Nursing Process




NURSING PROCESS

The nursing process is a problem-solving approach that enables the nurse to provide care in an organized scientific manner.

The goal of the nursing process is to alleviate , minimize, or prevent actual or potential health problems. The nursing process can be applied in any interaction that involves a nurse and a client.

The process can take place in a variety of settings, including a hospital, community setting, private home,or long term care facility.

The 5 steps/components of NURSING PROCESS are, assessment, nursing diagnosis, planning, implementation, and evaluation.

5 Components/ Steps of Nursing Process


ASSESSMENT

The nurse collects data about the health statis of the client. The data is subjective and objective.

Subjective data is usually documented in the clients own words. This data includes such things as previous experiences,and sensations or emotions that only the client can describe.

The Objective data is obtained by the health team, through observation, physical examination, or/and diagnosistic testing. Objective data can be seen or measured.
Sources of subjective data and objective data are the client, the family and significant others, medical records, and other health care team members.

Assessment includes, the "HEALTH HISTORY" and "physical assessment".

Physical assessment can be broken down into four components(2);

* Inspection,
* Palpation,
* Percussion,
* Auscultation.

INSPECTION:
Inspection is the visual examination of the client.

Guidelines for Effective Inspection
* Be systematic
* Fully expose the area to be inspected;cover other body parts to respect the client's modesty.
* Use good light, preferably natural light.
* Maintain comfortable room temperature.
* Observe color, shape, size, symmetry,position,and movement
* Compare bilateral structures for similarities and differencess.

PALPATION:

Palpation uses the sense of touch to assess various parts of the body and helps to confirm findings that are noted on inspection.

The hands, especially the finger tips are used to assess skin temperature,check pulses, texture, moisture, masses, tenderness , or pain.

Ask the Client for permission first and explain to your client what you intend to examine. Establish client trust with being professional. Please remember to use warm hands.

Any tender areas should be palpated last.
Types of Palpation:

1. Light Palpation:To check muscle tone and assess for tenderness
2. Deep Palpation:To identify abdominal organs and abdominal masses.

PERCUSSION:

Percussion is the striking of the body surface with short, sharp strokes in order to produce palpable vibrations and characteristic sounds. It is used to determine the location, size, shape, and density of underlying structures; to detect the presences of air or fluid in a body space; and to elicit tenderness. (2)
Note when examining Abdomen, you auscultate first followed by percussion then palpation.
Types of Percussion

1. Direct Percussion: Percussion in which one hand is used and the striking finger of the examiner touches the surface being percussed.
2. Indirect Percussion:Percussion in which two hands are used and the plexor strikes the finger of the examiner's other hand, which is in contact with the body surface being percussed.
3. Blunt Percussion: Percussion which the ulnar surface of the hand or fist is used in place of the fingers to strike the body surfae, either directly or indirectly.

Percussion Sounds

* Resonance:A hollow sound.
* Hyperresonance:A booming sound.
* Tympany:A musical sound or drum sound like that produced by the stomach.
* Dullness: Thud sound produced by dense strucvtures such as the liver, and enlarged spleen, or a full bladder.
* Flatness:An extremely dull sound like that produced by very dense structures such as muscle or bone.

AUSCULTATION:

Auscultation is listening to sounds produced inside the body. These include breath sounds, heart sounds, vascular sounds, and bowel sounds. It is used to detect the presence of normal and abdomal sounds and to assess them in terms of loudness, pitch, quality , frequency and duration.


NURSING DIAGNOSIS:


The nursing diagnosis is derived from data gatered during the assessment. Health problems or potential health problems are identified and formulated into nursing diagnosis. Nursing Diagnosis is the basis for planning nurisng interventions that help prevent, minimize or aleviate specific health issues.

A Medical Diagnosis is much different than nursing diagnosis, it is used to define etiology of the disease. It only focuses is on the function and malfunction of a specific organ system.

The two are very different.

A Nursing Diagnosis is written in a format called "PES ", devloped by NANDA(1).

* "P" stands for PROBLEM
* "E "satnds for ETIOLOGY or cause of problem
* "S "stands SIGNS and SYMPTOMS of problem

By usimg all of the components of the nursing diagnosis, the problem is clearly communicated to everyone involved in the clients care.
Measurement Criteria:

1. Diagnosis are derived from the assessment data
2. Diagnosis is validated with the client.
3. Diagnosis is documented to aid in the expected outcomes and plan of care.

PLANNING


The planning phase of the Nursing Process involves the devlopment of a nursing care plan for the client based on the nursing diagnosis. The nursing care plan is a communication tool used by Nurses to care for their clients. Care plans that are kept up to date are vital tools to provide continuity of care, prevent complications and provide for health teaching and discharge planning. Goals should be stated in terms of client outcomes. Nursing outcomes examplaes are: Skin and Mucous Membranes,Wound Healing,Primary Intention,and Urinary Continence. Each of these nursing sensitive outcomes is labeled,defined,and includes criteria for the assessing the status of the outcome over time.

Nursing orders are the actions for interventions prescribed to help achieve the stated goals and objectives. When writng nursing orders remember to include:

1. What
2. Where
3. When
4. How much
5. and How long.

The steps in Nursing Care Planning are:

1. Determine priorities from the list of nursing diagnoses.
2. Set long-term and short-term gols to determine outcomes of care.
3. Develop objectives to reach the goals.
4. and Write nursing orders to direct care to meet the goals.

Measurement Criteria:

1. The plan is individualized to the client's condition.
2. The plan is developed with the client and significant others if appropriate.
3. The plan reflects current nursing practice.
4. The plan is documented.
5. The plan provides for continuity of care.

IMPLEMENTATION

Implementation is the actual performance of the nursing interventions identified in the care plan. The implementations are co ordinated with other members of the health care team who have direct care of the client.These interventions include , but are not limited to; health teaching, direct client care, medical treatments, medications, and dressing changes. Nurses provide care to achieve established goals of care and then communicate the nursing interventions by documenting and reporting.

Not all interventions are planned. The nurse must use her critical thinking skills to respond to an unexpected crisis.
Measurement Criteria:

1. Interventions are consistent with the established plan of care.
2. Interventions are implemented in a safe and appropriate manner.
3. Interventions are documented according to Nursing Standards.

EVALUATION

Evaluation is an ongoing process that enables the nurse to determine what progress the patient has made in meeting the goals for care. The outcome criteria provide measures for determining outcomes of care.

Please Note that the nurse is not evaluating nursing interventions. In assessing outcomes of care, determine whether goals have been met, partially met, or not met at all. If the goals have not been met it will be necessary to re-evaluate the plan.The plan may need to be altered , to do this you will need to do a new assessment.

Evaluation also provides data for Quality Assurance audits.
Measurement Criteria:

1. Evaluation is systematic and ongoing.
2. The client's response to interventions is documented.
3. The effectiveness of interventions is evaluated in relation to outcomes.
4. Ongoing assessment data are used to revise diagnosis, outcomes, and the plan of care are documented according to nursing standards.
5. The client, significant others, and the health care providers are involved in the evaluation process, when appropriate.
Related Posts Plugin for WordPress, Blogger...
Template by - Abdul Munir | Daya Earth Blogger Template