Nursing process

Nursing process is a systematic, rational method of planning and providing nursing care. Its purpose is to identify a client’s health care status, and actual or potential health problems, to establish plans to meet the identified needs, and to deliver specific nursing interventions to address those needs. The nursing process is cyclical; that is, its component follows a logical sequence, but more than one component may be involved at one time. At the end of the first cycle, care may be terminated if goals are achieved, or the cycle may continue with reassessment, or the plan of care may be modified.

Characteristics of Nursing Process

The nursing process has distinctive 5 characteristics that enable the nurse to respond to the changing health status of the client. These characteristics include its cyclic centeredness; focus on problem solving and decision making, interpersonal and collaborative style, universal applicability, and use of critical thinking.

Data from each phase provide input into the next phase. Findings from evaluation feed back into the assessment. Hence, the nursing process is a regularly repeated event or sequence of events (a cycle) that is continuously changing (dynamic) rather than staying the same (static)
The nursing process is client centered. The nurse organizes the plan of care according to client problems rather than nursing goals. In the assessment phase, the nurse collects data to determine the client’s habits, routines, and needs, enabling the nurse to incorporate client routines into the care plan as much as possible.
The nursing process is an adaptation of problem solving and system theory. It can be viewed as parallel to but separate from the process used by physicians (the medical model). Both processes (a) begin with data gathering and analysis, (b) bas action (intervention or treatment) on a problem statement (nursing diagnosis or medical diagnosis), and (c) include an evaluate component. However, the medical model focuses on physiological systems and the disease process, whereas the nursing process is directed toward a client’s responses to disease illness.
Decision making is involved in every phase of the nursing process. Nurses can be highly creative in determining when and how to use data to make decisions. They are not bound by standard responses and may apply their repertoire of skills and knowledge to assists clients. This facilitates the individualization of the nurse’s plan of care.
The nursing process is interpersonal and collaborative. It requires the nurse to communicate directly and consistently with clients and families to meet their needs. It also requires that nurses collaborate, as members of the health care team, in a joint effort to provide quality client care.

There are 5 phases of nursing process: assessing, diagnosing, planning, implementing, and evaluating.

Steps of the nursing Process:

1-Assessing (Nursing Assessment)

The nursing assessment (Assessing) is the systematic and continuous collection, organization, validation, and documentation of data (information). In effect, nursing assessment is a continuous process carried out during all phases of the nursing process. For example, in the evaluation phase,nursing assessment is done to determine the outcomes of the nursing strategies and to evaluate goal achievement. All phases of the nursing process depend on the accurate and complete collection of data. There are 4 different types of nursing assessments: initial assessment, problem-focused assessment, emergency assessment, and time-lapsed reassessment. Assessments vary according to their purpose, timing, time available, and client status.

The assessment process involves 4 closely related activities: collecting data, organizing data, validating data, and documenting data.

– Types of Nursing Assessment

TYPE	TIME PERFORMANCE	PURPOSE	EXAMPLE
Initial Assessment	Performed within specified time after admission to a health care agency	To establish a complete database for problem identification, reference, and future comparison	Nursing admission
Problem-focused Assessment	Ongoing process integrated with nursing care	To determine the status of a specific problem identified in an earlier assessment	Hourly assessment of client’s fluid intake and urinary output in an ICU Assessment of client’s ability to perform self-care while assisting the client to bathe
Emergency Assessment	During any physiologic or psychologic crisis of the client	To identify life-threatening problems To identify new or overlooked problems	Rapid assessment of a person’s airway, breathing status and circulation during a cardiac arrest Assessment of suicidal tendencies or potential for violence.
Time-lapsed Reassessment	Several months after initial assessment	To compare the client’s current status to baseline data previously obtained	Reassessment of a client’s functional health patterns in a home care or outpatient setting or, in a hospital, at shift change

Collecting Data

Data collection is the process of gathering information about a client; it includes the health theory, physical assessment, primary care provider’s history and physical examination, results of laboratory and diagnostic tests, and material contributed by the other personnel.

Client data should include past history as well as current problems. For example, a history of an allergic reaction to penicillin is a vital piece of historical data. Past surgical procedures, folk healing practices, and chronic diseases are also example of historical data. Current data relate to present circumstances, such as pain, nausea, sleep patterns, and religious practices. To collect data accurately, both the client and nurse must actively participate. Data can be subjective or objective and constant or variable types, and from a primary or secondary source.

