Nursing process

Nursing process-

Nursing process is a systematic method of providing care to clients.

Definition-

Nursing process is a framework that enables the nurse and the client together to resolve health related problems of the client in a systematic, organized and logical way.

Nursing process is a critical thinking process that professional nurses use to apply the best available evidence to caregiving and promoting human function and responses to health and illness.

                                                                                                   (American Nursing Association, 2010)

Purposes-

  • It provides a framework within which nurses can identify client’s health status and provide quality care and checks its outcomes through evaluation.
  • It helps in providing organized priority based care.
  • It encourages clients and family participation in care.
  • It helps in rendering individualized care.
  • It avoids unnecessary (duplication of) nursing actions thus saves time.

Characteristics of nursing process-

  • Cyclic
  • Dynamic nature
  • Client centeredness
  • Focus on problem solving and decision making
  • Universal applicability
  • Use of critical thinking and clinical reasoning
  • Interpersonal and collaborative style
  • Prioritizing the needs

Steps-

Nursing process consists of the following steps-

  • Assessment
  • Nursing Diagnosis
  • Planning
  • Implementation
  • Evaluation

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. The information obtained helps to make nursing diagnosis and to develop a plan of care.  Information’s are obtained by data collection.

Types of Data-

  • Subjective data- What the client says about himself.
  • Objective data- What the health practitioner observes about the client.

The methods of data gathering are the following-

  • The interview
  • The nursing history
  • The physical examination ---- Observation and measurement
  • The psychological and mental health examination ----Psycho-Social measurement
  • Laboratory Data

Nursing Diagnosis

A clinical judgment concerning a human response to health condition/ life processes, or a vulnerability for that response, by an individual, family group, or community.

                                                                                                                         (NANDA)

Components of a NANDA-

A nursing diagnosis has three components-

  • The problem and its definition
  • The etiology
  • The defining characteristics

The diagnostic process involves processing the data by classification interpretation and validation. Writing nursing diagnostic statement is the basis of identifying client’s problems and strengths. The health problem and the etiological factor are reflected in the formulation of diagnostic statement. The diagnosis is verified with the client and documented.

Formulating Diagnostic Statement-

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

  • Problem (P) – Statement of the client health problem.
  • Etiology (E) - causes of the health problem.
  • Sign and symptoms(S)-Characteristics manifested by the client.

Planning-

Planning includes setting priorities and writing outcomes. The different problems of the client identified in the nursing diagnosis needs to be prioritized. The nurse can determine priority problems related to needs of client.

Outcomes/goals are written from the diagnostic statement in terms of client’s behaviour that are desired to be achieved by the nurse in the limited time. The characteristic features of outcomes are:

  • Client centered
  • Observable and measurable
  • Time limited and realistic.

The areas in which outcomes are written include-

  • Appearance and functioning of the body,
  • Specific symptoms,
  • Knowledge,
  • Psychomotor skills and emotional status.

Implementation-

Implementation involves preparation for executing the plan and carrying the interventions to resolve client’s problem. The interventions include all those independent, dependent and interdependent nursing actions carried out by the nurse to restore health, prevent illness, promote wellness and facilitate copying with altered functioning. The implementation of nursing action is followed by complete and accurate documentation of events.

  • To implement nursing care plan successfully, nurse need to have following skills.
  • Cognitive skills-Including problem solving and decision making
  • Interpersonal skills- include verbal and non- verbal response, communication
  • Technical skills- include hand on skills need to perform procedures such as administrating injection, drugs, lifting, moving.

Evaluation-

Evaluation is used to judge each component of nursing process. It measures the effectiveness of nursing interventions. It consists of comparing and judging the data about client’s progress. The client’s response to the nursing interventions will guide the nurse to continue with the plan care, modify it or terminate. In case the plan of care needs modification the nurse will reassess and carry out the remaining steps of nursing process. When the care is continued the ongoing process of assessment and evaluation is continued.

While documenting evaluating phase, the nurse can draw one of the three possible conclusion-

  • The goal was met-The client response is the same as the desire outcomes.
  • The goal was partially met- Either a short term goal was achieved but the long term was not, or the desire outcome was only partially attained.
  • The goal was not met

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