Nursing: February 2019

Monday 25 February 2019

NURSING PROCESS - DIAGNOSIS

Diagnosing is the 2^nd phase of nursing process
Nurse uses critical thinking skills to interpret assessment data
All the activities preceding this phase are directed toward formulating nursing diagnosis.
The use of the nursing process and nursing diagnoses is rapidly becoming an integral part of an effective system of nursing practice.
Identification & Development of Nursing Diagnosis began in year 1973.
It is derived from actual or potential problems.
Derived from physiological, social, cultural, developmental and spiritual dimensions of client.

NANDA INTERNATIONAL

NANDA -North American Nursing Diagnosis Association
a professional organization of nurses interested in standardized nursing terminology.
Officially founded in 1982 and develops, researches, disseminates and refines the nomenclature, criteria, and taxonomy of nursing diagnoses.
In 2002 Taxonomy II, which was a revised version of Gordon's functional health patterns, was released.
The current structure of NANDA's nursing diagnoses is referred to as Taxonomy II and has three levels: Domains (13), Classes (47) and (206)Diagnosis labels.

Taxonomy II

Domain

Health
promotion

Nutrition

Elimination/
Exchange

Activity/
Rest

Perception/
Cognition

Self-
perception

Role
relationship

Sexuality

Coping/Stress
tolerance

Life
principles

Safety/
Protection

Comfort

Growth/
Development

Class 1

Health
awareness

Ingestion

Urinary
function

Sleep/Rest

Attention

Self-concept

Caregiving
roles

Sexual
identity

Post-trauma
responses

Values

Infection

Physical
comfort

Growth

Class 2

Health
management

Digestion

Gastrointestinal
function

Activity/
Exercise

Orientation

Self-esteem

Family
relationships

Sexual
function

Coping
responses

Beliefs

Physical
injury

Environmental
comfort

Development

Class 3

Absorption

Integumentary
function

Energy
balance

Sensation/
Perception

Body image

Role
performance

Reproduction

Neuro-behavioral
stress

Value/Belief/
Action
congruence

Violence

Social
comfort

Class 4

Metabolism

Respiratory
function

Cardio-vascular/
Pulmonary
responses

Cognition

Environmental
hazards

Class 5

Hydration

Self-care

Communi-
cation

Defensive
processes

Class 6

Thermo-
regulation

MEANING

The word “diagnosis” is singular and “diagnoses” is plural.
The nursing diagnoses are involved with human responses to stressors or other factors that adversely effect achievement of optimum health.
Treatment is directed towards causes of the responses or factors influencing it.
Nursing diagnoses are different from medical diagnoses.

Differences between nursing and medical diagnosis

S. No.	Nursing	Medical
1.	Diagnose and treat human responses	Diagnose and treat disease
2.	Care for client	Cure disease
3.	Holistic-effects on whole individual	Biological, physical effects
4.	Teach clients to do selfcare and become more independent in daily activities	Teach clients about treatments for their disease

DEFINITION

Nursing diagnosis is a statement or conclusion of a client’s potential or actual health problem resulting from analysis of data.
Nursing diagnosis is a statement of client’s potential or actual alterations/changes in his health status.
A statement that describes a client’s actual or potential health problems that a nurse can identify and for which she can order nursing interventions to maintain the health status, to reduce, eliminate or prevent alterations/changes.
Nursing diagnosis is the problem statement that the nurse makes regarding a client’s condition which she uses to communicate professionally.
A Nursing diagnosis is a statement of a patient problem that is arrived at by making inferences from the collected data (Mundiger and Jauron, 1975),
American Nurses’ Association has implied nursing diagnosis in the definition of nursing: Nursing is the diagnosis and treatment of human responses to actual or potential health problems (ANA, 1980).
“A clinical judgement about individual, family, or community responses to actual or potential health problems/life processes. Nursing diagnoses provide the basis for selection of nursing interventions to achieve outcomes for which the nurse is accountable.” (NANDA, March 1990).

USE/PURPOSE OF NURSING DIAGNOSES
General

Gives Nurses a Common Language
Promotes Identification of Appropriate Goals
Provides Acuity Information
Can Create a Standard for Nursing Practice
Provides a Quality Improvement Base

Specific

For client:

Individualization of care
Appropriate selection of interventions
Establishment of goal

For Nursing:

Facilitates communication, documentation
Continuity of care among health care provider

CHARACTERISTICS OF NURSING DIAGNOSIS

It states a clear and concise health problem.
It is derived from existing evidences about the client.
It is potentially amenable to nursing therapy.
It is the basis for planning and carrying out nursing care.