Types of Data

Subjective data:

Subjective data, referred to as symptoms or covert data, are apparent only to the person affected and can be described or verified only by that person. Itching, pain, and feeling of worry are examples of subjective data. Subjective data include the client’s sensations, feelings, values, beliefs, attitudes, and perception of personal health status and life situation.

Objective data:

Objective data , also referred to as signs or overt data, are detectable by an observer or can be measured or tested against an accepted standard. They can be seen, heard, felt, or smelted, and they are obtained by observation or physical examination. For example, a discoloration of the skin or a blood pressure reading is objective data.

Constant data:

Constant data is information that does not change over time such as race or blood type. Variable data can be change quickly, frequently, or rarely and include such data as blood pressure, age, and level of pain.

Source of Data

Sources of data are primary and secondary. The client is the primary source of data. Family member or other support persons, other health professionals, records and reports, laboratory and diagnostic analyses, and relevant literature are secondary or indirect sources.

Data Collection Methods

The principal methods used to collect data are observing, interviewing, and examining.

Observing

To observe is to gather data by using the senses. Observation is a conscious, deliberate skill that is developed through effort and with an organized approach.

Interviewing

An interview is a planned communication or a conversation with a purpose, for example, to get or give information, identify problems of mutual concern, evaluate change, teach, provide support, or provide counseling or therapy.

There are two approaches to interviewing: directives and non-directives. The directive interview is highly structured and elicits specific information. The nurse establishes the purpose of the interview and controls the interview, at least at the outset. the client responds to questions but may have limited opportunity to ask questions or discuss concerns.

During a non-directive interview, or rapport-building interview, by contrast, the nurse allows the client to control the purpose, the subject matter, and pacing. Rapport is an understanding between two or more people.

Examining

The physical examination or physical assessment is a systematic data collection method that uses observation (i.e., the senses of sight, hearing, smell and touch) to detect health problems. To conduct the examination the nurse uses techniques of inspection, auscultation, palpation, and percussion.

Organizing Data

The nurse uses a written (or computerized) format that organizes the assessment data systematically. This is often referred to as a nursing history, nursing assessment or nursing data-base form. The format may be modified according to the client’s physical status such as one focused on musculoskeletal data for orthopedic clients.

Validating Data

The information gathered during the assessment phase must be complete, factual and accurate because the nursing diagnoses and interventions are based on this information. Validation is the act of “double checking” or verifying data to confirm that it is accurate and factual. Validating data helps the nurse to complete these tasks:

Ensure that assessment information is complete
Ensure that objective and related subjective data agree
Obtain additional information that may have been over-looked.
Differentiate between cues and inferences. Cues are subjective or objective data that can be directly observe by the nurse; that is, what the clients says or what the nurse can see, hear, smell, or measure. Inference are the nurse’s interpretation or conclusions made based on the cues (e.g., a nurse observes the cues that an incision is red, hot and swollen; the nurse makes an inference that the incision is infected).
Avoid jumping to conclusions and focusing in the wrong direction to identify problems.

Documenting Data

To complete the assessment phase, the records client data. Accurate documentation is essential and should include all data collected about the client’s health status. Data are recorded in a factual manner and not interpreted by the nurse. For example, the nurse records the client’s breakfast intake (objective data) as “coffee 240 ml, juice 120 ml, 1 egg, and 1 slice of toast,” rather than as “appetite good” (a judgment). A judgment or conclusion such as “appetite good” or “normal appetite” may have different meanings for different people. To increase accuracy, the nurse records subjective data in the client’s own words, using quotation marks. Restating in other words what someone says increase the chance of changing the original meaning.

2- Diagnosing (Nursing Diagnosis)

Nursing diagnosis (Diagnosing) is the second phase of the nursing process. In this phase, nurses use critical thinking skills to interpret assessment data and identify client’s strengths and problems. Nursing diagnosis is a pivotal step in the nursing process. Activities preceding this phase are directed toward formulating the nursing diagnoses; the care-planning activities following this phase are based on the nursing diagnoses.

