NURSING PROCESS

The term NURSING PROCESS was first used/mentioned by Lydia Hall, a nursing theorist, in 1955 wherein she introduced 3 STEPs: observation, administration of care and validation.

Since then, nursing process continue to evolve: it used to be a 3-step process, then a 4-step process (APIE), then a 5-step (ADPIE), now a 6-step process (ADOPIE) ASSESSMENT, DIAGNOSIS, OUTCOME IDENTIFICATION, PLANNING, IMPLEMENTATION and EVALUATION.

Outcome Identification

• efers to formulating and documenting measurable, realistic and client-focused goals that will provide the basis for evaluating nursing diagnosis.

Purposes:

1.  
1. To provide individualized care
2. To promote client participation
3. To plan care that is realistic and measurable
4. To allow involvement of support people

Activities during Outcome Identification:

1. Establish client’s goals and outcome criteria

Client Goal

• is an educated guess made as a broad statement about what the client’s state or condition will be AFTER the nursing intervention is carried out.
• are written to indicate a desired state. They contain action word/verb and a qualifier that indicate the level of performance that needs to be achieved.

Example of verbs used in client goals:

• Calculate
• Classify
• Communicate
• Compare
• Define
• Demonstrate
• Describe
• Construct
• Contrast
• Distinguish
• Draw
• Explain
• Express
• Identify
• List
• Name
• Maintain
• Perform
• Particular
• Practice
• Recall
• Recite
• Record
• State
• Use
• Verbalize
• Ambulates

*a QUALIFIER is a description of the paramenter or criteria for achieving the goal.

Example:

• Ambulates safely with one-person assistance.
• Identifies actual & risk environmental hazards.
• Demonstrates signs of sufficient rest before Surgery.

Goals may be short term or long term:

STG – can be met in a short period (within days or less than a week)

LTG – requires more time (several weeks or months)

Outcome Criteria – are specific, measurable, realistic statements goal attainment. They are written in a manner that they answer the questions: who, what actions, under what circumstance, how well and when.

Therefore the characteristic of well-stared outcome criteria are:

• S = smart
• M = measurement
• A = attainable
• R = realistic
• T = time-framed

Example of Goals and Outcome Criteria

1. Goal – The client will report a decreased anxiety level regarding Surgery.

Possible Outcome Criteria

• The client discusses fears & concern regarding surgical procedure after client teaching.
• After client teaching, the client verbalizes decreased anxiety.
• The client identifies a support system and strategies to use to reduce stress and anxiety related to the surgical experience.

1. Goal – The client will demonstrate safety habits when performing activities of daily living.

Possible Outcome Criteria:

• Immediately after instruction by the nurse, the client uses call light system for assistance when needs to use the bathroom.
• The client demonstrates safety practices when dressing and doing personal hygiene.
• The client uses over-the-bed lights, non-skid slippers when transferring to chair or getting out of bed.
• The client identifies modification for home safety (removal of throw pillows, installation of hand rails in hallway, better lighting of hallway and stairway), 12 hours after nurse’s instruction about home safety.

1.  
1. Goal – The client will mobilize lung secretions.

Possible Out come Criteria:

• After teaching session, the client demonstrates proper coughing techniques.
• The client drinks at least 6 glasses of water per day while in the hospital.
• The caregiver or significant other demonstrates proper technique of chest physiotherapy including percussion, vibration and postural drainage before discharge.

IMPLEMENTATION

• is putting the nursing care plan into action.

Purpose: To carry out planned nursing interventions to help the client attain goals and achieve optimal level of health.

Activities:

1. Reassessing – to ensure prompt attention to emerging problems.
2. Set priorities – to determine the order in which nursing interventions are carried out.
3. Perform nursing interventions – these may be independent. Dependent or collaborative measures.
4. Record actions – to complete nursing interventions, relevant documentation should be done. Remember: Something that is NOT written is considered as NOT done at all.

Requirements of Implementation:

1. Knowledge – include intellectual skills like problem-solving, decision-making and teaching.
2. Technical skills – to carry out treatment and procedures.
3. Communication skills – use of verbal and non-verbal communication to carry out planned nursing interventions.
4. Therapeutic use of self – is being willing and being able to care.

EVALUATION

• is assessment the client’s response to nursing interventions and then comparing that response to predetermined standards or outcome criteria.

Purpose: To appraise the extent to which goals and outcome criteria of nursing care have been achieved.

Activities:

1. Collect data about the client’s response.
2. Compare the client’s response to goals and outcome criteria.
3. The four possible judgments that may be made are as follows:

·         The goal was completely met.

·         The goal was partially met.

·         The goal was completely unmet.

·         New problems & nursing diagnosis have developed.

1. Analyze the reasons for the outcomes.
2. Modify plan of care as needed.

NURSING PROCESS

· is a systematic, organized method of planning, and providing quality and individualized nursing care.

· it is synonymous with the PROBLEM SOLVING APPROACH that directs the nurse and the client to determine the need for nursing care, to plan and implement the care and evaluate the result.

· It is a G O S H approach (goal-oriented, organized, systematic and humanistic care) for efficient and effective provision of nursing care.

Goal-oriented – nurse make her objective based on client’s health needs.

Remember: Goals and plan of care should be base according to client’s problems/needs NOT according to your own problem as the nurse.

Organized/Systematic – the nursing process is composed of 6 sequential and interrelated steps and these 6 phases follow a logical sequence.

Humanistic care

• plan to care is developed and implemented taking into consideration the unique needs of the individual client.
• plan of care therefore is individualized (no 2 person has the same health needs even with same health condition/illness)
• in providing care, it involves respect of human dignity

Efficient – plan of case is relevant/related to the needs of the client thereby promoting client satisfaction and progress.

Effective – in planning care, utilized resources wisely (staff, time, money/cost)

Aside from GOSH, other characteristic of Nursing Process

Cyclic and Dynamic in nature – data from each phase provides the input into the next phase so that is becomes a sequence of events (cycle) that are constantly changing (dynamic) base on client’s health status.

Involves skill in Decision-making – nurse makes important decisions related to client care, she choose the best action/steps to meet a desired goal or to solve a problem. She must make decisions whenever several choices or options are available.

Uses Critical Thinking skills – the nurse may encounter new ideas or less-than-routine or non-ordinary situations where decisions must be made using critical thinking.

Purpose of Nursing Process:

1. To identify a client’s health status; his Actual/Present and potential/possible health problems or needs.
2. To establish a plan of care to meet identified needs.
3. To provide nursing interventions to meet those needs.
4. To provide an individualized, holistic, effective and efficient nursing care.

Steps/Phases of the Nursing Process:

1. Assessment
2. Diagnosis
3. Outcome Identification
4. Planning
5. Implementation
6. Evaluation