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NursingProcess

Objectives:
Introducethehistoryofnursingprocess
Discusspurposeofnursingprocess
Includingphilosophy
Discussnursingmodelsinrelationto
assessment
Discussdefensibledocumentation
Criticismofprocess
Summary
Summary

NursingProcess
n
n

Assessment

n
n

Planning

n
n

Implementation

n
n

Evaluation
Evaluation

TheNursingProcess
ThetermNursingProcess
NursingProcesscametotheUK
inthe1970
inthe1970sandcametobeunderstood
as:
n
n Aformofdocumentation
n
n Asameansoforganisingwork,thatis
patientallocationorprimarynursing
n
n Asaneducationaltooltohelpachieve
patientcentrednursing
n
n Asaphilosophytohelpnursingattain
professionalstatusbyofferingan
alternativetothemedicalmodel.
alternativetothemedicalmodel.

ThenursingprocessisAnorganised,
systematicanddeliberateapproach
tonursingwiththeaimofimproving
standardsinnursingcare
standardsinnursingcareRushS,
FergyS&WeelsD(1996)
Itusesasystematic,holistic,problem
solvingapproachinpartnershipwith
thepatientandtheirfamily
thepatientandtheirfamily

NursingModels
Allmodelshave4corecomponents,
nTheperson,
nTheirenvironment,
nHealthand
nNursing
(butallhavedifferentemphasis)
(butallhavedifferentemphasis)

ThePerson
n
n

Body(physical/biological)

Activitiesofdailyliving

n
n

n
n

Geneticmake
Geneticmakeupgender

n
n

Nature/Nurture
Nature/Nurture

Mind(psychological)
Healthy,impairedordamaged
n
n Intellect
n
n Attitudes
n
n Effectofillness
Effectofillnessstress,fears,
memories
n
n Emotionalsupport
Emotionalsupport
n
n

Social
Familyandfriends
Work
Play
Effectsofillness(e.g.financial)
Effectsofillness(e.g.financial)

Spirit
Beliefsystemsaboutthemeaningof
life,death,hope,suffering,
n
n itmayinvolveorganisedreligion,
othercustomsorNewage
Newage
spirituality.
spirituality.
n
n

Environment
Home,neighbours,
neighbourhood,work,social
activities,town,county,country
andpoliticalfactors
andpoliticalfactors

Health
Thecompletestateofphysical,
psychologicalandsocialwell
psychologicalandsocialwellbeing
beingWorld
healthorganisation1946
Healthcarecontinuum(likedtoage)
Optimumhealth
Illhealth
Independence
Dependence
Adaptation
Maladaption
Self
Relianceonothers
Selfcare
Relianceonothers

HumanNeedsModel:RoperLogan
&Tierney
&TierneysModel(1980)(activities
ofdailyliving
ThisisthemainoneusedinBritain
andhas5dimensions:
n
n Physiological,
n
n psychological,
n
n socio
sociocultural,
n
n politico
politicoeconomical
n
n andenvironmental.
andenvironmental.

Thereare12activities,someof
whichareessentialsuchasbreathing
andothersthatwhichenhancethe
qualityoflife.
qualityoflife.

Itshouldbecarriedout:
n
n Byorunderthesupervisionofthe
NamedNurse
NamedNurse
n
n Withtheagreementandco
Withtheagreementandco
operationofthepatient
n
n Beevidencebasedandfollow
NationalandTrustPolicyand
guidelines
n
n MustusetheNMC
NMCsStandardsfor
recordkeeping
recordkeepingandCodeof
professionalconduct
professionalconduct

Thepurposeofcareplanning
Itisalegaldocument
n
n Showsaccountability
Thecareplan
isadocumentthatidentifiesthecare
tobegiven,andarecordthatshows
whoplannedandgavethatcare
n
n Itshouldguidetheworkofothers
andbeabasisforcontinuityofcare
n
n Shouldshowalogicalandsystematic
flowofideasthroughfromtheinitial
assessmenttothefinalevaluation
assessmenttothefinalevaluation
n
n

Assessment
Whatcomponentsareneededforasuccessfulassessment
n
n Goodcommunication
n
n Asystematicapproachtodatacollection
n
n Interpretation
Interpretationbasedonnursingknowledge
Objective(scientificQuantitative)
n
n Empirics
Empiricsmeasurementofknowledgewith
scientificfact
Subjective(Art,Qualitative)
n
n Aesthetics
Aestheticsgainedthroughempathyandishowa
nursebecomessensitivetoapatient
nursebecomessensitivetoapatientspain,
worryorjoy
n
n Ethics
Ethicsconcernedwithmotivation,morality,
humanrightsandlaw
n
n Personalknowledge
Personalknowledgeawarenessthatthenurse
hasanimpactonpatientcare
hasanimpactonpatientcare

SourcesofData
1.

