NURSING PROCESS CLASS HANDOUT DEFINITION OF THE NURSING PROCESS A systematic, rational method of planning and providing individualized nursing care.

CHARACTERISTICS OF THE NURSING PROCESS .The nursing process: .Is open and flexible to meet the unique needs of client, family, group, or community. .Is cyclic and dynamic; there is no absolute beginning and end. .Is client-centered; it individlializes the approachto a client's particular needs. .Is interpersonal and collaborative; it requires direct and consistent communication. .Is planned. .Is goal-directed. .Permits creativity for both nurse and client in devising solutions to problems. .Emphasizes feedback. .Is universally applicable to all clients and health care settings.

EVOLUTION OF THE NURSING PROCESS The nursing process has evolved as various nurse theorists and organizations wrote about the

process: .In

1952, Peplau (a psychiatric/MH nurse) identified four sequential phasesrelated to personal therapeutic interactions: (1) orientation, (2) exploitation, (3) resolution. .In 1955, Hall originated the term nursing process. .In 1959, Johnsondescribed the stepsas (1) assessingsituations, (2) decision making, (3) implementation of actions to resolve problems, (4) evaluation. .In 1961, Orlando (a psychiatric/MH nurse) described three phases: (1) client's behavior, (2) reaction of the nurse, (3) nursing actions. .In 1963, Wiedenbach described the steps as (1) identify help needed, (2) minister help, (3) validate help given. .In 1967, Knowles described the "five Ds": (1) discover, (2) delve, (3) decide, (4) do, (5) discriminate. .In 1967, Western Interstate Commission on Higher Education (WICHE) described the steps as (1) perception and communication, (2) interpretation, (3) intervention, (4) discrimination. .In 1967, Catholic University of America described four components: (1) assessing,(2) planning, (3) interventions, (4) evaluation. .In 1971, Orem described three steps: (1) initial and continuing determination of need for nursing care, (2) designing nursing actions that will contribute to client's achievement of health goals, (3) initiating, conducting and control of assisting actions. .In 1973, the ANA Standardsof Nursing Practice identified five steps: (1) assessing,(2) diagnosing, (3) planning, (4) intervention, and (5) evaluation. .In 1975, Gebbie and Lavin instituted the first national conference on classification of nursing diagnoses,which led to the use of the five stepnursing model: (1) assessment,(2) nursing diagnosis, (3) planning, (4) intervention (5) evaluation.

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HISTORY

ASSESSMENTPHASE DEFINITION OF ASSESSMENT The collection, organization, validation, and recording of data.

ELEMENTS OF ASSESSMENT Collecting data-the processof gatheringinformationabouta client's condition. .Factors that mayimpedeclient assessment data:Language,anxiety,fear, acuteillness/pain, limited mentalcapacity,previousnegativeexperiences. Organizing data-the process of organizing data using an assessmentframework that allows the establishmentof patterns and priorities for care. .Types of organizing assessmentframeworks in the literature: .Non-nurse models: EX: Maslow's hierarchy of needs. .Nurse models: EX: Gordon's functional health pattern framework. .Nurse theorist models: EX: Orem's Self-Care model or Roy's Adaptation model. Validating data-the process of verifying data for accuracy: .Compare subjective and objective data for consistency. .Clarify ambiguous or vague statements. .Use cues (direct observations) not inferences (conclusions). .Re-check data that is extremely abnormal. .Determine factors that may interfer with accuratemeasurement. .Use references(texts, journal reports) to explain phenomena.

Recording data-the processof accuratelydocumentingthe data.

DIAGNOSTIC PHASE DEFINITION OF NURSING DIAGNOSES Nursing Diagnosis--A clinical judgement about individual, family, or community responsesto actual and potential health problems/life processes. Nursing diagnosesprovide for the selection of nursing interventions to achieve outcomes for which the nurse is accountable. Wellness Diagnosis--A clinical judgement about an individual, family, or community in transition from a specific level ofwellness to a higher level ofwellness (NANDA, 1990).

OF NURSING DIAGNOSES .In

1973, the First Task Force to Name and Classify Nursing Diagnoses met and the Clearinghouse for Nursing Diagnosis was established at St. Louis University. .In 1977, a nurse theorist group (Callista Roy, Margaret Newman, Martha Rodgers, Dorothea Orem, Imogene King) presentedan organizing framework for nursing diagnoses called Patterns of Unitary Man (Humans) to the nursing diagnosis organization. .In 1982, the North American Nursing Diagnosis Association (NANDA) was created. .In 1987, TaxonomyI (list of nursing diagnoses)was published. 2

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In 2000, TaxonomyI/(updated list of nursing diagnoses)was published.

DlA GNOSISSUBMISSION GUIDELINES .Any

nurse can submit a possible new diagnosis or revision of a current diagnosis.

