Steps in Nursing Process

Mrs. Puvaneswari Ramesh

Associate Professor
NHCON , Bangalore
Introduction

EVALUATION

IMPLEMENTATION

PLANNING AND
OUTCOME IDENTIFICATION

NURSING DIAGNOSIS

ASSESSMENT
 Nursing Assessment
Itisthedeliberateandsystematic
collectionofinformationaboutapatienttodetermine
hisorhercurrentandpasthealthandfunctionalstatus
andhisorherpresentandpastcopingpatterns.

(Carpenito Moyet 2009)

 Purposes of Assessment

Toestablishadatabase
Toidentifyhealthpromotingbehaviors
Toidentifyactualand/orpotentialhealthproblems.
Types of nursing assessments

Comprehensive

Ongoing

Focused
 Knowledge

Communication Observation

Objectivity

Measurements Resources

Procedures
&
Techniques
SKILLS IN
ASSESSMENT
Steps in Nursing Assessment

1.Collecting STEPS
data 4.Interpreting
data

2.Validating
data

5.Documenting
3.Organizing data
data
Collecting Data
Sources of Assessment of Data
 Types of data

Subjective Objective

data data

Itching
Discoloration of
Pain
skin
Feelings
Changes in
Perceptions
vital sign
Approaches for data collection
Gordons11FunctionalHealthPatterns

y Usesaseriesofquestionswhichassistinformulatinga

nursingdiagnosis

Problemfocusedassessment

y Focusesonthepatientsproblemanddevelopthe

planofcarearoundtheproblem
 Gordons health patterns

y Healthperception y Selfperceptionself

management concept

y Nutritionalmetabolic y Rolerelationship

y Elimination y Sexualityreproductive

y Activityexercise y Copingstresstolerance

y Sleeprest y Valuebelief

y Cognitiveperceptual
 Framework for assessment
(Activities of living framework devised by Roper et al.) (2008)

Maintainingasafe Communicating Breathing

environment

Eatinganddrinking Eliminating Personalcleansing

anddressing

Controllingbody Expressingsexuality Workingandplaying

temperature

Mobilising Sleeping Dying

 Methods of Data Collection

y Interview

y Observation

y Historycollection

y PhysicalExamination

y ResultsofLabandDiagnostictests.
 1. Interview
Initiatedforspecificpurposeandfocusedon a
SpecificContent
Objectives of Interview

yEstablishTherapeuticRelationship

yCuesforindepthinvestigation

yEstablishNursessenseofcaring

yIntroducethefacilityinanonthreateningmanner

yObtainHistoryandIdentifyHealthNeeds
 2.Observation
Itisdefinedasadeliberatesearchcarriedout
withcareandforethought(VirginiaHenderson)

PRINCIPLES

Dependsonknowledgeandpast

experiences

Purposeful

Systematic

Baselineobservationserveforfuturecomparison
3.History Collection

Biological information

Reason for seeking health care

Present illness

Components Past health history

Family history

Environmental history

Psychosocial history
4. Physical Examination
5. Lab and Diagnostic tests
 Validating Data
y Validationpreventsomissions,misunderstandings,and
incorrectinferencesandconclusions

Organising Data

Collectedinformationmustbeorganizedtobeuseful.
DataClusteringisausefultooltoidentifyissues
 Interpreting Data
y Distinguishrelevantandirrelevantdata
y Determinewhetherandwheretherearegapsinthedata
y Identifypatternsofcauseandeffect

Documenting Data
Assessmentdatamustberecordedand
reported.
Accurateandcompleterecordcommunicates
informationtohealthcareteam.
 Example of Subjective and
Objective data
Subjective data Objective data

y Mr.Xtellsthat,Iam Patienthas
worriedaboutmy yPooreyecontact
disease(Prostate
yFacialexpression
cancer).Whatwill
ANXIETY yClencheshands
bemyfuture?
yRestlessness
 Nursing Diagnosis
Anursingdiagnosisisdefinedasaclinical

judgmentaboutanindividual,familyorcommunityresponsesto

actualandpotentialhealthproblems/lifeprocesses.