Nonverbalobservation
n
n
n
n
n
n
n
n

Sight
SightPhysical,psychological(andsocial)
Touch
TouchSkintemp,hydration,pulse/BP
Sound
SoundBreath
Breathwheeze,stridor
Smell
Smellbreathbodyfluidsinfections,gangrene

2.VerbalCommunication
n
n
n
n
n
n
n
n
n
n

Patients/clients
Familyandfriends(Meaningfulothers)
Nursingcolleagues
Medicalcolleagues
Othermembersofmultidisciplinaryteam

3.Writtenrecords
n
n
n
n

G.PLetter
Transferletter

Communication
Whyaregoodcommunicationskillsrequired?
n
n Toestablishandmaintainarelationshipwith
patientsandtheirfamilies
n
n Toencouragepatientstodescribeallrelevant
aspectsoftheirproblems
n
n Togetandgiveaccurateinformation
n
n Tousetimeandopportunityeffectively
n
n Toimprovepatientsatisfactionwiththecare
given
n
n Toimprovethrustandcooperationwiththecare
n
n Toreducenegativeemotionsandfear
Toreducenegativeemotionsandfear

Guidetoasuccessfulassessment
Prepareadequately
n
n Introduceyourself
Introduceyourselfpreparepatient
n
n Usenon
Usenonverbalcommunication
n
n Becourteous
n
n Usesensitivity,compassionandempathy
n
n Usefocusedquestions(openedand
closed)
n
n Listen
n
n Clarify
n
n Summarisewhattheydescribe
n
n Makenotes
n
n reflect
reflect
n
n

Planning
Effectiveplanningdependsonthequality
andcomprehensivenessoftheassessment
n
n Determinetheproblems
n
n Establishtherisksandpriorities
EstablishtherisksandprioritiesHowill
arethey?
n
n Cantheybreathadequately(safeairway?)
n
n Aretheyinpain?(physical/psychological)
n
n Cantheymaintainasafeenvironment?If
notwhynot?(Drugs,drink,mentalor
psychologicalproblem?)
n
n Non
Noncompliancewithmedicaladvice
compliancewithmedicaladvice

Writingacareplan(s)
Thinkabout
n
n Whoisitfor?(Thepatientandothermembersof
nursingteam)
n
n Whataretheshort
Whataretheshorttermandlongtermgoals?
n
n Howcanyoudeterminethatyouhavereached
thegoals?(measurable)
n
n Howwillthepatientknowhe/shehasachieved
thegoals?(realistic)
n
n Whoisinvolvedinthedeliveryofthecare?(The
patient(andfamily),yourself,thenursingteam,
medicalstaff,multidisciplinaryteam,labs,
investigations,proceduresetc)
n
n Howquicklyistheproblemlikelytochange
HowquicklyistheproblemlikelytochangeHow
soonwillyouneedtore
soonwillyouneedtoreevaluatetheplan?
evaluatetheplan?

Howmanyproblemsarethere
Howmanyproblemsarethere
Whichorderofpriority?
n
n Howcanyouprovethattheyare
evidencebased(whatresourcesdo
youneed?)(corecareplansVs
individualisedones)
individualisedones)
n
n

Implementing
Atthestartoftheshift,duringhandoverand
whenyoufirstmeetthem,thinkaboutwhether
theoralreportmatchesthepatientsactual
condition
b)
Comparethistowhatyoualreadyknowofthe
patientandtotheexistingcareplans
c)
Hasanythingchangedforbetterorworse
d)
Decide:
Whataretheprioritiesforlookingafterthis
patient?
a)

Istheirconditionstable?Whatobservations
needdoing
needdoinghowoften
Aretheygoingoffthewardtests/investigations/
operations
Aretheybeingdischarged?Whenarethey
going?Iseverythingready?
going?Iseverythingready?

Repeatthisprocessforallthe
patientsyouarelookingafter.
f)

g)

h)

i)

j)

Whatroutineworkmustbedoneand
whenshouldthisbedone
Whoisgoingtodothiswork
Whoisgoingtodothisworkareyouon
yourownordoyouhaveaClinical
supportworkerwithyou?Howwillthey
giveyoufeedback?
Whoisavailabletogiveyouhelpor
adviceifneeded?(seniornurse
adviceifneeded?(seniornursemedical
team)
Howareyougoingtoorganisethework
TIMEMANAGEMENT
Whatresourcesdoyouneed?
Whatresourcesdoyouneed?