Submitteddiagnosesundergoa systematicreviewto determineconsistencywith established criteria for a nursingdiagnosis. Submissionsmustincludethe label,definition, andan integrativereview of the literature describingthe defining characteristics. Eachdiagnosticlabel approvedby NANDA includesa definition, etiology/relatedfactors, anddefining characteristics. COMP~ENTS

OF A ~ING DIAG~TIC ETIOLOGY /RELATED FACTORS A statein which an Sedentarylifestyle individual has Prolongedimmobility insufficient Sensorydeficits psychologicalor Impairedmotor function psychologicalenergyto Alterations in oxygen endureor complete transport requiredor desireddaily Lack of motivation outcomes. Obesity Acute or chronic pain

DIAGNOSIS DEFINITION Activity

intolerance

LABEL

DEFINING CHAUCTE]!!STICS Major (mustbe present) .Dysnea, SOB,tachypnea, rapid shallowrespirations .Weak irregularpulse, tachycardia,EKG changesafteractivity. .Hypotension, failure of BP to increasewith activity. .Weakness, fatigue. Minor (maybe present) .Pallor, cyanosis,vertigo, diaphoresis,confusion.

CHARACTERISTICS OF NURSING DIAGNOSES .A

nursing diagnosis is a judgement made after thorough, systematic data collection. Nursing diagnoses relate to independent nursing functions (areas of health care that are unique to nursing and separate and distinct from medical management). Nurses are also obligated to carry out physician-prescribed therapies and treatments (dependent nursing functions). Nurses carry out some dependent functions, such as using analgesics for pain, but will also use independent nursing interventions for alleviating pain. Registered nurses are responsible for making nursing diagnoses, even though other nursing personnel may contribute data to the proc;:essand may implement specific interventions.

Nursing diagnosesdescribea continuumof healthstates(a) actualhealthproblems,or deviationsfrom health; (b) potentialhealthproblems(presenceof risk factorsthat predispose personsand families to healthproblems;and (c) healthyresponses(areasof emiched personalgrowth). 3

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The domainof nursingdiagnosesincludesonly thosehealthstatesthat nursesareable and licensedto treat. Nursing diagnosesinvolve humanresponsesthatvary greatlyfrom one personto the next, anda singlenursingdiagnosismay occurasa responseto anynumberof diseases. Nursing diagnosesareorientedtowardthe individual (in contrastto a medicaldiagnosis which is orientedto the pathology). Nursing diagnoseschangeasthe client's responses change(in contrastto the medical diagnosiswhich remainsconstantthroughoutthe durationof the illness) Nursing diagnoseshave no universally accepted classification system although this systemis being developed. Medicine, on the other hand, has a well developed classification ( code) systemaccepted by the profession and by third party payers. JCAHO currently requires evidence of nursing diagnoses in client records.

TYPESOF NURSING DIAGNOSES Actual diagnosis-a clinical judgment about a client's responseto a health problem that is present at the time of the nursing diagnosis.

Potential/risk diagnosis-a clinical judgmentthat a client is ~ othersin the sameor similar situation.

vulnerableto developthan

Collaborative Problems .A type of Qotential risk/problem. .NOTE: The PES format (see below) is nQ!used for collaborative problems becausethey are Qotential problems. .Collaborative problems tend to be present any time a particular disease or treatment is present, that is, eachdiseaseor treatment has specific complications that are always associatedwith it. .Collaborative problems require both medical and nursing interventions. .Independent nursing interventions focus on monitoring the client's condition and prevention of potential complications.

Possiblediagnosis-a clinical judgmentabouta healthproblemthat is unclearor the causative factorsareunknown. Wellness diagnosis-a clinical judgment indicating a healthy responseof a client who desires a higher level of wellness.

COMPONENTSOF A NURSING DIAGNOSIS .Problem Statement(P) (also known as the Diagnostic Label) .Describes the client's healthproblemor the responsefor which therapyis given. .Directs the formationof client goalsandoutcomecriteria.

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May include qualifiers to give additional meaning to the diagnostic label-altered, impaired, decreased,ineffective, acute, chronic.

Etiology (E) /Related Factors .Identifies one or more probable causes of the health problem--"related to.. ." .May include client behaviors, environmental factors, or interactions between the two. .Gives direction to the nursing interventions; different etiologies require different interventions. .Enables the nurse to individualize care. .Related factors-describe the etiology or likely cause of actual nursing diagnoses. .Risk factors-describes the etiology of potential nursing diagnoses; there are no subjective and objective signs present. Defining Characteristics (also known as Signs/Symptoms (S) ) .Cluster of signs and symptoms that indicate a particular diagnostic label--"manifested by.. ." .Major-those signs/symptoms that must be present for valid diagnosis. .Minor-those signs/symptoms that mayor may not be present for a valid diagnosis. .Actual nursing diagnoses-the defining characteristics are the client's signs and symptoms. .Risk nursing diagnoses-the defining characteristics are the same as the etiology, indicating the client is more than "normally" vulnerable to the problem.

