Definition
It is a systematic method of assessing the health status, diagnosis health care needs, formulating a plan of care, initiating the plan and evaluating the effectiveness of the plan.
Purpose of Nursing Process
- To help the patient to maintain health.
- To protect client from illness.
- To identify client's health status.
- To identify client's actual and potential health problem.
- To determine priorities.
- To make a plan for the needs.
- To promote highest level of health.
Steps of Nursing Process
1. Assessment - Assessment refers to the collection and interpretation of clinical information. It focuses on gathering the data about a client's state of wellness, functional ability, physical status, strengths, responses and potential health problems.
2. Nursing diagnosis - It is a summary statement of the cause or basic of identifying problem. The specification of the cause is very important in diagnosis.
3. Planning - Planning is the voluntary systemic phase which allows to make a decision and to solve the problems.
4. Implementation - According to campbell, " A nursing intervention is a single action, treatment, procedure or activity."
5. Evaluation - Evaluation is the continuous process in which nurse assess and reassess the programme. Patients have made towards reaching the pre-established goals.
Definition of Assessment
Assessment refers to the collection and interpretation of clinical information. It focuses on gathering the data about a client's state of wellness, functional ability, physical status, strengths, responses and potential health problems.
Purpose of Assessment
- To gather information regarding client's health.
- To determine client's normal health.
- To organize the collected information.
- To enhance investigation of nursing problem.
- To increase greater managing skill of handling patient's problem.
- To identify the health problems.
- To identify need for health teaching.
Types of Assessment
1. Initial assessment -
• It is the assessment done within admission time to a health care agency.• This assessment is done as soon as client comes to hospital and it is very comprehensive.
2. Focus Assessment -
• This is daily assessment done by nursing personnel of admitted client.3. Emergency Assessment -
• It is done, if client has sudden physiologic or psychologic crisis.• It helps to identify life threatening problem.
4. Time lapsed Assessment -
• This is done several months / weeks after initial assessment.e.g. Assessment is done as patient comes for follow up.
• This type of assessment is less comprehensive.
Components of Assessment
1. Collected data -
• Data collection refer to the systemic and continuous process of gathering information of a patient's health problems.• Data collection must be systematic and continuous to prevent the omission of significant data.
• Collected data should be relevant to actual or potential health problems.
• Collected data should be descriptive, concise, complete and accurate.
# Types of Data -
A. Subjective Data - It is provided by client himself through interview or in written form.
B. Objective Data - It is obtained by the sense, measuring devices, laboratory studies or family members.
2. Organizing Data -
• In order to obtain data systematically a professional nurse uses an organized assessment treatment.• Many framework are available for the systematic collection and documentation of assessment data.
e.g.- Roy's adaptation model
• Frameworks help to present the omission of pertinent information and enhances data analysis in diagnostic phase.
• These frameworks can be modified based on client's health status.
3. Validating Data -
• It is the process of confirming the the accuracy of assessment data collected, while collecting data nurse gets many cues and inferences.# Validation of collected data can be done by following -
- Recheck the collected data.
- Confirm the subjective through objective.
- Ask some other professional expert to collect the same data.
- Recheck the data which is extremely abnormal.
- Clarify client's statements by sharing observations with client, family members.
- Use references such as text books, journals, research studies to enhance knowledge and skill.
4. Recording Data -
• To complete the assessment phase of nursing process, recording / documentation is very important.• Recording of collected data should be done systematically.
• It can be done either on the assessment record or computerised assessment. Record depending upon hospital policies.
Definition of Nursing Diagnosis
It is a summary statement of the cause or basic of the identifying problem. The specification of the cause is very important in diagnosis.
E.g- Ankle edema due to fracture.
Purpose of Nursing Diagnosis
• To analyse collected data.
• To identify client's normal functional level statement.
• To identify client's strength and weakness.
• To formulate a diagnostic weakness.
NANDA Diagnosis
• NANDA Diagnosis is a list of nursing diagnosis which formed by North American Nursing Diagnosis.
• Now a days NANDA Diagnosis is used everywhere as a standard list.
# Why NANDA Nursing Diagnosis lists are used?
• It has some common terminology which helps the nurses to learn easily and to communicate with each others.
• Using common terminology enhance the use of computer nursing.
• All nurses can work together toward testing and refining the diagnostic categories by identifying assessment criteria and nursing interventions that nurse can use to improve nursing care.
• It is a judgement about a client's response to a health problem that is present at the time of nursing assessment.
E.g- Anxiety related to hospitalization, pain related to surgery.
E.g- An obese client is under gone for hip replacement surgery. As patient is immobile / bed ridden, nurse may diagnose a frame for it.
• High risk to the infection due to hospitalization of patient.
