Nursing Process

 Is a systematic, rational method of planning and providing individualized

nursing care.
 Purposes:

 to identify client’s health status and actual or potential health care

problems or needs
 to establish plans to meet the identified needs

 to deliver specific nursing interventions to meet those needs

Characteristics of the Nursing Process

1. it is cyclic and dynamic in nature
2. client centered-ness
3. focus on problem solving and decision making
4. it is interpersonal and collaborative
5. it is universal
6. Use of critical thinking and clinical reasoning

Phases of the Nursing Process

Overview of the Nursing Process

1. ASSESSMENT
2. DIAGNOSIS
3. PLANNING
 4. IMPLEMENTATION
5. EVALUATION

I. Assessment
 Is collecting, validating, organizing and recording data about the client's
health status (may be an individual, family or community)
• Purpose: To establish a data base.

Activities During Assessment:

 Collection of data. Gathering information about the client, considering the
physical, psychological, emotional, socio-cultural, and spiritual factors that
may affect his/or her health status.
 Verifying/ Validating Data. Making sure your information is accurate

 Organizing data. Clustering facts into groups of information

Types of Data:
a. Subjective data (symptoms). Those that can be deseribed only by the
person experiencing it, e.g. vertigo, pain, tinnitus (vertigo is dizziness;
tinnitus is ringing of the ears).
b. Objective data (signs). Those that can be observed and measured e.g.
pallor, diaphoresis, BP=120/80, reddish urine.

Methods of Collection of Data:

a. Interview. Planned purposeful conversation.
b. Observation. E.g. use of sense, use of units of
measure, physical examination techniques, interpretation of laboratory results

Sources of Data:
 Primary: Patient/ Client
 Secondary: Family members, significant others, patient’s record/ chart,
health team members
Types of Assessment
(pls refer to attached files) book no. page

II. Diagnosis
 Is a process which results to a diagnostic statement or nursing diagnosis.

 It is the clinical act of identifying problems.

 It means to analyze assessment information and derive meaning from this

analysis
 Purpose: to identify the client’s health care needs and to prepare
diagnostic statements.

Nursing Diagnosis is a statement of client’s potential or actual alteration of

health status. It uses the critical-thinking skills of analysis and synthesis. Uses
PRS/ PES format
o P – problem

o R – related to factors

o S – signs and symptoms

o P – problem

o E – etiology

o S – sign and symptoms

Activities During Diagnosing:

 Organize cluster or group data.

 Compare data against standard.

 Analyze the data after comparing with the standards

 Identify gaps and inconsistencies in data

 Determine the clients health problems, health risks, and strengths.

 Formulate Nursing Diagnoses statements. (See attached file)

III. Planning
 Involves determining beforehand the strategies or course of actions to be
taken before implementation of nursing care.
 To be effective, involve the client and his family in planning

Purposes:
 To identify the clients goals and appreciate nursing interventions

 To direct client care activities

 To promote continuity of care

 To focus charting requirements

 To allow for delegation of specific activities

Types of Planning
 Initial Planning

 This is done by the nurse who performs the admission

assessment.

 Ongoing Planning

 Occurs at the beginning of a shift a the nurse plans the care to

be given that day.
 Purpose:

 To determine whether the clients health status has

changed
 To set priorities for the clients 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
  The process of anticipating and planning for needs after
discharge
 Effective discharge planning begins at first client contact and
involves comprehensive and ongoing assessment to obtain
information about the client’s ongoing needs

Developing Nursing Care Plan

 The nursing plan of care is a written summary of the care that a client is to
receive. It is the “Blueprint” of the nursing proces
 The plan of care is nursing centered. This is essential to identify the scope
and depth of the nursing practice. By focusing on the treatment of human
responses to actual or potential health problems, the nurse remains in the
nursing practice domain

 The plan of care is a step by step process. This is evidenced by the

following:
 Sufficient data are collected to substantiate nursing diagnosis

 Atleast one goal must be stated for each nursing diagnosis

 Outcome criteria must be identified for each goal

 Nursing intervention must be specifically designed to meet the

identified goal
 Each intervention should be supported by a scientific rationale is
the justification or reason for carrying out the intervention
 Evaluation must address whether each goal was completely met,
partially met, or completely unmet.