THE DIA GNOSTIC PROCESS .Analyzing Data .Comparing .Clustering .Identifying

data against standards(identifying significant cues). data either inductively or deductively (generating tentative hypotheses). gaps and inconsistencies.

Formulating Diagnostic Statements .One Part Statements(P)-used for wellness nursing diagnoses. .Use "Potential for enhanced" followed by desired higher level wellness ."Potential for enhancedparenting. .." Two Part Statements(PE}-used for risk nursing diagnoses that are NOT "usual". .Problem (P)- "Risk for infection. .. .Etiology (E}-related to recent radiation therapy" (but patient was admitted for OI bleeding). Collaborative Problem Statements-used for potential problems that are "usual". .NOTE: The PES format is !lQ! used for collaborative problems becausethey are ~otential problems. .Include diseaseor treatment plus the possible complication the nurse is monitoring ."Potential complication of head injury: Increasedintracranial pressure." Three Part Statements(PES)-used for actual nursing diagnoses .Problem (P)-" Activity intolerance... 5

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Etiology (E)-related to prolongedbedrest... Signs/Symptoms (S)-manifested by weaknessandfatigue." Setting Priorities .Nursing diagnosesare grouped according to high, medium, or low priority. .High priority-life threatening conditions (EX: loss of respiratory function). .Medium priority-Health threatening conditions (EX: acute illness). .Low priority-Normal developmental needs or minimal nursing support. .Using a nursing theoretical framework (Orem, Roy) makes priority setting easier.

[PROGNOSIS PHASE] Someauthorsadd an additional step(prognosticphase)betweenthe diagnosticandplanning phase. DEFINITION OF NURSING PROGNOSIS Prognosis-A prediction of the possible or probable course of events and outcomes associated with a particular health status or situation under various treatment options or lack of treatment.

CHARACTERISTICS OF A NURSING PROGNOSIS .A

nursing prognosis is similar to a medical prognosis in that it precedes treatment decisions, but it differs from a medical prognosis in that prognostic data relate to the client's functioning capacities. Nursing prognoses deal with the likelihood that the client and his/her support system will be able to respond in such a way that: .Health, .Daily

well-being, and effective functioning are promoted. living is as effectively managed as capacities, external resources, and daily living

permit. .The resulting quality of life is satisfying.

Prognostictermsincluderesolution,stablilization,progression,continuation,good,poor, etc. If nursing prognoses are contingent on a variety of uncertain variables-if,

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then are used.

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COMPONENTS OF A NURSING PROGNOSIS

.Prognostic Variables (Indicators) .Examples of variablesarethe client age,generalhealth,effectsof healthproblemand treatment,functional capacityfor ADL, demandsplacedon supportsystem,healthcare resources,etc. Prognostic Outcome-can predict success,failure, or some improvement. .Prevention or avoidance of a problem. .Delay/minimization of the problem or dysfunction. .Resolution of the diagnosedproblem. .Improvement or remission. .Stabilization of a problem that will continue. .Deterioration requiring palliative treatments. Trajectory-deals with the course of events as well as the outcomes. .Consideration of what is expected to happen, direction of the change, and the pattern or rate of change. .Used as a basis for setting realistic goals and evaluating responsesto nursing interventions.

PLANNIN G PHASE DEFINITION OF PLANNING The phaseof the nursingprocessthat involvesdecision-makingand problemsolving. ELEMENTS OF PLANNING .Setting Priorities-the process of establishing a preferential order for nursing strategies. .Priorities may be partially and concurrently addressedby nursing strategies. .Priorities do not remain fixed; they changeas the client's responseschange.

Establishing Client Goals/ExpectedOutcomes .Also known as outcome criterion, objective, predicted outcome or outcome identification .Well-stated goals/expectedoutcomesare: .Derived from the first clause of the nursing diagnosis. .Possible to achieve. .Stated in terms of client responses,not nursing activities. .Statements of one specific response or behavior. .Specific and concrete. .Measureable, that is, the outcome can be seen,heard, or felt--even by another nurse. .Valued by the client and family. .Compatible with other therapies. Goals-a broad statement. EX: "The client's nutritional status will improve." .Goals are derived from the nursing diagnosis. If the nursing diagnosesis "Fluid volume deficit. ..", then the goal statementis "The client's fluid volume will be restored... "