Types of nursing diagnoses

The five types of nursing diagnoses are actual, risk, wellness, possible, and syndrome.

An actual nursing diagnosis is a client problem that is present at the time of the nursing assessment. Examples are ineffective breathing pattern and anxiety. An actual nursing diagnosis is based on the presence of associated signs and symptoms.
A risk nursing diagnosis is a clinical judgment that a problem does not exist, but the presence of risk factors indicates that a problem is likely to develop unless nurses intervene. For example, all people admitted to hospital have some possibility of acquiring an infection; however, a client with diabetes or a compromised immune system is at higher risk than others. Therefore, the nurse would appropriately use the label risk for infection to describe the clients health status.
A wellness nursing diagnosis “describes human responses to levels of wellness in an individual, family or community that have a readiness for enhancement”. Examples of wellness diagnoses would be readiness for enhanced spiritual well-being or readiness for enhance family coping.
A possible nursing diagnosis is one in which evidence about a health problem is incomplete or unclear. A possible diagnosis requires more data either to support or to refute it. Fro example, an elderly widow who lives alone is admitted to the hospital. The nurse notices that she has no visitors and is pleased with attention and conversation from the nursing staff. Until more data are collected, the nurse may write a nursing diagnosis of possible social isolation related to unknown etiology.
A syndrome nursing diagnosis is a diagnosis in which is associated with a cluster of other diagnoses. Currently six syndrome diagnoses are on the NANDA international list. Risk for disuse syndrome, for example, may be experienced by long-term bedridden clients. Clusters of diagnoses associated with this syndrome include impaired physical mobility, risk for impaired tissue integrity, risk for activity intolerance, risk for constipation, risk for infection, risk for injury, risk for powerless, impaired gas exchanged, and so on.

Analyzing Data

In the diagnostic process, analyzing involves the following steps:

Compare date against standards (identify significant cues).
Cluster cues (generate tentative hypothesis).
Identify gaps and inconsistencies.

For experienced nurses, these activities occur continuously rather than sequentially.

Comparing data with Standards

Nurses draw a knowledge and experience to compare client data to standards and norms and identify significant and relevant cues. A standard or norm is generally accepted measure, rule, model, or pattern. The nurse uses a wide range of standards, such as growth and developmental patterns, normal vital signs, and laboratory values.

Clustering Cues

Data Clustering or grouping cues is a process of determining the relatedness of facts and determining whether any patterns are present, whether the data represent isolated incidents, and whether the data are significant. This is the beginning of synthesis.

Identifying Gaps and Inconsistencies

Skillful assessment minimizes gaps and inconsistencies in data. However, data analysis should include a final check to ensure that the data are complete and concrete.

Inconsistencies are conflicting data. Possible sources of conflicting data include measurement error, expectations, and inconsistent or unreliable reports. For example, the nurse may learn from the nursing history that the client reports not having seen a doctor in 15 years, yet during the physical health examination, he states, “My doctor takes my blood pressure every year.” All inconsistencies must be clarified before a valid pattern can be established.

Identifying Health Problems, Risks, and Strengths

After data are analyzed, the nurse and client can together identify strengths and problems. This is primarily a decision-making process.

Determining Problem and Risks

After grouping and clustering the data, the nurse and client together identify problems that support tentative actual, risk, and possible diagnosis. In addition, the nurse must determine whether the client’s problem is a nursing diagnosis, medical diagnosis or collaborative problem.

Determining Strengths

At this stage, the nurse and client’s strengths, resources, and abilities to cope. Most people have a clearer perception of their problems or weaknesses than of their strengths and assets, which they often take for granted. By taking inventory strengths, the client can develop a better-rounded self concept and self image. Strengths can be an aid to immobilizing health and regenerative processes.

Formulating Diagnostic Statements

Most nursing diagnoses are written as two-part or three-part statements, but there are variations of these.

Basic Two-Part Statements

The basic two-part statement includes the following:

Problem (P): statement of the client’s response
Etiology (E): factors contributing to or probable causes of the responses.

The two-parts are joined by the words related to rather than due to. The phrase due to implies that one part causes or is responsible for the other part. By contrast, the phrase related to merely implies a relationship.