Guidelines for Writing Nursing Care Plans

1. Date and sign the plan
2. Use category heading
3. Use standardized/ approved medical or englush symbol and keywords
rather than complete sentences to communicate your ideas unless agency
policy dictates otherwise.
4. Be specific
5. Refer to procedure books or other sources of information rather than
including all the steps on a written plan.
6. Tailor the plan to the unique characteristics of the client by ensuring the
clients choices, such as preferences about the times of care and methods
used, are included.
7. Ensure that the nursing plan incorporates preventive anfd health
maintenance spect as well as restorative ones.
8. Ensure that the plan contains ongoing assessment of the client.
9. Include collaborative and coordination activities in the plan.
10. Include plans for the client’s discharge and home care needs

THE PLANNING PROCESS

 In the process of developing client care plana, the nurse engages in the
following activities:
1. Setting priorities
2. Establishing client goals/ desired outcomes
3. Selecting nursing interventions and activities
4. Writing individualized nursing interventions on care plans.

SETTING PRIORITIES
 Is the process of establishing a preferential sequence for
addressing nursing diagnosis and interventions
 The nurse and the client begin panning by deciding which nursing
diagnosis requires attention first, which second, and so on.
 The nurse must consider a variety of factors when assigning
priorities, includes the following:
 Client's health values and beliefs

 Client’s priorities

 Resources available to the nurse and the client

 Urgency of the health problem

  Medical treatment plan

ESTABLISH CLIENT GOALS/ DESIRED OUTCOMES

 What the nurse hopes to achieve by implementing the nursing
interventions
 Goals – broad statement

 Desired outcomes – specific statements

 Writing the broad, general goal first may help to think of the specific
outcomes that are needed.

 Outcome criteria are SMART:

S – SPECIFIC
M – MEASURABLE
A – ATTAINABLE
R – REALISTIC
T – TIME FRAMED

Purpose of Goals/ Desired Outcomes

1. Provide direction for planning nursing interventions.
2. Serve as criteria for evaluting client progress
3. Enable the client and nurse to determine when the problem has been
resolved
4. Help motivate the client and nurse by providing a sense of achievement

Short – term and Long – term goals

 Short – term: can be met in a relatively short period (days to less than a
week)
 Long – term: require more time (several weeks or months)
Components of Goals/ Desired Outcome statements
1. Subject – the client or a client’s parts of the body
2. Verb – action the client is to perform
3. Conditions or modifiers – behavior to be performed
4. Criterion of desired performance – specify the time or speed, accuracy,
distance, and quality. The time established criterion.

SELECTING NURSING INTERVENTION AND ACTIVITIES

 TYPES OF NURSING INTERVENTION

 Independent intervention

 Dependent intervention

 Collaborative intervention

WRITING INDIVIDUALIZED NURSING INTERVENTIONS ON CARE PLANS

(see attached files)

IV. Implementation
 Is putting the nursing care plan into action

 Purpose: to carry out planned nursing interventions to help the client

attain goals and achieve optimal level of health

 Activities:

 Reassesing: to ensure prompt attention to emerging problems

 Set priorities: to determine the order in which nursing interventions

are carried out
 Perform Nursing Intervention: these may be independent,
dependent, or collaborative measures.
 Record actions: to complete nursing interventions, relevant
documentation should be done.
  Requirements for Implementation:

1. Knowledge: include intellectual skills like problem solving, decision making

and teaching
2. Technical skills – to carry out treatments and procedure
3. Communication skills: use of verbal and non verbal communication to
carry out planned nursing interventions
4. Therapeutic use of self: it is being willing and being able to care.

V. Evaluation
 Is assessing the client’s response to nursing interventions and then
comparing the response to predetermined standards or outcome criteria.
 Purpose: to appraise the extent to which goals and outcome criteria of
nursing care have been achieved

 Activities:

 collect data about the client’s response

 compare the client’s response to goals and outcome criteria

 the four possible judgements that may be made are as follows:

a. the goal was completely met

b. the goalwas partially met
c. the goal was completely unmet
d. new problems or nursing diagnosis habe developed
 analyze the reason for the outcome

 modify care plan as needed.