(NANDA,2009)
 Identifying client needs

y Step1:ProblemSensing

y Step2:RuleOutProcess

y Step3:SynthesizingtheData

y Step4:EvaluatingorConfirmingtheHypothesis

y Step5:ListtheClientsNeeds

y Step6:ReevaluatetheProblemList
Diagnostic Process

DataClustering Formulation
of
Nursing
diagnosis
Datainterpretation
 Components in Nursing Diagnosis
(PES Format)
y Problem statement or diagnostic label

y Etiology

y Defining characteristics

Problem Etiology Defining

statement characteristics
Deficient fluid Diarrhea Dry skin ,dryness of
volume the mouth.
Formulation of nursing Diagnosis

Powerlessness
ONE PART Spiritual Distress
STATEMENT
Problem. (P)
Disuse Syndrome,

Acute Pain, leg

Title in here Problem related to tissue
TWO PART
STATEMENT
distention
Etiology (P & E (edema)
)
Ineffective Coping,
related to
THREE PART
Problem, maturational crisis as
STATEMENT Etiology evidenced by inability
Signs and to meet role
Symptoms (PES) expectations
and alcohol abuse.
Types of Nursing Diagnosis-
NANDA I 2012
Wandering,
ACTUAL Impairedsocialinteraction
Stressurinaryincontinence

Riskforloneliness, RISK
HighRiskforinjury

HEALTH Readinessforenhancedfamily
PROMOTION coping
Readinessforenhancednutrition

SYNDROME
PostTraumasyndrome
Advantages of nursing diagnosis
y Communication

y IdentificationofAppropriateGoals

y Qualityimprovement

y StandardforNursingPractice

y AcuityInformation

y AssistinDischargeplanning

y Commonlanguage
Limitations of Nursing Diagnosis

y Lackofconsensus

y Nurseshavelesstimewithclients.

y Careisorganizedaroundthemedicaldiagnosis.

y Afraidandunwillingtouse

y Thenursingdiagnosislistdoesnotfitthe

clientsituation.
 Sources of diagnostic error
Wrongdiagnosticlabel Lackofknowledge,
Failuretoseekguidance Inaccuratedata
Failuretovalidatenursing Collecting Disorganization
diagnosis Missingdata

Labelling Clustering

Inaccurateinterpretation
ofcues
Usinginsufficient,invalid
cue
Failuretoconsiderculture
Interpreting Insufficientclusterofcues.
Prematureorearlyclosure
Incorrectclustering
 Potential Errors in Choosing a
Nursing Diagnosis
Formulationofnursingdiagnosis
AclientreportsdiscomfortattheinsertionsiteofanIV
catheter,areaisslightlyreddened

ThenurseformulatesanursingdiagnosisieDiscomfort .

ButfailtoconsidertheRiskforinfection.

Dontusemedicaltermsinnursingdiagnosis
y Selfcaredeficit,HygienerelatedtoStroke

ySelfcaredeficit,HygienerelatedtoweaknesssecondarytoStroke
 Errors in Choosing a Nursing
Diagnosis
Dontcombinetwoproblemsatthesametime
yPainandfearrelatedtoupcomingabdominalsurgery

yPainrelatedtotissueinjurysecondarytoabdominalsurgeryas

evidencedbypain6/10.

Dontmakestatementsthatarelegallyinadvisable
yImpairedskinintegrityR/Tinfrequentturningaeb3cmankleulcer

yImpairedskinintegrityR/Timmobilityrelatedtofracture.
Overcoming Barriers to Nursing
Diagnosis

y Familiarityofnursingdiagnosislanguage

y SupportfromHealthcareagency

y Enhancedcommunication

y Documentanewnursingdiagnosis

y Experiencednursesneedopportunitiestoreviewnursing

diagnoses.

y StandardizedNursingeducationprogramscontent
3.Nursing Planning and Outcome
Identification

Planningisacategoryofnursingbehaviourin
whichclientcenteredgoals andexpectedoutcomesare
establishedandnursinginterventions areselectedtoachieve
thegoalsandoutcomesofcare
Phases of Planning
Ongoing
Planning

