REVIEW OF THE NURSING PROCESS

Enie Novieastari, SKp.,MSN DKKD FIK UI

EVALUATION

ASSESSMENT

IMPLEMENTATION

DIAGNOSIS

PLANNING

OVERVIEW

The nursing process enables the nurse to organize and deliver nursing care The nurse integrates elements of critical thinking to make judgments and take actions based on reasons The nursing process is used to identify , diagnose, and treat human responses to health and illness (ANA, 1995) It is a dynamic, continuous process as the clients need change

Assessment

The nurse must able to review information from a variety of sources and to make critical judgments During a nursing assessment, the nurse systematically collects, verifies, analyses, and communicates data about client This phase of nursing process includes two steps: collection and verification of data from a primary and secondary sources and the analysis of that data as a basis for nursing diagnosis

Nursing Diagnosis

After completing the nursing assessment, the nurse proceeds to the process of forming appropriate nursing diagnosis A nursing diagnosis is a clinical judgment about individual, family, or community responses to actual or potential health problems or life process A nursing diagnosis is a statement that describes the clients actual or potential response to a health problem that the nurse is licensed and competent to treat it Nursing diagnosis provide the basis for selection of nursing interventions to achieve outcomes for which the nurse is accountable

Sources of diagnostic error

Collecting: lack of knowledge or skill, inaccurate data,

missing data, disorganization

Interpreting: inaccurate interpretation of cues, failure to

consider conflicting cues, using unreliable or invalid data, failure to consider cultural influences or dev. stage

Clustering: insufficient cluster of cues, premature or early

closure, incorrect clustering

Labeling: wrong diagnostic label selected, condition is

collaborative problem, failure to validate nursing diagnosis with client, failure to seek guidance

Avoiding diagnostic errors

Identify clients response to illness State NANDA diagnostic statement Identify an etiology treatable by nursing Identify a client need associated with a treatment or test Identify clients response to equipment Identify clients not nurses problem Identify clients problem not interventions Identify clients problem not goals Avoid prejudicial statements State the etiology legally Identify a problem and an etiology Identify only one client problem in a diagnostic statement

Planning for Nursing Care

The nursing assessment and the formulations of nursing diagnoses are essential to the planning step Planning is a category of nursing behaviors in which the client-centered goals and expected outcomes are established and nursing interventions are selected to achieve the goals and outcomes of care During planning, priorities are set, in order to help the nurse anticipate and sequence nursing interventions when client has multiple problems

Establishing priorities

Priority selection is the method the nurse and the client use to mutually rank the diagnoses in order of importance based on the clients desires, needs, and safety. For example: Maslows hierarchy of needs Priorities are classified as high, intermediate, or low, depend on the urgency of the problem, the nature of the treatment indicated, and the interactions among the nursing diagnoses High priority: if the nursing diagnoses were untreated, it could result in harm to the client or others (include both physiological and psychological dimensions) Intermediate priority: involve the non-emergent, non-life threatening needs of client Low priority: client needs that may not be directly related to a specific illness or prognosis

Establishing Goals and Expected Outcomes

Before delivering any form of nursing care, the nurse must decide what the end point of nursing care should be for the client It requires that the nurse critically evaluate the preestablished priority diagnoses, the urgency of the problems, and the resources of the client and the health care delivery system Goals and expected outcomes are specific statements used to indicate anticipated client behavior or responses from nursing care The purposes: to provide direction for individualized nursing interventions and to set standard of determining the effectiveness of the interventions

Goals of care

A client-centered goal: a specific, measurable objective designed to reflect the clients highest possible level of wellness and independence in function. It require active involvement by the client Goals should be realistic and based on client needs and resources Short-term and long-term goal could be developed depend on the nature of the clients need/problem and the nature of the nursing services provided

Expected outcomes

It is the specific, step-by-step objective that leads to attainment of the goal and the resolution of the etiology for the nursing diagnosis An outcome is a measurable change of the clients status in response to nursing care Outcomes are the desired responses of clients condition in physiological, social, emotional, developmental or spiritual dimensions This change in condition is documented through observable or measurable client responses The expected outcomes determine when a specific , clientcentered goals has been met and later assist in evaluating the response to nursing care and resolution of the nursing diagnosis

Guidelines for writing goals and expected outcome

Client-centered factors Singular factors Observable factors Measurable factors Time-limited factors Mutual factors Realistic factors

related to postoperative venous status and risk for thrombophlebitis Goals: client will maintain adequate tissue perfusion by discharge

NDx: Altered peripheral tissue perfusion

Expected outcomes: - client will perform active range of motion exercises

every 2 hours while restricted to bed - clients toes remain warm, dry with capillary refill of < 2 seconds - client increases ambulation by 15 meters every day

Nursing Interventions

Types of interventions: - nurse-initiated interventions

- physician-initiated interventions - collaborative interventions

1) 2)

Choosing nursing interventions based on:

Characteristic of nursing diagnoses, expected outcome, research base, feasibility, acceptability to the client, competencies of the nurse

3)
4) 5) 6)

Planning nursing care

Care plans in various setting: - institutional care plans - computerized care plans - student care plans - care plans for community-based settings - critical pathways to develop integrated care plans for clients

Writing the nursing care plan

What is the intervention? When should the intervention be implemented? How should the intervention be performed? Who should be involved in each aspect of intervention? See Potter & Perry (2005),pp.324-336

Implementation process

Reassessing the client Reviewing and revising the existing nursing care plan Organizing resources and care delivery (personnel, equipment, environment, client, anticipating and preventing complications), identifying areas of assistance) Implementing nursing interventions (cognitive, interpersonal, psychomotor skills)

Implementation methods
Direct care:

Assisting with daily living activities Physical Care techniques Counseling Teaching Controlling for adverse reactions Preventive measures Communicating nursing interventions Delegating, supervising and evaluating the work of other staff members

Indirect care

Evaluation

It is important to evaluate each client according to the level of wellness or recovery The nurse evaluates whether the clients behaviors or responses reflect a reversal or improvement in a nursing diagnosis or in maintenance of a healthy state It measures the clients response to nursing actions and the clients progress toward achieving goals Data are collected on an ongoing basis to measure changes in functioning, in daily living, and in availability or use of external resources

Evaluation of goal attainment

The purpose of nursing care is to assist the client in resolving the actual health problems, preventing the occurrence of potential problems, and maintaining a healthy state. Evaluation of the goals of care determines whether this purpose was accomplished. The nurse matches the clients behavior pr physiological response with the behavior or response specified in the goal

Steps to evaluate

Examine the goal statement to identify the exact desired client behavior or response Assess the client for presence of the behavior or response Compare the established outcome criteria with the behavior or response Judge the degree of agreement between outcome criteria and the behavior or response If there is no agreement between the outcome criteria and the behavior or response, what is/are the barriers? Why did they not agree?

The degrees of goal attainment: - if the clients response matches or exceeds the
outcome criteria, the goal is met - if the clients behavior begins to show changes but does not yet meet the criteria, the goal is partially met - if there is no progress, the goal is not met

Discontinuing a care plan Modifying a care plan

References

Potter & Perry (2005). Fundamentals of Nursing. 6th Ed. St. Louis, USA: Mosby, Inc. Chapter 14-19. Kozier, et al (2004). Fundamentals of Nursing. 7th Ed. New Jersey: Pearson Education, Inc. Chapter. 15 Rubenfeld & Scheffer (1999). Critical thinking in Nursing. 2nd Ed. Philadelphia: Lippincott Co. Chapter 3-4.