• Risk for the skin integrity impairment due to the surgery.
E.g- Birth of newborn twins.
Diagnosis - Potential for growth related an unexpected birth of twins.
E.g- Rape-trauma syndrome.
• It provides a common language or communication. It helps to understand the problems.
• It provides a means of communicating to other nurses, health care team.
• As nursing diagnosis is framed by nurse and she is licensed to treat it independently. It facilitates development of nurses autonomy.
• It helps the nurses to be accountable for their profession.
• Nursing diagnosis gives direction for planning nursing intervention.
• Nursing diagnosis taxonomy helps to make bridge between knowledge and practice which is very important for developing nurses' professional role in health care.
Planning is the voluntary systemic phase which allows to make a decision and to solve the problems.
A plan of care is developed to direct nursing care activities related to individual for whom the goals end outcome were set.
• Gives direction to client care activities.
• Enhances continuity of care.
• Permit the delegation of specific activities.
1> Setting priorities.
2> Determining the goal or expected outcomes.
3> Selecting the nursing strategies.
4> Developing nursing care plan.
• Priorities are classified as -
a. High priority -
The nursing diagnosis, if not treated may give more harm to the client or others who have high risk priorities.
E.g- Ineffective airway clearance after surgery related to abdominal incision pain.
b. Intermediate priorities -
Nursing diagnosis includes the non emergent, non-life threatening needs of the patient.
E.g- Pain related to surgical procedure.
c. Low priorities -
Low priorities are clients needs which may not be directly related to specific illness or prognosis.
E.g- Deficit knowledge regarding smoking cessation programme.
• Types of goal -
a. Short term goal -
It is an objective that is expected to achieve in a shorter period. Usually less than a week.
b. Long term goal -
Expected to be achieve over a longer period of time. Usually over weeks or months.
• Expected outcomes -
Expected outcomes describe the behaviour of the patient is expected to achieve.
# Rules for formulating the outcomes -
• Outcome should be related to the problem statement.
• Outcome should be reflect the first half of the diagnosis statement.
• Outcome should be client centered.
• Outcome should be summarised and understandable.
• Outcome should be measurable and remarkable.
• Outcome should be time limited.
• It should be realistic.
• It should be determined by the client and nurse together.
Nursing strategies, interventions are the specific approaches designed to assist the client to achieve outcomes.
Types of nursing intervention -
1. Nurse initiated intervention -
These are activities that may be performed by nurse without a direct physicians order.
E.g- Increasing client's knowledge about nutrition related to hygiene.
2. Physician initiated intervention-
Based on physician's response to a medical diagnosis and the nurse completes the physician's written order.
E.g- Administrating medication.
3. Collaborative intervention -
It describes the activities that the nurse carries out in co-operation with other health team members.
# Component of nursing strategies -
• A set of nursing intervention should be written to accomplish each outcome.
• It should be short and understandable to be a effective nursing intervention.
• Nursing intervention should specify who will complete the intervention.
• It should on list what specific activities must be implemented to accomplished the identified outcomes.
• It should define where, when and how often the activities will take place.
• Describe how the activity should be implemented.
4> Developing nursing care plan -
It defined care planning as the process of identifying the problems a patient is experiencing, and selecting appropriate intervention to solve or minimise these problem.
Nursing intervention is the therapeutic nursing care through activities, procedures and treatments.
Reassessment in this phase ensures that planned intervention are still appropriate or not.
Nurse makes the nursing problem based on following factors.
• client's condition.
• New information from reassessment.
• Time and resource available.
• Feedback from client/ family/ health care staff.
• Nurses knowledge and experience in setting priority.
• Helping a client to do some activities by himself.
• Teaching the client about his health care.
• Monitoring the client in making choices about seeking and utilizing appropriate health care resources.
• Monitoring the client for potential complications of illness.
• Performing nursing interventions may vary from simple to complex while performing interventions.
Evaluation is the continuous process in which nurse assess and reassess the programme. Patients have made towards reaching the pre-established goals.
• Collect data for making adjustment about nursing care delivered.
• Determine client's response with pre-determined outcome criteria.
• Appraise / appreciate the involvement of client / family member in health care decision.
• . It assess the co-operation between health care team members and client.
• Assess the mistakes in the plan of nursing care.
• Examine nursing care if it effective or not
• Collect data to assess if there is any new problem.
• Look for all the factor affecting goal attainment described in figure.
• Examine the nursing diagnosis again and rearrange with priorities and additional data.
• Reassess the accuracy and appropriateness of the prompt diagnosis.
• Makes goal realistic, accurate.
• Remove inappropriate and changed data form the nursing diagnosis list.
• Don't forget to involve client / family members / health care team members while providing care.