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Goals can be long term (chronic conditions) or short term (acute conditions). Specific expected outcome MUST follow a goal. The phrase that points to the expected outcome is ''as evidencedby... " Expected Outcome-measurable criteria. EX: ''as evidenced by moist mucous membranes by 11/05/01." Components of Goal/Expected Outcome Statements .Subject (noun)-is the client. (EX: "The client will. ..") .~an action the client will do, learn, experience. (EX: "demonstrate... ") .Condition/Modifier--explains the circumstances under which the behavior is to be perfonned(what, where, when, how). (EX: "correct crutch walking ...'j .Criterion of desired Derfonnance-the standard or level (evidence) by which the perfonnance is evaluated(time, speed,accuracy, distance quality) (EX: "@ evidenced by accurate positioning of hands and legs while crutch walking in the hal/way. ") Selecting Nursing Strategies .For "actual" nursing diagnosis, the focus is on interventions to eliminate or reduce the etiology found in the nursing diagnostic statement. .For "potential" nursing diagnosis, the focus is on interventions to reduce the client's risk factors (also found in the etiology of the nursing diagnostic statement).

DevelopingNursing Care Plans .May be pre-planned and pre-printed (standardized), computerized, or completely handwritten. Standardizedplans of care: .Ensure that minimally acceptedstandardsof care are provided. .Promote efficient use of nurses time by eliminating repetition in writing. .Must be individualized to the patient. RELATIONSHIP BETWEEN NURSING DIAGNOSIS, CLIENT GOALS AND OUTCOME CRITERIA

IJ}MGNOrnC STATE~NT Altered peripheraltissueperfusion (left leg) relatedto impairedarterial circulationmanifestedbXcool skin temperature,decreasedleft popliteal and pedalpulses,capillary refill < 3

I CLIENT ~Ais

The client will have improvedperipheral tissueperfusionin left leg and foot ~ evidencedbX...

sec. Fearrelatedto outcomeof cardiac catheterizationmanifestedbX sleeplessness, repeatingsame questionsaboutprocedure.

The client will have decreasedfear ~ evidencedbX...

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I OUTC~ME

CRITERIA

Skin intact, pink andwarm. Lt pedaland poplitealpulses palpableand equalto right. Capillary refill 1-3 sec. Verbalizesfactors that increase circulation. Ability to describewhat is expectedof him beforeand after the procedure. Ability to communicateconcerns clearly and lbgically. Ability to sleep.

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IMPLEMENTATION (INTERVENTION) PHASE DEFINITION OF IMPLEMENTATION Consists of doing, delegating, and recording

ELEMENTS OF IMPLEMENTATION .Reassessing the Client Determining the Need for Nursing Assistance (to carry out the plan)

Implementing Nursing Strategies .Most be specific as to what, where when, and how so that subsequentnurses can carry out the plan. .Subject (noun)--is the nurse. (EX: "The nurse will...") .Verb-an action the nurse will do. (EX: "encourage 300cc/fluid q 8 hours...")

Communicating Nursing Actions .Recorded data-must be up to date, accurate,and available to other nurses. .Verbal data-used with rapid changesin the client's condition, change of shift, transfers, and discharges.

EVALUATION PHASE DEFINITION OF EVALUATION Processof making judgements on goals/expectedoutcomes

TYPESOF CLIENT EVALUATION .Ongoing evaluation-done while or immediatelyafterdoing an intervention. .Intermittent evaluation-done at specificintervalsand showsextentof progresstoward goal .Terminal evaluation-indicates the client's conditionat the time of discharge. COMPONENTSOF CLIENT EVALUATION .Identifying Expected Outcomes--completed in planning phase. .Collecting Data-both subjective and objective data, so that conclusions can be drawn. .Judging Goal Attainment-goal/expected outcome was completely, partially, or not met .Relating Nursing Actions to Outcome--nursing interventions may need to be modified. .Drawing Conclusions about Problem Status.Prevention, elimination, or resolving of the problem. .Partial resolving of problem-the plan may need revision or more time.

EVALUATING QUALITY OF NURSING CARE .Quality assessment-examination of servicesonly. .Quality assurance-implies evaluationof andassurance of quality healthcare Types of Evaluation for Nursing Care 9

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Retrospectiveaudit-application of objectivecriteriato evaluatea client's record after discharge. Nursing audit-a reviewof patients'chartsto evaluatenursing competencyor performance(requiredfor JCAHO). Professional review organization (pRO)--develop standardsandmonitoring the quality of, costof, andaccessto care(requiredfor Medicare/Medicaid). Peerreview-a personequalin education,abilities,and qualificationswho critically reviewsthe practicesthatthe otherhasdocumentedin a client's record. Approaches to Evaluating Nursing Care .Structure evaluation-focuses on the organization/administration of the patient care system. .Process of care-focuses on the activities of the nurse or the nurse performance. .Outcomes of care-focuses on the outcomes related to a client's health status, welfare, and satisfaction in terms of changesfor the client.

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