IV. Documentation and Reporting

 Documentation
 a. Records are legal documents and are admissible as evidence in a court of
law
b. Falsification is a crime
c. Nurses must accurately documented each step of the nursing process in
the client’s record
d. It should be brief, accurate, legible, chronologic, made on consecutive
lines and appropriately signed
Ensuring Confidentiality of Computer Records
1. A personal password is required to enter and sign off computer files. Do not
share this password with anyone, includign other healthcare team members.
2. After logging on, never leave a computer terminal unattended.
3. Do not leave client information displayed on the monitor where others may
see it.
4. Shred all unneeded computer generated worksheet.
5. Know the facility’s policy and procedure for correcting an entry error
6. Follow agency procedure for documenting sensitive material, such as
diagnosis of AIDA.
7. Information technology (IT) personnel must install a firewall to protect the
server from unauthorized access.

PURPOSES OF CLIENT RECORDS

1. Communication
2. Planning client care
3. Auditing health agencies
4. Research
5. Education
6. Reimbursement
7. Legal documentation
8. Health care analysis

DOCUMENTATION SYSTEMS
1. Source-Oriented Record
 Traditional client record

 Narrative charting

 Convenient because care providers from each discipline can easily locate
the forms on which to record data and it is easy to trace the information
specific to one’s discipline.
2. Problem-Oriented Medical Record
 Establish by Lawrence Weed in 1960

 Data are arranged according to the problems the client has rather than the
source of the information

POMR
 Advantage of POMR

1. It encourages collaboration
2. The problem list in the front of the chart alerts caregivers to the clients
need and make it easier to track the status of each problem.

 Disadvantages of POMR

1. Care givers differ in their ability to use the required charting format
2. It takes constant vigilance to maintain an up to date problem list
3. It is somewhat inefficient because assessments and interventions that
apply to more than one problem must be repeated

4 basic components of POMR

1. Data base
 Consist of all the information known about the client when the client
first enters the health care agency.
2. Problem list
 Derived from the data base
  Usually kept at the front of the chart and serves as an index to the
numbered entries in the progress notes.
 Primary care providers write problems as medical diagnoses,
surgical procedures, or symptoms; nurses write problems as
nursing diagnoses
3. Plan of care
 Made with reference to the active problems.

 Doctors order

 Nursing care plan

4. Progress notes
 Chart entry made by all health professionals involved in a client’s
care
 Use the same type of sheets for notes

 Format: S-O-A-P/ S-O-A-P-I-E/ S-O-P-I-E-R

S – subjective
O – objective
A – assessment
P – plan
I – intervention
E – evaluatin
R – revision
3. PIE
 Problem, Interventions, and Evaluation

 This system eliminates the traditional care plan and incorporates an ongoing
care plan into the progress notes. Therefore, the nurse does not have to
create and update a separate plan
 The disadvantage is that the nurse must review all of the nursing notes before
giving care to determine which problems are current and which interventions
were effective.
4. Focus Charting
1. Intended to make the client and client concerns and strengths the
focus of care.
2. Example:

5. Charting by Exception (CBE)

 Documentation system in which only abnormal findings or
exceptions to norms are recorded
 Elements of CBE:

1. Flow sheets
2. Standards of nursing care
3. Bedside access to chart forms

6. Computerized Documentation (Electronic Health Record/ EHRs)

 Used to manage the huge volume of information required in contemporary
healthcare
 Can integrate all pertinent client information into one record.

7. Case Management
 This model emphasizes quality, cost-effective care delivered within an
established length of stay.
 Uses a multidisciplinary approach to planning and documenting client
care, using critical pathways.
 These forms identify the outcomes that certain groups of clients are
expected to achieve on each day of care, along with the intervention
necessary for each day.
 Promotes collaboration and team work among caregivers, helps to
decrase the length of stay, and makes efficient use of time
  Care is goal focused, quality may improve

DOCUMENTS NURSING ACTIVITIES

1. Admission Nursing Assessment
2. Nursing Care Plans
3. Kardexes
4. Flow Sheets
a. Graphic record
b. Intake and Output Record
c. Medication Administration Record
d. Skin Assessment Record
5. Progress Notes
6. Nursing Discharge/ Referral Summaries

GENERAL GUIDELINES FOR RECORDING

1. Date and Time
2. Timing
3. Legibility
4. Permanence
5. Accepted Terminology
6. Correct Spelling
7. Signature
8. Accuracy
9. Sequence
10. Appropriateness
11. Completeness
12. Conciseness
13. Legal Prudence
REPORTING
 Purpose: to communicate specific information to a person or group of
people
1. Change of Shift Report
2. Telephone Reports
3. Telephone Orders
4. Care Plan Conference
5. Nursing Rounds