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Nursing Process care plan

What Is Nursing Process

The nursing process is a scientific method used by nurses to ensure the quality of patient care. It is specific to the nursing profession and it is framework for critical thinking.

One definition of the nursing process…”an assertive, problem solving approach to the identification and treatment of patient problems. It provides an organizing framework for the practice of nursing and the knowledge, judgments, and actions that nurses bring to patient care.”

“Diagnose and treat human responses to actual or potential health problems”

  • Organized framework to guide practice
  • Problem solving method – client focused
  • Systematic- sequential steps
  • Goal oriented- outcome criteria
  • Dynamic-always changing, flexible
  • Utilizes critical thinking processes

This approach can be broken down into five separate steps…

Assessment

the first step in delivering nursing care. Assessment includes not only physiological data, but also psychological, socio-cultural, spiritual, economic, and life-style factors as well. For example, a nurse’s assessment of a hospitalized patient in pain includes not only the physical causes and manifestations of pain, but the patient’s response—an inability to get out of bed, refusal to eat, withdrawal from family members, anger directed at hospital staff, fear, or request for more pain mediation. Nurse can gather information/collect data from two ways….

  • Primary Source – Gather information from Client / Family
  • Secondary Source – Gather information with physical exam, nursing history, team members, lab reports, diagnostic tests…..
  • Subjective -Client and relatives himself verbalized the feelings or pain (symptom)
    • “I have a headache”
  • Objective – Nurse or healthcare worker observes (sign)
    • Blood Pressure 130/80

Assessment-collection of Data

  • Nurse has to interview the client related to his health and family history.
  • Health Assessment -Head to foot examination
  • Physical Examination
    • Inspection
    • Palpation
    • Percussion
    • Auscultation
  • Make sure information is complete & accurate

Nursing Diagnosis

The second phase of the nursing process is diagnosing. The diagnosing phase involves a nurse making an educated judgment about a potential or actual health problem with a patient. Multiple diagnoses are sometimes made for a single patient. The nurse takes the information from the assessment, analyzes the information and identifies problems where patient outcomes can be improved through the use of nursing interventions. Formulate Nursing Diagnosis (NANDA : North American Nursing Diagnosis Association)-Statement of how the client is RESPONDING to an actual or potential problem that requires nursing intervention

Formulation of nursing diagnosis

Composed of 3 parts

  • Problem statement- the client’s response to a problem
  • Etiology- what’s causing/contributing to the client’s problem
  • Defining Characteristics- what’s the evidence of the problem

Types of nursing diagnosis

  • Actual – Imbalanced nutrition; less than body requirements RELATED TO chronic diarrhea, nausea, and pain, height 5’5” weight 105 lbs.
  • Risk – Risk for falls RELATED TO altered gait and generalized weakness
  • Wellness – Family coping: potential for growth RELATED TO unexpected birth of twins.

Collaborative problems

Customer require both nursing interventions and medical interventions

EXAMPLE: Client admitted with medical diagnosis of pneumonia

Collaborative problem = respiratory insufficiency

Nursing  interventions: Raise height of bed, Encourage deep breathing exercises

MD interventions: Antibiotics IV, oxygen therapy

Planning

This is third step of the nursing process. Once a patient and nurse agree on the diagnoses, a plan of action can be developed. If multiple diagnoses need to be addressed, the nurse will prioritize each assessment and devote attention to severe symptoms and high risk factors. Each problem is assigned a clear, measurable goal for the expected beneficial outcome

  • This is when the nurse organizes a nursing care plan based on the nursing diagnoses.
  • Nurse and client formulate goals to help the client with their problems
  • Expected outcomes are identified
  • Interventions (nursing orders) are selected to aid the client reach these goals.

Planning – Begin by prioritizing client problems

  • Prioritize list of client’s nursing diagnoses using Maslow
  • Rank as high, intermediate or low
  • Client specific
  • Priorities can change

Goals are patient-centered and SMART

  • Specific
  • Measurable
  • Attainable
  • Relevant
  • Time Bound

Planning-selects intervention

  • Interventions are selected and written.
  • The nurse uses clinical judgment and professional knowledge to select appropriate interventions that will aid the client in reaching their goal.
  • Interventions should be examined for feasibility and acceptability to the client
  • Interventions should be written clearly and specifically.

Intervention-3 types

  • Independent ( Nurse initiated )- any action the nurse can initiate without direct supervision
  • Dependent ( Physician initiated )-nursing actions requiring MD orders
  • Collaborative- nursing actions performed jointly with other health care team members

Implementation

The fourth step in the Nursing Process. This is the “Doing” step. Carrying out nursing interventions (orders) selected during the planning step. Nursing care is implemented according to the care plan, so continuity of care for the patient during hospitalization and in preparation for discharge needs to be assured. Care is documented in the patient’s record. This includes monitoring, teaching, further assessing, reviewing Nursing Care Plan, incorporating physicians orders and monitoring cost effectiveness of interventions

The implementation phase may be performed using a combination of direct care and indirect care.

Direct care – is care that is given directly to the patient in either a physical or verbal manner.

Indirect care – is care that is given while away from the patient.

Evaluation

Final step of the Nursing Process but also done concurrently throughout client care. Once all nursing intervention actions have taken place, the nurse completes an evaluation to determine of the goals for patient wellness have been met. The possible patient outcomes are generally described under three terms:

  • Patient’s condition improved
  • Patient’s condition stabilized
  • Patient’s condition deteriorated, died, or discharged.

In the event the condition of the patient has shown no improvement, or if the wellness goals were not met, the nursing process begins again from the first step. It evaluates…..

  • A comparison of client behavior and/or response to the established outcome criteria
  • Continuous review of the nursing care plan
  • Examines if nursing interventions are working
  • Determines changes needed to help client reach stated goals.
  • Outcome criteria met? Problem resolved!
  • Outcome criteria not fully met? Continue plan of care- ongoing.
  • Outcome criteria unobtainable- review each previous step of Nursing Care Plan and determine if modification of the Nursing Care Plan is needed.
  • Were the nursing interventions appropriate/effective?
  • Outcome criteria met? Problem resolved!
  • Outcome criteria not fully met? Continue plan of care- ongoing.
  • Outcome criteria unobtainable- review each previous step of Nursing Care Plan and determine if modification of the Nursing Care Plan is needed.
  • Were the nursing interventions appropriate/effective?