus meeting the

patients health needs.


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BASIC CONCEPTS IN NURSING PRACTICE


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Evaluation

Evaluation, the final step of the nursing

process, allows the nurse to determine the

patients response to the nursing

interventions and the extent to which the

objectives have been achieved.


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Through evaluation, the nurse can answer the followingquestions:

Were the nursing diagnoses and collaborative problems

accurate?

Did the patient achieve the expected outcomes withinthe

critical time periods?

Have the patients nursing diagnoses been resolved?

Have the collaborative problems been resolved?

Have the patients nursing needs been met?

Should the nursing interventions be continued, revised,or discontinued?

Have new problems evolved for which nursinginterventions

have not been planned or implemented?

What factors influenced the achievement or lack ofachievement

of the objectives?

Do priorities need to be reassigned?

Should changes be made in the expected outcomes andoutcome criteria?


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nursing process application1

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