TOPIC 15: THE NURSING PROCESS 3) Plan

- Outcome identification
NURSING PROCESS DEFINED - Objective
- Goal
• A systematic rationalized method of planning and providing
4) Implement
individualized nursing care based on data observed during the nursing
- Patient education
assessment.
5) Evaluate
• Characteristics of the Nursing Process:
- Reporting
1) Helps identify nursing priorities and helps direct nursing
- Documentation DPA
interventions based on identified concerns.
2) Helps the formulation of expected outcomes for quality ASSESSMENT: What data is collected?
assurance requirements of third-party payers.
3) Identifies how a client responds to actual or potential health. • The systematic and continuous collection of data to determine a
4) Provides a common language and forms a basis for patient’s current and past health status and functional status.
communication and understanding between nurses and the • Purposes:
healthcare team. 1) To establish a data base
5) Provides a basis for evaluation to determine if nursing care was - Nursing health history
beneficial and cost-effective to the client. - Physical assessment
6) Enhances problem-solving and critical thinking skills of student - Laboratory and diagnostic test results
nurses. 2) Patient’s response to health concerns or illness
• Qualities of the Nursing Process: 3) Ability to manage health care needs
1) System is open and flexible • Types:
2) Meet the unique needs of individual, family, group, or Initial Comprehensive • Performed within a specified time
community Assessment after admission.
3) Cyclic and dynamic • AKA: admission assessment
• Example: nursing admission
4) Client centered
assessment
5) Planned and goal directed • Purposes:
6) Interpersonal and collaborative 1) To evaluate health status
7) Permits creativity for the nurse and patient to solve the stated 2) To identify functional health
health problems patterns
8) Emphasizes feedback, which leads either to re-assessment of 3) To provide an in-depth
comprehensive databases
the problem or revision of the care plan
Problem Focused • Collects data about a problem that
9) Universally applicable
Assessment has been identified.
• Phases of the Nursing Process: • On-going process integrated with
1) Assess nursing care
2) Diagnose • Nurses determine whether problem
still exist or whether changes in the
 status of the problem are observed o Observed data (using the 5 senses)
• Example: hourly assessment of o Heart rate
patient’s I&O o Bleeding
Emergency Assessment • Occurs during any life-threatening
• Method of data collection
condition
- Interview
• Physiologic or psychologic crisis
• Example: rapid assessment of - Observation
patient’s vital signs during cardiac - Palpation
arrest - Percussion
Time Lapsed • Several months after initial assessment - Auscultation
Assessment • Evaluate the changes in the patient’s
health and functional status Organize • Arrange date:
• Example: periodic output of patient’s Data - Systematically
clinic visits - Meaningful cluster
- Home health visits o Cluster – a set of signs and symptoms
- Health and development that are grouped together in a logical
screening order.
o E.g.:
• Components:  Self-care need
 Physiological need
Collect • The process of gathering information about a  Adaptation need
Data patient’s health status  Coping need
• Includes physical, psychological, emotional, Validate • Involves comparing the collected data with
socio-cultural, spiritual factors that may affect the Data another source.
patient’s health status • Act of doing checking or verifying data to
• Include: confirm that they are accurate and factual.
- Past health history • Steps:
o Allergies - Deciding whether the data require
o Complementary alternative medicine validation
- Present problems - Determining ways to validate the data
• Types of Data: - Identifying areas where data are missing
- Subjective - Failure to validate data may result in
o Anything stated that cannot be premature closure of assessment or
verified collection of inaccurate data
Document
o Feelings
Data
o Pain
o Patient feels dizzy
o Patient reports falling down the stairs
- Objective
o Measured metric
DIAGNOSIS: What is the problem? 4) Syndrome Diagnosis
- Associated with a cluster of problem or other nursing