Basic Three-Part Statements

The basic three-part nursing diagnosis statement is called the PES format and includes the following:

Problem (P): statement of the client’s response
Etiology (E): factors contributing to or probable causes of the response
Signs and Symptoms (S): defining the characteristics manifested by the client.

Actual nursing diagnoses can be documented by using the three-part statement because the signs and symptoms have been identified. This format cannot be used for risk diagnoses because the client does not have signs and symptoms of the diagnosis.

The PES format is especially recommended for beginning diagnosticians because the signs and symptoms validate why the diagnosis was chosen and make the problem statement more descriptive.

One-Part Statement

Some diagnostic statements, such as wellness, diagnoses and syndrome nursing diagnoses, consist of a NANDA label only. As the diagnostic labels are refined, they tend to become more specific, so that nursing interventions can be derived from the label itself. Therefore, an etiology may not be needed. For example, adding an etiology to the label Rape-Trauma Syndrome does not make the label any more descriptive or useful.

Evaluating the Quality of the Diagnostic Statement

In addition, to using the correct format, nurse must consider the content of their diagnostic statements. The statements should, for example, be accurate, concise, descriptive, and specific. The nurse must always validate the diagnostic statements with the client and compare the client’s signs and symptoms to the NANDA defining characteristics. For risk problems, the nurse compares the client’s risk factors to NANDA risk factors.

3- Planning

Planning is a deliberative, systematic phase of the nursing process that involves decision making and problem solving. In planning, the nurse refers to the client’s assessment data and diagnostic statements for direction in formulating client goals and designing the nursing interventions required to prevent, reduce, or eliminate the client’s health problems. A Nursing intervention is “any treatment, based upon clinical judgment and knowledge that a nurse performs to enhance patient/client outcomes”. The end product of the planning phase is a client care plan.

Although planning is basically the nurse’s responsibility, input from the client and support persons is essential if a plan is to be effective. Nurses do not plan for the client, but encourage the client to participate actively to the extent possible. In a home setting, the client’s support people and caregivers are the one’s who implement the plan of care; thus, its effectiveness depends largely on them.

Types of planning

Planning begins with first client contact and continues until the nurse-client relationship ends, usually when the client is discharge from the health care agency. All planning is multidisciplinary (involves all health care providers interacting with the client) and includes the client and family to the fullest extent possible in every step.

Initial planning

The nurse who performs the admission assessment usually develops the initial comprehensive plan of care. This nurse has the benefit of the client’s body language as well as some intuitive kinds of information that are not available solely from the written database. Planning should be initiated as soon as possible after the initial assessment, especially because of the trend toward shorter hospital stays.

Ongoing planning

Ongoing planning is done by all nurses who work with the client. As nurses obtain new information and evaluate the client’s responses to care, they can individualize the initial care plan further. Ongoing planning also occurs at the beginning of a shift as the nurse plans the care to be given that day. Using ongoing assessment data, the nurse carries out daily planning for the following purposes:

to determine whether the client’s health status has changed
to set priorities for the client’s care during the shift
to decide which problems to focus on during the shift
to coordinate the nurse’s activities so that more than one problem can be addressed at each client contact.

Discharge planning

Discharge planning, the process of anticipating and planning for needs after discharge, is a crucial part of comprehensive health care and should be addressed in each client’s care plan. Because the average stay of clients in acute care hospitals has become shorter, people are sometimes discharge still needing care. Although many clients are discharge to other agencies (e.g. long-term care facilities), such care is increasingly being delivered in the home. Effective discharge planning begins at first client contact and involves comprehensive and ongoing assessment to obtain information about the client’s ongoing needs.

Developing a nursing care plan

The end product of the planning phase of the nursing process is a formal or informal plan of care. An informal nursing care plan is a strategy for action that exists in the nurse’s mind. For example, the nurse may think, “Mrs. Pham is very tired. I will need to reinforce her teaching after she is rested.” A formal nursing care plan is a written or computerized guide that organizes information about the client’s care. The most obvious benefit of formal written care plan is that it provides for continuity of care.

A standardized care plan is a formal plan that specifies the nursing care for groups of clients with common needs. An individualized care plan is tailored to meet the unique needs of specific client-needs that are not addressed by the standardized plan.