TYPES OF NURSING DIAGNOSES
Actual Nursing Diagnoses

A client problem that is present at the time of the nursing assessment.
It is based on the presence of signs and symptoms.
Actual Nursing Diagnoses defined as “a clinical judgment that the nurse has validated because of the presence of major defining characteristics.”
EXAMPLES

Ineffective breathing pattern related to bacterial / viral inflammatory Process.
Anxiety related to changes in the environment and routines, threat to socio economic status.
Body image disturbance related to temporary presence of a visible drain/ tube.

Risk Nursing Diagnoses

A clinical judgment that a problem does not exist, therefore no S/S are present, but the presence of risk factors is indicates that a problem is only is likely to develop unless nurse intervene or do something about it.
A clinical judgment that an individual/group is more vulnerable to develop the problem than others in the same or a similar situation because of risk factors.
Describes human responses to health conditions / life processes that may develop in a vulnerable individual / family / community.
EXAMPLES

Risk for impaired skin integrity related to immobility.
Risk for impaired skin integrity related to edema and neuropathy
Risk for injury related to generalized weakness
Risk for Impaired skin integrity (left ankle) related to decrease peripheral circulation in diabetes.
Risk for Impaired skin integrity related to loss of pain perception

Wellness Nursing Diagnoses

Also known as Health-promotion Nursing Diagnosis
A clinical judgment about an individual, family, or community in transition from a specific level of wellness to a higher level of wellness (NANDA-I, 2012).
Describes human responses to levels of wellness in an individual, family or community that have a readiness for enhancement.
A clinical judgment about a person's, family’s or community's motivation and desire to increase wellbeing and actualize human health potential as expressed in the readiness to enhance specific health behaviours, and can be used in any health state.
Health-promotion nursing diagnosis are one part statement includes diagnostic label.

EXAMPLES

Readiness for Enhanced Self-Esteem.
Readiness for enhanced spiritual well being
Readiness for enhanced family coping.

Syndrome Nursing Diagnoses

A syndrome diagnosis comprises a cluster of actual or risk nursing diagnoses that are predicted to present because of a certain situation or event.
A clinical judgment describing a specific cluster of nursing diagnoses that occur together, and are best addressed together and through similar interventions.
Example –

Rape-trauma syndrome as manifested by anger, genitourinary discomfort, and sleep pattern disturbance.

Potential/ Possible Nursing diagnosis

Possible nursing diagnosis is not a type of diagnosis as are actual, risk, and syndrome.
A possible nursing diagnosis is one in which evidence about a health problem is incomplete or unclear. It requires more data either to support or to refuse it.
Possible nursing diagnoses are a diagnostician’s option to indicate that some data are present to confirm a diagnosis but are insufficient at this time.
One in which evidence about a health problem is incomplete or unclear therefore requires more data to support or reject it; or the causative factors are unknown but a problem is only considered possible to occur.
For Eg.

Possible social isolation R/t unknown etiology
Potential risk of constipation as a result of enforced bed rest.
Potential risk of pressure sore development from enforced bed rest.

COMPONENTS OF A NURSING DIAGNOSIS STATEMENT
A nursing diagnostic statement consists of four parts:

Label
Problem
The Related Factor
Defining characteristics

LABEL

It is a concise term or phrase that represents a pattern of related clues.
It may include Qualifiers and modifiers.
Describes the client's health problem or response for which nursing therapy is given.
It describes the client's health status clearly and concisely in few words.
Each diagnostic label approved by NANDA carries a definition that clarifies its meaning.

Purpose:

Is to direct the formation of client goals and desired outcomes.
It may also suggest some Nursing interventions.

Qualifiers and Modifiers - these are words that have been added to some NANDA labels to give additional meaning to the diagnostic statement.

Qualifiers for e.g.