Initial
Discharge
Planning
Planning
 PLANNING PROCESS

1 Settingpriorities.

2 Establishingclientgoals/desiredoutcomes.

3 Selectingnursingstrategies.

4 Writingnursingorders.
 1.Priorities of planning
Prioritysettingistheorderingofnursingdiagnosis
andpatientproblemsusingdeterminationsofurgencyandor
importancetoestablishapreferentialorderfornursingactions

Hendryandwalker2004
 High

Intermediate Low

Classification of priorites
 2.Goals of care and expected
outcome
Goal - Itreflectsapatientshighestpossiblelevelof
wellnessandindependenceinfuntion

Short term Goal Long term

Expected outcome
Anexpectedoutcomeisameaurablechange
inapatientsstatusthatisexpectedtooccurinresponseto
nursingcare.
 MACROS criteria- For Goal
y Measurableandobservable

y Achievableandtimelimited

y Clientcentred

y Realistic

y Outcomewritten

y Short
 Example for Goal and expected
outcome
Goal

Mr.Xwillambulateindependentlyin3days

Expected outcome

Mr.Xwillturninbedindependentlyin24hours

Mr.Xwillgetuptochair3timesdailyfornext2days

Mr.Xwillwalkwithassistancetohallwayin48hours
 3.Selection of intervention
y Characteristicsofnursingdiagnosis

y Goalsandexpectedoutcome

y Feasibilityoftheintervention

y Acceptabilityofthepatient

y Owncompetency

y Evidencebasefortheinterventions

Bulecheketal2008
 Selecting Nursing
Interventions/ Strategies

Actions Actions
initiated by that
nurse that do require an
not require order
Actions
direction or an
implemented
order
in
collaborative
manner
Planning Nursing care

Realistic Prioritised

Explicit
Involved

Evidence Goal
based centred
Systems for Planning nursing
care
y Nursingkardex

y Criticalpathways

y Nursingcareplan
 The Nursing Care Plan
Awrittenguidethatorganizesdataabouta

clientscareintoaformalstatementofthestrategiesthatwill
beimplementedtohelptheclientachieveoptimalhealth.

Purposes
y Helpstoidentifythenursingactionstobedelivered

y Identifyandcoordinateresourcestodelivernursingcare

y Enhancecontinuityofcare
Care Plan in various settings

y Institutionalcareplan

y Interdisciplinarycare

y Computerizedcareplan

y Studentcareplan

y Careplanincommunitysettings
 GUIDELINES FOR WRITING
NURSING CARE PLAN
y Incorporatespreventive,healthmaintenanceandrestorative

aspects.

y UsestandardizedMedicalorEnglishsymbols.Eg.Clean

woundwithH2O2 ,b.i.d.

y Bespecific.

y UsecategoryheadingsandDateandsigntheplan
 GUIDELINES FOR WRITING
NURSING CARE PLAN

y Refertoprocedurebooksorothersourcesofinformation

y Tailortheplantotheuniquecharacteristicsoftheclient.

y Plantheinterventionsforongoingassessmentofthe

client(eg.Inspectincisionq8h)

y Includecollaborativeandcoordinationactivities.
 4. Writing Nursing orders
Afterchoosingappropriatenursing
interventionsthenursewritethoseoncareplanonnursing
orders.
yComponents of Nursing order

Date Action Content Time Sign

MonitorVitalsignsEveryq4h

AuscultateAbdomenq6h
Eg- for Planning and Rationale
for Acute pain in urethra A client with UTI
Planning Rationale
y Assesspainnotinglocation, y Provideinformationaidinchoice
intensity(scaleof010)and ofdeterminingchoiceor
duration. effectivenessofinterventions
y Encourageincreasedfluid y Increasedhydrationflushes
intake bacteriaandtoxins
y Observethechangesinmental y Accumulationofuremicwasteand
statusbehaviourandLevelof electrolyteimbalancesmaybe
consiousness toxictoCNS
 Implementation
Thisfourthstepofthenursingprocessinvolvesthe
executionofthenursingcareplanderivedduringthe
Planningphase.

