Nursing Process

Nursing Process is a systematic, logical and cyclical method of planning and providing nursing care. It is characterized by 5C: Constantly Changing, Cyclic, Client-centered, Collaborative and Can be universally applied.

 


Phases of Nursing Process

Assessment - vital first phase of nursing process. Collecting, organizing, validating and documenting client's data.

•  Obtain nursing health history.
•  Conduct physical assessment.
•  Update data as needed.
•  Review client records.
•  Consult support persons.

          Types of Data

     Subjective Data

•  Covert Data or Symptoms
•  Patient's Perception about his/her problems.
•  Usually includes feeling of anxiety, physical discomfort or mental stress.

     Objective Data

•  Overt Data or Signs
•  Observations or measurements made by the nurse.
•  Involves inspection, palpation, percussion and auscultation.

Nursing Diagnosis - Analyzing of data. The goal is to identify client's health care needs and response to illness.

•  Components: Problem + Etiology + Signs and Symptoms/Risk Factors
•  Identify strengths, risks and health problems.
•  Formulate diagnostic statements duly approved by NANDA

        Types of Nursing Diagnosis

• Actual - the patient shows manifestations of a health problem or condition.
• High Risk - a health problem or condition is likely to develop as a result of risk factors being assessed.
• Wellness - the client is healthy as assessed but he/she wishes to achieve a higher level of functioning.
• Possible - evidence is unclear unless further provided.
• Syndrome - a clustered nursing diagnosis.

Planning - determining how to prevent, reduce or resolve client problems. The purpose is to develop individualized care plan.

• Written plan of action
• Prioritizing Needs
• Formulation of Goals
• Selection of Nursing Interventions
• Writing Nursing Orders
• Should be S.M.A.R.T: Specific, Measurable, Appropriate, Realistic and Timely 

          Stages of Planning

• Assign priorities to the nursing diagnosis.
• Establish client goals/outcome.
• Select appropriate nursing interventions.
• Document the Nursing Diagnosis, expected outcomes and interventions.
• Evaluate the effectiveness of the plan of care.

Implementation - carrying out the planned interventions. To assist the patient meet desired goals or expected outcomes.

• Reassessment of Client and their response to Care
• Determination of any need for assistance.
• Implementation of Nursing Intervention.
• Supervising Delegated Care.
• Documenting Nursing Actions.

           Types of Implementation

• Independent - nurses are licensed to act related to their knowledge and skills.
• Interdependent/Collaborative - carried out by a nurse with collaboration of other healthcare team.
• Dependent - carried out by a nurse in collaboration with the physician.

Evaluation - measuring the degree to which goals have been achieved. the purpose is whether to continue, modify or terminate the nursing interventions.

• Collects and compare data with the outcome.
• Relate nursing actions to client's goals
• Conclude problem status
• Continue, modify or terminate the nursing care.
• Goal Met - client's response is the same with goals.
• Goal Partially Met - only part of the desired outcome is met.
• Goal Unment/Not Met - failure to achieve desired outcome in expected time.

          Types of Evaluation

• Ongoing - done while or immediately after implementing the nursing intervention.
• Intermittent - performed at specified intervals, such as twice a week.
• Terminal - performed to indicate the patient's condition at the time of discharge