• Co-operate factors leading to successful attainment of goal.
• Nurse must know the hospital policies, procedure and protocols of intervention and recording etc.
• Nurse must have up to dated knowledge and information of many subjects such as physiology, patho-physiology, bio-chemistry, psychology, sociology, pharmacology.
• It helps her to understand client's response.
• Nurse must have intellectual and technical skill to monitor the effectiveness of nurse interventions.
• Nurse should have enough knowledge and skill for collecting subjective and objective data.
• It examines the accuracy and effectiveness of nursing care plan.
• It assess the nursing care plan goals whether it achieved or not.
• It helps the nurse to discover and identify the errors in the previous steps of Nursing process.
• It helps the nurse to assess the client's behavioural responses to the planned course of action.
• It has some common terminology which helps the nurses to learn easily and to communicate with each others.
• Using common terminology enhance the use of computer nursing.
• All nurses can work together toward testing and refining the diagnostic categories by identifying assessment criteria and nursing interventions that nurse can use to improve nursing care.
Types of Nursing Diagnosis
1. Actual Diagnosis -
• Represents a problem which has many defining characteristics.• It is a judgement about a client's response to a health problem that is present at the time of nursing assessment.
E.g- Anxiety related to hospitalization, pain related to surgery.
2. High risk Diagnosis -
• It describes a potential problem. It means client is prone to develop a problem than other problems if left in similar condition.E.g- An obese client is under gone for hip replacement surgery. As patient is immobile / bed ridden, nurse may diagnose a frame for it.
• High risk to the infection due to hospitalization of patient.
• Risk for the skin integrity impairment due to the surgery.
3. Wellness Diagnosis -
• It refers to the higher level wellness of an individual, family or community from present level of wellness.E.g- Birth of newborn twins.
Diagnosis - Potential for growth related an unexpected birth of twins.
4. Syndrome Diagnosis -
• It is the prediction of high risk to be present due to a particular event of situation.E.g- Rape-trauma syndrome.
Importance of Nursing Diagnosis
• It provides a common language or communication. It helps to understand the problems.
• It provides a means of communicating to other nurses, health care team.
• As nursing diagnosis is framed by nurse and she is licensed to treat it independently. It facilitates development of nurses autonomy.
• It helps the nurses to be accountable for their profession.
• Nursing diagnosis gives direction for planning nursing intervention.
• Nursing diagnosis taxonomy helps to make bridge between knowledge and practice which is very important for developing nurses' professional role in health care.
Definition of Planning
Planning is the voluntary systemic phase which allows to make a decision and to solve the problems.
A plan of care is developed to direct nursing care activities related to individual for whom the goals end outcome were set.
Purpose
• Gives direction to client care activities.
• Enhances continuity of care.
• Permit the delegation of specific activities.
Types of Planning
1. Initial Planning -
• The planning done immediately after initial assessment.2. Ongoing Planning -
• . It is the daily planning based on the current and on going assessment.3. Discharge Planning -
• Planning about the needs which will occur after the discharge of client.Phase of Planning
1> Setting priorities.
2> Determining the goal or expected outcomes.
3> Selecting the nursing strategies.
4> Developing nursing care plan.
1> Setting priorities -
As a decision making process in which nurse approached.• Priorities are classified as -
a. High priority -
The nursing diagnosis, if not treated may give more harm to the client or others who have high risk priorities.
E.g- Ineffective airway clearance after surgery related to abdominal incision pain.
b. Intermediate priorities -
Nursing diagnosis includes the non emergent, non-life threatening needs of the patient.
E.g- Pain related to surgical procedure.
c. Low priorities -
Low priorities are clients needs which may not be directly related to specific illness or prognosis.
E.g- Deficit knowledge regarding smoking cessation programme.
2> Determining goals or expected outcome -
• Types of goal -
a. Short term goal -
It is an objective that is expected to achieve in a shorter period. Usually less than a week.
b. Long term goal -
Expected to be achieve over a longer period of time. Usually over weeks or months.
• Expected outcomes -
Expected outcomes describe the behaviour of the patient is expected to achieve.
# Rules for formulating the outcomes -
• Outcome should be related to the problem statement.
• Outcome should be reflect the first half of the diagnosis statement.
• Outcome should be client centered.
• Outcome should be summarised and understandable.
• Outcome should be measurable and remarkable.
• Outcome should be time limited.
• It should be realistic.
• It should be determined by the client and nurse together.
3> Selecting the nursing strategies -
Nursing strategies, interventions are the specific approaches designed to assist the client to achieve outcomes.
Types of nursing intervention -
1. Nurse initiated intervention -
These are activities that may be performed by nurse without a direct physicians order.
E.g- Increasing client's knowledge about nutrition related to hygiene.