INTERVENTION

Direct care Indirect care

 Implementation skills

1.CognitiveSkills

2.InterpersonalSkills

3.Psychomotorskills
Standard Nursing Interventions
y Clinicalpracticeguidelinesandprotocols

y Standingorders

y NICinterventions

y StandardsofPractice
Managing Nursing Care in the
Clinical Environment

Task
allocation

Primary
nursing
Title

Personcentred
Client Team
planning
allocation nursing
Careprogramme
approach
Caseload
management
 Implementation process
1.Reassessingtheclient

2.Reviewingandrevisingtheexistingnursingcareplan

3.Organizingresourcesandcaredelivery

4.Anticipatingandpreventingcomplications

5.Implementingnursinginterventions.
 1.Reassesses the client

Beforeimplementingthenursemust

reassess.Ithelpstoidentifytheproposednursingactions

arestillappropriatefororthepatientslevelofwellness
 2. Reviewing and revising the
existing nursing care plan
Iftheclientstatushaschangedthenmodifythecareplan.

Modification of existing care plan

Revisethe Revisethe Choosethe

Revisethe specific evaluation
nursing
Data intervention method
Diagnosis
3.Organising Resources And
Care Delivery
 4. Anticipating and preventing
complications
Itcanberesultedfromboththeillnessand

treatment.

Anursewitha

yThoroughKnowledgeonpathophysiology

yThoroughassessment

yScientificrationaleforinterventions
5. Implementing Interventions

Directcare
ADL
IADL
Indirect care
Physicalcare Communicating
Techniques Interventions
Lifesavingmeasures Delegating,Supervising
Counselling andevaluatingthework
Teaching ofstaff
Eg- for Implementaion
Acute pain in urethra A client with UTI
Planning
y Assesspainnotinglocation,
intensity(scaleof010)and
duration.
y Encourageincreasedfluid
intake
y Observethechangesin
Implementation
y Clientcomplainedburningpaininurethra
duringmicturitionwhichscores5/10
lastingfor15minwitheachurination.
y OralandIVtherapystarted.(NS 10
Drops/min).Intake 3000mlandOutput
2200mlforthelast24Hours
y ElectrolytesandUremiclevelswerenormal

mentalstatusbehaviourand Urea 18mg/dl,Creatinine0.8mg/dl.

Levelofconsiousness Clienthasappropriatementalstatus
behaviour.
 Evaluation

Evaluationisdefinedasthejudgment ofthe

effectivenessofnursingcaretomeetclientgoals;inthis

phasenursecomparetheclientbehavioralresponseswith

predeterminedclientgoalsandoutcomecriteria.

{CRAVEN1996}
 Purposes
1.Determineclientsbehavioralresponse.

2.Comparetheclientsresponsewithoutcomecriteria.

3.Appraisetheextenttowhichclientsgoals.

4.Assessthecollaborationofclientandhealthteam

5.Identifytheerrorsintheplanofcare.

6.Monitorthequalityofnursingcare.
COMPONENTS OF EVALUATION

Continue
Continue
Relating
Relating
Collect Compare Draw
Draw modify,
modify,
Collect Compare nursing
nursing
thedata
thedata thedata conclusion
conclusion Terminate
Terminate
thedata activities
activities careplan
careplan
Competencies For Evaluation
y CriterionbasedEvaluation

y Documenttheresults

y Careplanrevision

y Collaboratingandevaluateeffectivenessofintervention

ANA-2010
Methods of Evaluation of nursing
care
Patient
Nursing handover satisfaction
Handoverinformation Appreciationthatis
aboutthenursingcare sometimesoffered
ofclientstonurses byclients
Evaluating
nursing
care Reviewing the
Reflection plan
Reflectonown Evaluatesthecare
experiences
bothsociallywith
givenagainstthe
otherfriends.. setgoals.
 Evaluation skill required for
nurses
y Knowthehospitalpolicies,procedureandprotocolsof

interventionsandrecording

y Uptodateknowledgeandinformationofmanysubject.

y Intellectualandtechnicalskill

y Knowledgeandskillofcollectingsubjectivedataand

objectivedata.
 Example for Evaluation
Attheendof8hours,patientpainhas

reducedasevidencedbypainscore2/10andimproved

activity