“Deficient” – inadequate in amount, quality, degree, insufficient, incomplete
“Impaired” – made worse, weakened, damaged, reduced, deteriorated
“Decreased” – lesser in size, amount, degree
“Ineffective” – not producing the desired effect
“Compromised” – to make vulnerable to threat

Modifiers for e.g. –

“Acute” – sever, serious, intense, critical
“Chronic” - constant, persisting, ever present
“Depleted” - exhausted, tired, useless
“Disturbed” - troubled, uneasy, unbalanced, bothered
“Dysfunctional” - inability to function, organ or part of body unable to function
“Enhanced” - improved, better
“Excessive” - extreme, too much, unnecessary, disproportionate
“Increased” - greater than before, improved
“Intermittent” - irregular, alternating, discontinuous
“Potential for” - likely to occur, may or might

PROBLEM

The problem in the statement is as identified by the nurse during the assessment phase. The nurse needs to consider two areas while identifying the problem.
Provides a clear, precise description; delineates its meaning and helps differentiate it from similar diagnoses.
Based on data collected
Must be approved NANDA format begin with qualifier or modifiers
Use the exact NANDA wording to state the problem
Examples

Poor sleep pattern/ Sleep Pattern, disturbed
Poor circulation / Tissue perfusion, ineffective (cardiopulmonary)

Problem Identification

What is the problem that is inferred by assessment data?

For example:

Client worried about surgery planned for the next day.
High glucose level due to lack of knowledge about right selection of food items.
Pupil dilated with medicine for eye testing.
Not able to sleep in changed setting of hospital.
Feeling of loneliness.

To what degree is the problem present ?

A degree of problem can be explained as:

Post-operative patient on first day require assistance to brush his teeth.
A malnourished child is at risk for acquiring infection, hypothermia.
A nurse observes indifferent behaviour of mother towards the child.

THE RELATED FACTOR/ ETIOLOGY

The related factors are “conditions or circumstances that can cause or contribute to the development of a diagnosis.”
The factors contributing to or causing the problem
It can't be a medical diagnosis
Must be modifiable by nursing intervention
Nurse must be able and license to do something about it.
The etiology component of a nursing diagnosis identifies one or more probable cause of the health problem, gives direction to the required nursing therapy, and enables the nurse to individualize the client's care.
Examples of related factors are given below:

Environmental – Excessive noise, light, fumes, pollutants.
Psychological – Fear of death, feeling of loneliness, impaired parent-child bonding.
Socio-cultural – Inability to procure food, lack of support system, lack of finances, literacy level.
Physiological – Abnormal fluid loss, sensory deficit, loss of skin integrity, breathing difficulty.
Spiritual – Inability to practice religious rituals, conflict between religious beliefs and prescribed health regimen.

DEFINING CHARACTERISTICS

Defining Characteristics are the cluster of signs an symptoms that indicate the presence of a particular diagnostic label

For Actual Nursing Diagnosis- The Defining Characteristics are the client's signs and symptoms
For Risk Nursing Diagnosis- No subjective and objective signs are present Thus the factors that cause the client to be more than ''Normally'' vulnerable

WRITING THE DIAGNOSTIC STATEMENT
Most Nursing Diagnoses are written as two part or three part statements, but there are variations of these.

One part statements
Two part statements
Three part statements

One-Part Statements

Wellness nursing diagnoses will be written as one-part statements.

e.g., Readiness for Enhanced Parenting

Related factors are not present for wellness nursing diagnoses because they would all be the same: motivated to achieve a higher level of wellness.
Syndrome diagnoses, such as Rape-Trauma Syndrome, have no “related to” designations.

Two-Part Statements

The basic two part statement includes the following.

Problem (P) :- Statement of the client's response (NANDA Label)
Etiology (E) :- Factors contributing to or probable cause of 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.
Risk and possible nursing diagnoses have two parts. The validation for a risk nursing diagnosis is the presence of risk factors. The
Risk factors are the second part, as in:

Risk Nursing Diagnosis Related to Risk Factors
Possible nursing diagnoses are suspected because of the presence of certain factors.

For Examples -

Risk for Impaired Skin Integrity related to immobility secondary to fractured hip
Possible Self-Care Deficit related to impaired ability to use left hand secondary to IV

Three-Part Statements

The three part Diagnostic Statements called the PES format and includes the following:

Problem (P) :- Statement of the client's response (NANDA Label)
Etiology (E) :- Factors contributing to or probable cause of the response.
Signs and Symptoms (S) :- Defining characteristics manifested by the client.