• A clinical judgment about the individual, family, or community’s diagnoses that are predicted to present because if a
responses to actual and potential health problems/life processes certain situation or event.
(NANDA). - Example:
- Analyse data o Chronic pain syndrome
- Identify the health problems, risks, and strengths o Post-trauma syndrome
- Formulate diagnostic statements o Frail elderly syndrome
• Types of Nursing Diagnosis: 5) Possible Nursing Diagnosis
1) Actual Diagnosis (Problem-Focused Nursing Diagnosis) - Evidence/s about a health problem is incomplete or
- Problem is observed at the time of the nursing unclear
assessment - Additional data are needed to confirm or rule out the
- Based on the presence of associated signs and suspected problem
symptoms - Additional data collection is needed (collaborate with
- Example: other nurses)
o Ineffective breathing pattern - Example:
o Anxiety o Possible social isolation related to unknown
2) Risk Nursing Diagnosis etiology
- A clinical judgement that a problem does not exist, but o Possible chronic low self-esteem
the presence of risk factors indicate that a problem is • Three Components:
likely to develop. The Problem • Describes the patient’s response to
- Example: (diagnostic label) health problems
o Risk for infection AEB immunosuppression • E.g.:
o Risk for falls AEB muscle weakness - Activity intolerance
o Risk for injury AEB altered mobility - Constipation
3) Wellness Diagnosis (Health Promotion) The Etiology (related • Etiology are causative factors that
factors and risk have influenced the patient’s
- Indicates a healthy response of a patient (family or
factors) actual or potential response to the
community) who desire a higher level of wellness health problem
- A clinical judgment about motivation and desire to • The related phase identifies the
increase wellbeing etiology or cause of the patient’s
- Components generally include only the diagnostic label response to health problem
or one-part statement • E.g.:
- Example: - Activity intolerance related
to generalized weakness or
o Readiness for enhanced well-being
obesity or sedentary life
o Readiness for enhances family coping - Constipation related to
o Readiness for enhanced parenting inadequate fluid intake or
inadequate fiber intake
 The Defining • These are the cluster of signs and PLANNING: How to manage the problem?
Characteristics symptoms that indicate the
presence of diagnostic label • A category of nursing behaviors wherein the selection of the following
• Example: are done:
- Impaired response to - Client-centered goals
activity, weak, thread pulse, - Expected outcomes
tachycardia, irregular pulse
- Nursing interventions
and shallow respiration
• Types:
• Formulating Diagnostic Statements 1) Initial – established as soon as possible after the primary
- Basic Two-Part Statements (PE Format) assessment.
o Problem (P). Statement of the patient’s response. 2) Ongoing – beginning f the shift as the nurse plans the care for
o Etiology (E). factors contributing to/or probable causes that day,
of the response. 3) Discharge – begins at first client contact and involves a
o Example: activity intolerance related to generalized comprehensive and ongoing assessment to obtain information
weakness or obesity. about the patient’s ongoing needs.
• Nursing Diagnosis vs Medical Diagnosis • Developing:
NURSING DIAGNOSIS MEDICAL DIAGNOSIS - End product of the planning.
Made by nurses, condition that Made by physicians and a - Types:
nurses are licensed to treat condition that only a physician 1) Informal
can treat o Exist in the nurse’s mind
Statement of nursing judgment Statement of medical judgment o Example: “Ms. Dela Cruz is very tired; I will need to
Describe a patient’s physical, Describes a patient’s specific reinforce her teaching after she is rested”
sociocultural, psychological, and pathophysiologic responses to an 2) Formal
spiritual responses to an illness or illness
o Written guide that organizes the information
health problem.
e.g. tepid sponge bath for fever e.g. Paracetamol 500mg. PO for about the patient’s care
fever
2.1) Standardized
 A care plan for a group of patients with
common need
 Example: all patients with fever
2.2) Individualized