Evaluation.
n
n

MENTAL
MENTALOngoingthroughout
implementation

n
n

WRITTEN(thisshouldpreferablybedone
withthepatientpresentinordertoget
accuratefeedback)
Mustbecarriedoutatleasttwicein24hours
n
n Andwheneveranyincidentoccurs.(date,time
signature)
n
n Writeageneralstatementaboutpatient
Writeageneralstatementaboutpatientscondition
(better,same,worse)
n
n Evaluateeachcareplaninturnandbynumber
Evaluateeachcareplaninturnandbynumber
n
n

Personalise
Personaliseusepatient
usepatientsownwords
appropriate
n
n Statewhatcareyouhavegiven
Careof
planned
plannedoranyvariation/commente.g.
pressureareacaregivenskinslightlyred
on
sacrum
sacrum
n
n Amendthecareplanifcircumstances
havechanged
n
n Discontinuecareplansifthegoal(s
goal(s)have
beenreached
n
n Legally
Legallyifthecaregivenhasnotbeen
recordedthanithasn
recordedthanithasntoccurred!
toccurred!
n
n

Criticismsofthenursingprocess&
RoperLogan&Tierney
RoperLogan&TierneysModel
Assessment
n
n Itisonlya
snapshot
snapshotandisoftennotreferred
toaftertheinitialassessmentorupdated
n
n Thereisthedangerofa
reductionist
reductionistapproach
inwhichpatientsaremadetofit
fitintotheboxes
ratherthanallowingflexibility
n
n Itisonlyoneamongseveralnursingassessment
tools(
tools(waterlow
waterlow,moving&handling,nutrition,
painetc)inadditiontoothermedical.
Paramedicalrecords
n
n Patientsmaylieorconceal
incriminating
incriminatingor
embarrassinginformation
n
n Psychological,sexual,spiritualorissues
surroundingdeathmaynotbementioned
surroundingdeathmaynotbementioned

PlanningandGivingCare
Thepatient
Thepatientsmaynotbeconsulted,
empoweredtocooperate,orcomplientin
theircare
n
n WithincreasingskillmixCSW
CSWsnow
providemostofthephysicalcare,Butthe
oftenhavenotbeentaught(orexpected)
toreadcareplans,maynotreportback
(orrealisethesignificanceof)changesto
theRNwhoiswritingtheevaluationand
mayormaynotdocumentthecarethey
havegiven
n
n Patientcareisfragmented
tasknursing
tasknursing
ratherthanholisticnursing
ratherthanholisticnursing
n
n

Evaluation
Thereisnotenoughtime
n
n Itisjustpaperworkthattakesnurses
awayfromhands
awayfromhandson
oncare
n
n Wearebadatreading:socareplansare
notconsulted
notconsultednursesrelyonverbal
handoversandtheirnotes.(Buttheseare
onlyasgoodastheindividualsmemory
andcontinuityofcare
n
n Evaluationtendstoconcentrateon
objectivemeasurableactivity
objectivemeasurableactivityitmaynot
beappropriatetodescribetherapeutic
therapeutic
careinterventionsorsetmeasurablegoals
careinterventionsorsetmeasurablegoals
n
n

OtherModels
Theseinclude
n
n Nightingale(1859)
n
n Medicalmodel
n
n Henderson(1966)
n
n Systemsmodel:usedinUSA
n
n Developmentmodels
n
n Maslow(1970)
Hierarchyofneeds
Hierarchyofneeds
n
n BurfordNursingDevelopmentUnit
NursingDevelopmentUnit

?
Any
Questions

FurtherReading:
BowmanG.S,ThompsonD&SuttinT(1983)Nursesattitudes
towardsthenursingprocessJournalofAdvancedNursing
8(2)p.125
8(2)p.125129
BradenS(1998)Evaluatingnursinginterventions:Atheory
drivenapproachSagepublicationsLondon
CohenE,GestaT(2001)Nursingcasemanagementfrom
essentialtoadvancedpracticeapplication3rdeditionMosby
USA
FaulknerA(2000)Nursing:Thereflectiveapproachtoadult
practice2ndEditionBailliereTindallCheltenham
HincliffS,NormanS,SchoberJ(1998)Nursingpracticeand
healthcare:Afoundationtext 3rdeditionArnoldOxford
3rdeditionArnoldOxford

n
n

n
n

n
n

n
n

KowalakJ&HughesAetal(2002)Bestpractices
aguidetoexcellenceinnursingcareLippincott
Williams&Wlikins
LeahyJ,KizilayP(1998)Foundtionsofnursing
practice:AnursingprocessapproachSaunders
Philadelphia
LittlejohnC,(2002)Arenursingmodelstoblame
forlowmorale?NursingStandardVol16(17)
p.39
p.3941
MasonC(1999)Guidetopracticeorloadof
rubbish
rubbish?Theinfluenceofcareplansonnursing
practiceinfiveclinicalareasinNorthernIreland
JournalofAdvancedNursingVol29(2)P.380
29(2)P.380387
387

RoperW,LoganW,&TierneyA(1990)
Theelementsofnursingbasedona
modelofliving3rdeditionChurchill,
LivingstonLondon
SwashM(2002)Hutchinson
Hutchinsonsclinical
methods21steditionSaunders
Ediburgh
WalshM(2001)Modelsandcritical
pathwaysinclinicalnursingBailliere
TindallCheltenham
Cheltenham

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