Diagnostic label(Problem) related to contributing factors (Etiology) as evident by signs and symptoms
The presence of major signs and symptoms (defining characteristics) validates that an actual diagnosis is present. This is the third part.
Actual nursing diagnoses can be documented by using the three part statement because the signs & symptoms have been identified.
It is not possible to have a third part for risk or possible diagnoses because signs and symptoms do not exist.
Examples

Anxiety related to unpredictable nature of asthmatic episodes as evident by statements of “I’m afraid I won’t be able to breathe”
Urge Incontinence related to diminished bladder capacity secondary to habitual frequent voiding as evident by inability to hold off urination after desire to void and report of voiding out of habit, not need.

GUIDELINES TO FORMULATE NURSING DIAGNOSTIC

First write an actual or high-risk health problem and not an environmental problem. State environmental factors in the second part.

For e.g.:

Wrong: Excessive environmental stimuli related to monitoring equipment
Right: Sensory perceptual alterations (auditory and visual) related to excessive environmental stimuli

Do not write several unrelated problems in the first part even though the related factor of the problem may be the same.
Judge the problems as unrelated when the nursing plan requires separate interventions for each problem.

For e.g.:

Wrong: Anxiety and activity intolerance related to frequent episodes of chest pain
Right: Activity intolerance related to frequent episodes of chest pain
Right: Anxiety related to frequent episodes of chest pain

Write the diagnostic statement in a manner that both the problem and related factors refer to different findings.

For e.g.:

Wrong: Self-feeding deficit related to inability to feed self.
Right: Self-feeding deficit related to muscle weakness.

Write the diagnosis in legally advisable terms.

For e.g.:

Wrong: Ineffective airway clearance related to inadequate suction.
Right: Ineffective airway clearance related to effects of sedation.

Write the nursing diagnosis in terms of response rather than the need.

For e.g.:

Wrong: Need for maintenance of nutritional intake.
Right: Altered nutrition (less than body requirements) related to nausea and vomiting.

The purpose of nursing diagnosis is to keep the planning care focused on problems that are amenable to nursing interventions.

VERIFICATION OF THE DIAGNOSIS
The accuracy of nursing diagnosis is verified by the nurse asking the following questions.

Is the data base sufficient and accurate?
Does a pattern exist?
Is the nursing diagnosis based on nursing knowledge?
Can the nursing diagnosis be altered by independent nursing actions?

DOCUMENTATION

After developing and verifying nursing diagnosis the nurse documents the statements on the chart and care plan.
The statement must also be included on nurses notes or progress notes, discharge summary and referral forms.
Diagnostic statements are reviewed and revised when it is necessary.

BIBLIOGRAPHY

BNS-101 Nursing Foundation, Published By -IGNOU; 2017 [cited 2018 Feb 25].
“Birpuri” S Sharma. Principles and practice of nursing, Published By -Jaypee Publication, 2012
Burton M, Ludwig LJM. Fundamentals of nursing care: concepts, connections & skills. Second edition. Philadelphia, PA: F.A. Davis Company; 2014.
Kozier B, Berman A, editors. Kozier & Erb’s fundamentals of nursing: concepts, process, and practice. 9th ed. Boston: Pearson; 2012.
Nugent PM, Vitale BA. Fundamentals of nursing: content review plus practice questions. 2014.
Perry AG, Potter PA, Ostendorf W. Clinical nursing skills & techniques. 8th edition. St. Louis, Missouri: Elsevier; 2014.
Potter PA, Perry AG, Hall A, Stockert PA. Fundamentals of nursing. Eighth edition. St. Louis, Mo: Mosby Elsevier; 2013.
Treas LS, Wilkinson JM. Basic nursing: concepts, skills, & reasoning. Philadelphia, PA: F.A. Davis Company; 2014.

Saturday 9 February 2019

NURSING PROCESS - ASSESSMENT

Assessment is the foundation step of nursing process.
It consists of systematic and orderly collection of information pertaining to and about the health status of the client.
It includes the client’s perceived needs, health problems, related experiences, health practices, values and lifestyles.
The information obtained helps to make nursing diagnoses and to develop a plan of care.