2. Physician initiated intervention-
Based on physician's response to a medical diagnosis and the nurse completes the physician's written order.
E.g- Administrating medication.
3. Collaborative intervention -
It describes the activities that the nurse carries out in co-operation with other health team members.
# Component of nursing strategies -
• A set of nursing intervention should be written to accomplish each outcome.
• It should be short and understandable to be a effective nursing intervention.
• Nursing intervention should specify who will complete the intervention.
• It should on list what specific activities must be implemented to accomplished the identified outcomes.
• It should define where, when and how often the activities will take place.
• Describe how the activity should be implemented.
4> Developing nursing care plan -
It defined care planning as the process of identifying the problems a patient is experiencing, and selecting appropriate intervention to solve or minimise these problem.
Definition of Implementation
Nursing intervention is the therapeutic nursing care through activities, procedures and treatments.
Purpose
- To help the patient to maintaining health.
- To protect client from illness.
- To promote the maximum level of wellness of health from the present health status.
- To provide technical nursing care.
- To provide therapeutic nursing care.
Activities
1. Re-assess -
Whenever nurse meets client, she / he will assess the client's condition which may change quickly.Reassessment in this phase ensures that planned intervention are still appropriate or not.
2. Setting priority -
As client's needs change quickly priorities may also change, priority should be set based on reassessment.Nurse makes the nursing problem based on following factors.
• client's condition.
• New information from reassessment.
• Time and resource available.
• Feedback from client/ family/ health care staff.
• Nurses knowledge and experience in setting priority.
3. Organizing resources -
It is the arrangement of equipment and personnel for providing best nursing care to the client. Preparation of the client as well as environment is important.4. Performing nursing intervention -
• It is direct activity for a client's health.• Helping a client to do some activities by himself.
• Teaching the client about his health care.
• Monitoring the client in making choices about seeking and utilizing appropriate health care resources.
• Monitoring the client for potential complications of illness.
• Performing nursing interventions may vary from simple to complex while performing interventions.
5. Recording -
As soon as nursing intervention are carried out they are recorded in the client's health record.# Implementation skill required for nurses
1. Cognitive skill -
It involves application of nursing knowledge to anticipate and identify client's needs. It includes problem solving, decision making and teaching.2. Interpersonal skill -
It is the ability to work with others to achieve the goal.3. Psychomotor skill -
It needs the combination of cognitive and motor activities.4. Technical skill -
It is the skill which use equipments and machines.Definition of Evaluation
Evaluation is the continuous process in which nurse assess and reassess the programme. Patients have made towards reaching the pre-established goals.
Purpose
• Collect data for making adjustment about nursing care delivered.
• Determine client's response with pre-determined outcome criteria.
• Appraise / appreciate the involvement of client / family member in health care decision.
• . It assess the co-operation between health care team members and client.
• Assess the mistakes in the plan of nursing care.
• Examine nursing care if it effective or not
Activities in the Evaluation Phase
1. Revising the client goal and outcome criteria -
Revising the client goals and outcome of nursing plan is very important of measure the goal. Nurse will judge the attachment of goal by measuring the outcome criteria of planning phase.2. Collecting data -
In this phase subjective and objective data is collected to evaluate the effectiveness and outcome of nursing care.3. Measure goal attainment -
After collecting data nurse forms a picture regarding client's behavioural responses to the pre-determined outcome criteria.4. Revise or modify the nursing plan of care -
• Revision includes complete reassessment of the nursing process.• Collect data to assess if there is any new problem.
• Look for all the factor affecting goal attainment described in figure.
• Examine the nursing diagnosis again and rearrange with priorities and additional data.
• Reassess the accuracy and appropriateness of the prompt diagnosis.
• Makes goal realistic, accurate.
• Remove inappropriate and changed data form the nursing diagnosis list.
• Don't forget to involve client / family members / health care team members while providing care.
• Co-operate factors leading to successful attainment of goal.
Evaluation skill required for Nurses
• Nurse must know the hospital policies, procedure and protocols of intervention and recording etc.
• Nurse must have up to dated knowledge and information of many subjects such as physiology, patho-physiology, bio-chemistry, psychology, sociology, pharmacology.
• It helps her to understand client's response.
• Nurse must have intellectual and technical skill to monitor the effectiveness of nurse interventions.
• Nurse should have enough knowledge and skill for collecting subjective and objective data.
# Why nurse should do the evaluation in Nursing process ?
• It examines the accuracy and effectiveness of nursing care plan.
• It assess the nursing care plan goals whether it achieved or not.
• It helps the nurse to discover and identify the errors in the previous steps of Nursing process.
• It helps the nurse to assess the client's behavioural responses to the planned course of action.