 Tailored to meet the unique needs of

specific patients
 Example: patient with MI
 3) Kardex IMPLEMENTATION: Putting the Plan into Action
o A system wherein patients’ information and
instructions are kept for accessibility.
o Contains information about diet, activity level, Nurse puts the nursing care plan in
self-care or hygienic needs, treatments, and Continues with the data collection
Documents the care provided
procedures.
• Categories:
• Implementing Skills:
1) Student Care Plan
a) Cognitive or Intellectual Skills
- Learning activity as well as plan of care
- Problem solving
- Lengthy and detailed
- Decision making
2) Computerized Care Plan
- Critical thinking
- Generate both standardized and individualized care
- Curative thinking
plans
b) Interpersonal Skills
- Nurse chooses the appropriate diagnosis from a menu
- Verbal and non-verbal activities when communicating
suggested by the computer
c) Technical Skills
• Process: Stages of Planning
- Hands-on skills
1) Setting priorities
- Manipulation of equipment
- Process of establishing a preferential order for nursing
- Nursing procedures
diagnoses and interventions
• Implementing Skills: The Process
- Maslow’s Hierarchy of Needs
2) Establish patient goals or desired outcomes Reassessing the client
- A specific and measurable behavior or response that
reflects a patient’s highest possible level of wellness and
independence in function Communicating the Determining the nurse’s
3) Select nursing interventions and activities nursing actions need for assistance
- Performed to achieve the patient’s goals
4) Writing the nursing orders
- Instructions for the specific activities the nurse performs
Delegating and Implementing the
to help the patient meet established health care goals
Supervising nursing orders
Content Time
Date Action Signature
Area Element
08/20/21 Palpate Abdomen Hourly x2, Sign
for then Q4H x MSC Domingo,
DNS, RN
firmness 24 hours
a) Reassessing the patient PATIENT EDUCATION
- Before implementation
o To ensure that the intervention is needed • Starts from the time patients are admitted to the hospital and continues
o The patient’s condition may have changed until they are discharged.
b) Determining the nurse’s need for assistance • Why?
- The nurse is unable to implement the nursing care safely - Empowers the patient to improve their health status
o Turning an obese patient in bed - More likely to engage in interventions that may increase their
- Reduce the stress on the client chances for positive outcomes
o Turning a patient who experiences acute pain when - Prevention of medical conditions
moved - Decreases the possibility of complications
- Lack of knowledge and skills to implement the nursing care - Retaining independence by self-sufficiency
o Unfamiliarity with an equipment • Nurse’s Role: take advantage of any appropriate opportunity
c) Implementing the nursing orders throughout the patient’s stay to teach about self-care
- Explain to the patient during implementation: • What?
o What will be done - Self-care and its importance
o What sensations to expect - Recognizing the warning signs
o What the patient is expected to do - What to do if problem occurs
d) Delegating and supervising - Who to call
- Nurse’s responsibilities: • How?
o Appropriate delegation of duties a) Assess
o Adequate supervision of personnel - Physical and psychosocial needs
e) Communicating the nursing actions - Determine learning needs, readiness to learn
- Documenting the interventions and client responses in the b) Plan
nursing progress notes - Develop care plan based on mutual goal setting to meet
individual needs
c) Implementation
- Perform teaching using specific instructional methods and
tools
d) Evaluation
- Determine physical and psychosocial changes (KAS)
EVALUATION DOCUMENTATION

• The last phase of the nursing process • What?

• Patients and health care professionals determine: - Any written or electronically generated information about a
- The patient’s progress toward goal achievement patient’s status and care of services
- Effectiveness of the nursing care plan • Why?
• Types:
1) Ongoing Communicate:
- Done while or immediately after implementation o Observations NURSING
- Enables to make on-the-spot modification in an o Decisions PROCESS
intervention o Actions
2) Intermittent o Outcomes
- Performed at specified intervals
- Shows the extent of progress toward goal achievement
- Essential for good clinical communication
- Enables to correct any deficiencies and modify the care
- Quality improvement
plan as needed
- Basic to the professional and medico legal requirement of
3) Terminal
nursing practice
- Indicates the patient’s condition at the time of discharge
- Research
- Includes the status of goals achievement
• How?
- Evaluation of the patient’s elf-care abilities about follow-
up care FUNDAMENTAL ASPECTS OF DOCUMENTATION
• Reviewing and Modifying the NCP F = Factual
• Contains descriptive, • Breath sounds
- After drawing conclusions about the status of the patient’s objective information • Chest expansions
problems, the nurse modifies the care plan as indicated. • Direct observation and • Nail beds
- Whether or not goals were met, there are several decisions to measurement
make about continuing, modifying, or terminating nursing care A = Accurate • Use of exact • Oral intake was 1000mL
measurements and over 8 hours
for each problem.
establishes accuracy
C = Complete • Charting should include • Document:
appropriate and - Changes in status
essential information - Patient responses
- Communication
with s/o
T = Timely • Essential to the patient’s • Resist the temptation to
ongoing care in order to leave documentation
reflect a clear record of until the end of shift
what has happened
 DATA PRIVACY ACT (DPA) OF 2012: RA 10173

• September 8, 2012 – DPA enforced

• Health information is considered sensitive personal information that
requires a higher level of data protection
• Personal Data – all types of personal information:
- Personal Information – any information:
o Recorded in a material form or not, from which the
identity of an individual is apparent
o Will directly and with certainty identify an individual
when information are clustered together
o Example:
 Race
 Ethnic origin
 Marital status
 Age
 Color
 Religion
 Political affiliations
 Philosophical beliefs
 Health
 Education
 Genetic or sexual life
 Any alleged or committed offense
• Sensitive Data – sensitive personal information under the ACT
- Privileged information:
o Any and all forms of data that constitute privileged
communication
 Information between health provider and a
patient
 Client and lawyer