PURPOSE OF ASSESSMENT

To establish a data base (all the information about the client) such as -

Nursing health history
Physical assessment
The physician’s history & physical examination
Results of laboratory & diagnostic tests
Material from other health personnel

TYPES OF ASSESSMENT

Initial assessment – Assessment performed within a specified time on admission. To establish a complete database for problem identification, reference and future comparison. Ex: nursing admission assessment
Problem-focused assessment – Ongoing process integrated with nursing care, To use to determine status of a specific problem identified in an earlier assessment. Ex: problem on urination-hourly assessment of fluid intake & urine output hourly
Emergency assessment – Rapid assessment done during any physiologic/physiologic crisis of the client, to identify life threatening problems. Ex: Rapid assessment of a client’s airway, breathing status & circulation after a cardiac arrest; Assessment for suicidal tendency or potential for the violence.
Time-lapsed assessment – reassessment of client’s functional health pattern done several months after initial assessment to compare the client’s current status to baseline data previously obtained. Ex: Follow-up assessment.

COMPONENTS OF ASSESSMENT PHASE

Collection of data
Organization of data
Validation of data
Analyzing of data
Documentation of data

COLLECTION OF DATA

Collection of data is the process of gathering of information about the client’s health status.
It includes accumulation of comprehensive information about the client on initial assessment.
It must be both systematic and continuous to prevent the omission of significant data and reflect a client’s changing health status.
Database is the all information about a client; It includes –

The nursing health history, physical assessment, primary care provider’s history, and physical examination, result of laboratory and diagnostic tests and material contributed by the other health care personnel.
Current/present problems of client (pain, nausea, sleep pattern, religious practices, meds or treatment the client is taking now)
Past health history of client (allergies, past surgeries, chronic diseases, use of folk healing methods)
Physical, psychological, emotion, socio-cultural, spiritual factors that may affect client’s health status

The gathering of information about the client’s well-being status includes:

Strengths as well as weaknesses of patient,
Response of patient to his health concerns,
Analysis of the circumstances associated with patient’s well-being status,
Knowledge related to health and well-being,
Beliefs and values about health,
Life-style,
Health-related goals, and
Support system.

TYPES OF DATA
Subjective data

Also referred to as Symptom/Covert data
Information from the client’s point of view or are described by the person experiencing it.
Information supplied by family members, significant others and other health professionals are considered subjective data.
Example: pain, dizziness, ringing of ears/Tinnitus

Objective data

Also referred to as Sign/Overt data
Those that can be detected observed or measured/tested using accepted standard or norm.
Example: pallor, diaphoresis, BP=150/100, yellow discoloration of skin

SOURCE OF DATA

Primary source - Data directly gathered from the client using interview and physical examination.
Secondary source - Data gathered from client’s family members, significant others, client’s medical records/chart, other members of health team, and related care literature/journals.

METHODS OF DATA COLLECTION
a) Interview

Interview is a planned, purposeful conversation/communication with the client to get information, identify problems, evaluate change, to teach, or to provide support or counseling.
It is used while taking the nursing history of a client.
The client interview is conducted to gather specific information about the client.
The purposes of interview in this phase of assessment are:

To collect specific information required for diagnosis and planning.
To establish a trusting nurse-client relationship.
The allow the client to participate in identification of problems and goal setting.
The assist nurse to determine areas for specific investigation during the process of assessment.
To assist nurse to gain insight into client’s ability to function, severity of his illness and his behavior.

b) Observation

Observation is a method of data collection through the conscious use of 5 senses — sight, smell, hearing and feeling (touch) and instruments.
Observation is a skill that requires practice.
Through the use of senses, the nurse collects data about client, his family and his environment.
Through observation, nurse can also understand the interaction between the client and the environment.
Each observation finding requires further investigation to confirm the impression.

c) Examination

Systematic data collection to detect health problems using unit of measurements, physical examination techniques (IPPA), interpretation of laboratory results.
Substantial data are also obtained by physical examination of the client.

Nurse uses physical examination with the following purposes:
To define the client’s response to the disease process.
To establish baseline data to evaluate the nursing interventions.
To compare the efficiency of medical and nursing interventions.
To substantiate subjective data obtained during interview and other nurse-client interaction.

Physical examination includes various techniques such as inspection, palpitation, percussion, auscultation.
Physical examination Should be conducted systematically:

Cephalocaudal approach – head-to-toe assessment
Body System approach – examine all the body system
Review of System approach – examine only particular area affected

ORGANIZATION OF DATA

Data is organize systematically –

Either in written or computerized format such as Nursing Health History, Nursing Assessment, Or Nursing Data-base Form.
These all formats are based on the conceptual models. These are Maslow’s basic needs, Body System Model and Gordon’s 11 Functional Health Patterns.