Guidelines for writing nursing care plan

The nurse should use the following guidelines when writing nursing care plans:

Date and sign the plan.
Use category headings.
Use standardized/approved medical or English symbols and key words rather than complete sentences to communicate your ideas unless the agency policy dictates otherwise.
Be specific.
Refer to procedure books or other sources of information rather than including all the steps on a written plan.
Tailor the plan to the unique characteristics of the client by ensuring that the client’s choices, such as preferences about the times of care and the methods used.
Ensure that the nursing plan incorporates preventive and health maintenance aspects as well as restorative ones.
Ensure that the plan contains interventions for ongoing assessment of the client.
Include collaborative and coordination activities in the plan.
Include plans for the client’s discharge and home care needs.

4- Implementing

In the nursing process, implementing is the action phase in which the nurse performs the nursing interventions. Using NIC terminology, implementing consists of doing and documenting the activities that are the specific nursing actions needed to carry out interventions. The nurse performs or delegates the nursing activities for the intervention that were developed in the planning step and then concludes the implementing step by recording nursing activities and the resulting client responses.

Implementing Skills

To implement the care plan successfully, nurses need cognitive, interpersonal and technical skills. These skills are distinct from one another; in practice, however, nurses use them in various combinations and with different emphasis, depending on the activity. For instance, when inserting a urinary catheter the nurse needs cognitive knowledge of the principles and steps of the procedure, interpersonal skills to inform and reassure the client. And technical skill in draping the client and manipulating the equipment.

The cognitive skills (intellectual skills) include problem solving, decision making, critical thinking, and creativity. They are crucial to safe, intelligent nursing care.

Interpersonal skills are all of the activities, verbal and non-verbal people use when interacting directly with one another. The effectiveness of a nursing action often depends largely on the nurse’s ability to communicate with others. The nurse uses therapeutic communication to understand the client and in turn be understood. A nurse also needs to work effectively with others as a member of the health care team

Technical skills are purposely “hands-on” skills such as manipulating equipment, giving injections, bandaging, moving, lifting and repositioning the clients. These skills are also called tasks, procedures or psychomotor skills. The term psychomotor refers to physical actions that are controlled by the mind, not reflexive.

Process of implementing

The process of implementing normally includes the following:

Reassessing the client
Determining the nurse’s need for assistance
Implementing the nursing interventions
Supervising the delegated care
Documenting nursing activities

5- Evaluating

To evaluate is to judge or to appraise. Evaluating is the fifth and last phase of the nursing process. In this context, evaluating is a planned, ongoing, purposely activity in which clients and health care professionals determine (a) the client’s progress toward achievement of goals/outcomes and (b) the effectiveness of the nursing care plan. Evaluation is an important aspect of the nursing process because conclusions drawn from the evaluation determine whether the nursing interventions should be terminated, continued or changed.

Evaluation is continuous. Evaluation done while or immediately after implementing a nursing order enables the nurse to make on-the-spot modifications in an intervention. Evaluation performed at specified intervals (e.g. once a week for the home care client) shows the extent of progress toward goal achievement and enables the nurse to correct any deficiencies and modify the care plan as needed. Evaluation continuous until the client achieves the health goals or is discharged from nursing care. Evaluation at discharge includes the status of goal achievement and the client’s self-care abilities with regard to follow-up care. Most agencies have a special discharge record for this evaluation.

Through evaluating, nurses demonstrates responsibility and accountability for their actions, indicate interest in the results of the nursing activities, and demonstrates a desire not to perpetuate ineffective actions but to adopt more effective ones.

Process of evaluating client response

Before evaluation, the nurse identifies the desired outcomes (indicators) that will be used to measure client goal achievement. (This is done in the planning step). Desired outcomes serve twp purposes: They establish the kind of evaluative data that need to be collected and provide a standard against which the data are judged. For example, given the following expected outcomes, any nurse caring for the client would know what data to collect.

Daily fluid intake will not be less than 2500ml.
Urinary output will balance with fluid intake.
Residual urine will be less than 100ml.

The evaluation process has 5 components

Collecting data related to the desired outcome (NOC indicators)
Comparing the data with outcomes
Relating nursing activities to outcomes
Drawing conclusions about problem status
Continuing, modifying, or terminating the nursing care plan.

Nursing Process (ADPIE) Guide