VALIDATION OF DATA

The information gathered during 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 complete.
Purposes of data validation

Ensure that data collection is complete
Ensure that objective and subjective data agree
Obtain additional data that may have been overlooked
Avoid jumping to conclusion
Differentiate cues and inferences

Cues – Subjective or objective data observed by the nurse; it is what the client says, or what the nurse can see, hear, feel, smell or measure.
Inferences – The nurse interpretation or conclusion based on the cues.
For Example:

A nurse observes the cues that are an incision is red, hot and swollen wound = nurse make inference that the incision is infected.
A nurse observes the cues that the client’s skin is dry = nurse make inference that the client is dehydrated.

ANALYZE DATA

Compare data against standard and identify significant cues.
Standard/norm are generally accepted measurements, model, pattern.
For Ex:

Normal vital signs,
Standard weight and height,
Normal laboratory/diagnostic values,
Normal growth and development pattern.

DOCUMENTING DATA

The documentation is recording of data accumulated during the assessment.
It is the integral part of all the phases of the nursing process.
Nurse records all data collected about the client’s health status
Data are recorded in a factual manner not as interpreted by the nurse
Record subjective data in client’s word; restating in other words what client says might change its original meaning.

Purposes of Documentation

To communicate the information to the other members of the health team and thereby prevent repetition of asking same questions by other personnel.
To facilitate the delivery of quality client care. The information collected allows the nurse to develop preliminary nursing diagnoses, outcomes and nursing interventions, which later on can be updated, clarified to provide quality care.
To provide a mechanism for the evaluation of individual client care.
To provide a legal record of the care provided to the client.
To serve as a source for identification of research topics for nursing practice.

Guidelines for Documentation for a Nurse

Make entries very objectively without personal opinion, biases. Use quotation marks to clearly identify the statements. For e.g. client’s description of illness: “I have a lump in the abdomen and have come to get it operated”.
Support description or interpretations of objective data by specific observation. For e.g. nurse interprets excessive crying as - Subjective data -moderate hypothermia in a baby; Objective data: Baby looking pale, skin mottled, skin temperature 35º C.
Avoid using generalised terms like “good”, “fair”, “normal”. These descriptions do not mean same to everyone. What is “good” for one person may mean “fair” to another. For e.g. instead of writing bowel pattern - normal, record “bowels moved everyday without the use of laxatives.”
Avoid using superfluous information. For e.g. “The child had swallowed kerosene, one year back and was taken to nursing home, there the child was kept in ICU and discharged after one week.” This information can be written as “History of kerosene poisoning one year back, treated in private agency and discharged after one week.”
Record the findings with description like size and shape. These kinds of descriptions are important to evaluate the effectiveness of nursing intervention at a later date. For e.g. description of wound will include information related to colour, size, location, drainage.
Write legibly and correct any errors by drawing a line so that the original entry is also readable e.g. Pain chronic
Use correct language and spelling.
Use abbreviations approved for use.

BIBLIOGRAPHY

BNS-101 Nursing Foundation, Published By -IGNOU; 2017 [cited 2018 Feb 25].
“Birpuri” S Sharma. Principles and practice of nursing, Published By -Jaypee Publication, 2012
Burton M, Ludwig LJM. Fundamentals of nursing care: concepts, connections & skills. Second edition. Philadelphia, PA: F.A. Davis Company; 2014.
Kozier B, Berman A, editors. Kozier & Erb’s fundamentals of nursing: concepts, process, and practice. 9th ed. Boston: Pearson; 2012.
Nugent PM, Vitale BA. Fundamentals of nursing: content review plus practice questions. 2014.
Perry AG, Potter PA, Ostendorf W. Clinical nursing skills & techniques. 8th edition. St. Louis, Missouri: Elsevier; 2014.
Potter PA, Perry AG, Hall A, Stockert PA. Fundamentals of nursing. Eighth edition. St. Louis, Mo: Mosby Elsevier; 2013.
Treas LS, Wilkinson JM. Basic nursing: concepts, skills, & reasoning. Philadelphia, PA: F.A. Davis Company; 2014.

NURSING PROCESS - INTRODUCTION

Practice of nursing is caring which is directed by the way the nurses view the client, the client’s environment, health and the purpose of nursing.
To nurses the nursing process provides a useful description of how nursing should be performed.
As nurses remain in constant interaction with their clients, professional colleagues, medical and health care team members, they have the best opportunity to assess the patient’s needs and provide evidence-based care.

HISTORY OF NURSING PROCESS

The term ‘Nursing Process’ was first used/mentioned by ‘Lydia Hall’, a nursing theorist, in 1955 wherein she introduced 3 STEPs: Observation, Administration of care and Validation.
In 1967, Yura and Walsh added assessment to the three steps and described a four phase process (APIE).
In the mid-1970s an addition of diagnostic phase resulted into a five step process (ADPIE).
The use of nursing process in clinical practice was started in 1973 by the American Nurses Association (ANA) in Standards of Nursing Practice.
After 1980 the nursing process was added to the General Nursing Curriculum in India.
In 1991, revisions were made to the standards to incorporate outcome identification in the planning phase. now a 6-step process (ADOPIE) Assessment, Diagnosis, Outcome Identification, Planning, Implementation and Evaluation.

DEFINITION

The two words of nursing process are significant - Nursing and Process.

Nursing - caring the clients during times of illness and assisting the client to achieve maximum health potential throughout the life cycle.
Process - a series of rational thoughts, decisions and acts to achieve a goal. It implies a movement which has beginning, middle and an ending.

“The nursing process is systematic, goal directed, Client-centered method for structuring the delivery of nursing care.”
Nursing Process (NP) is defined as a systematic, continuous and dynamic method of providing care to clients. It comprises series of sequential phases built upon the preceding step. Each phase logically leads to the next. As one step leads to the next step it results into ultimate achievement of mutually determined nursing outcomes/goals.

CHARACTERISTIC OF NURSING PROCESS

It is a G O S H approach (goal-oriented, organized, systematic and humanistic care) for efficient and effective provision of nursing care.

Goal-oriented – Nurse make her objective based on client’s health needs.
Note: Goals and plan of care should be base according to client’s problems / needs NOT according to your own problem as the nurse.
Organized / Systematic – The nursing process is composed of 6 sequential and interrelated steps and these 6 phases follow a logical sequence.
Individualized & Humanistic care - plan to care is developed and implemented taking into consideration the unique needs of the individual client in providing care, it involves respect of human dignity. Therefore, it is individualized (no 2 person has the same health needs even with same health condition/illness).

OTHER (ASIDE FROM GOSH)

Cyclic and Dynamic in nature – data from each phase provides the input into the next phase so that is becomes a sequence of events (cycle) that are constantly changing (dynamic) base on client’s health status.
Involves skill in Decision-making – nurse makes important decisions related to client care, she choose the best action/steps to meet a desired goal or to solve a problem. She must make decisions whenever several choices or options are available.
Uses Critical Thinking skills – the nurse may encounter new ideas or less-than-routine or non-ordinary situations where decisions must be made using critical thinking.

PURPOSE OF NURSING PROCESS

General

To help the nurse provide goal-directed, client-cantered care

Specific

To identify a client’s health status; his Actual/Present and potential/possible health problems or needs.
To establish a plan of care to meet identified needs.
To provide nursing interventions to meet those needs.
To provide an individualized, holistic, effective and efficient nursing care.

PHASES OF NURSING PROCESS

Assessment - involves collection of information or details about the client obtained from different sources, e.g., through interview, physical examination using different methods and clinical examination.
Nursing Diagnosis- identify the client’s problem(s).
Outcome identification & Planning - development of strategies to alleviate client’s problem identified in nursing diagnosis through a series of steps.
Implementation - starting and completing the strategies planned with help of client, family members and health care team members.
Evaluation - assessment of strategies planned to alleviate the clients’ suffering or otherwise re-plan and revise the care.

BIBLIOGRAPHY

BNS-101 Nursing Foundation, Published By -IGNOU; 2017 [cited 2018 Feb 25].
“Birpuri” S Sharma. Principles and practice of nursing, Published By -Jaypee Publication, 2012
Burton M, Ludwig LJM. Fundamentals of nursing care: concepts, connections & skills. Second edition. Philadelphia, PA: F.A. Davis Company; 2014.
Kozier B, Berman A, editors. Kozier & Erb’s fundamentals of nursing: concepts, process, and practice. 9th ed. Boston: Pearson; 2012.
Nugent PM, Vitale BA. Fundamentals of nursing: content review plus practice questions. 2014.
Perry AG, Potter PA, Ostendorf W. Clinical nursing skills & techniques. 8th edition. St. Louis, Missouri: Elsevier; 2014.
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