NURSING PROCESS:

NURSING DIAGNOSIS Is a client that is present of the nursing assessment. Refers to reasoning process, whereas the term a diagnosis is a statement or conclusion regarding the nature of phenomenon. Nursing diagnosis is a judgment made only after thorough, systematic data collection. Nursing diagnosis describe a continuum of health states: deviations from health, presence of risk factors, and areas of enhanced personal growth.

ASSESSMENT
Is the systematic and continuous collection, organization, validation, and documentation of data (information) A nursing assessment should include the client s perceived needs; health problems related experience, health practices, values lifestyles.

FOUR TYPES OF ASSESSMENT: 1. 2. 3. 4. Initial assessment Problem-focused assessment Emergency assessment Time-lapsed reassessment

FOUR CLOSELY RELATED ACTIVITIES 1. Collective Data - Is the process of gathering information about the client s health - Must be both systematic and continuous. *Database all the information about the client - includes the nursing health history, physical assessment, primary care provider s history and physical examination, results of laboratory and diagnostic tests, and material contributed by other health personal. 2. Organizing Data - This is often referred to as a nursing health history; nursing assessment, or nursing database form. 3. Validating Data - Complete, factual, and accurate because the nursing diagnoses and interventions are based on this information - Validation is the act of double-checking or verifying data to confirm that it is accurate and factual

The nurse validates data when there are discrepancies between data obtained in the nursing interview (subjective data) and the physical examination (objective data). To collect data accurately, nurses need to be aware of their own biases, values, and beliefs and to separate fact from influences, interpretation and assumption.

*Cues are subjective or objective data that can be directly observed by the nurse. (Sense of touch, sense of sight) *Inferences are the nurse s interpretation on conclusions made based on the cues Documenting Data Accurate documentation is essential and should include all data collected about the client s health status. They are recorded in a factual manner and not interpreted by the nurse.

PLANNING
Involves setting priorities, writing goals/desired outcomes, and establishing a written plan for nursing interventions.

*Priority Setting is the process of establishing a preferential sequence for addressing nursing diagnoses and interventions.
FACTORS:

1. Client s health values and beliefs - Values concerning health may be more important to the nurse than to the client. 2. Client s priorities - Involving the client in prioritizing and care planning enhances cooperation. - Sometimes, the client s perception of what is important, conflicts with the nurse s knowledge of potential problems or complications. 3. Resources available to the nurse and the client - Availability of resources like money, equipment, or personnel are needed by both the nurse and the client. - If resources are scarce in health care agency, then a problem may be given a lower priority than usual. 4. Urgency of the health-problem - Life-threatening situations require that the nurse assign them in high priority. 5. Medical treatment plan - The priorities for treating health problems must be congruent with treatment by other health professionals. SHORT-TERM GOALS are useful:

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For clients who require health care for a short time For those who are frustrated by long-term goals that seem difficult to attain and who need the satisfaction of achieving a short-term goal

LONG-TERM GOAL y Clients in acute care settings also need long-term goals to guide planning for their discharge to long-term agencies or home care, especially in a manage care environment.

INTERVENTIONS
Are identified and written during the planning step of the nursing process; However, they are actually performed during the implementing step Include both direct and indirect care, nurse-initiated, physician-initiated, and otherprovider-initiated treatments.

Independent Interventions Are those activities that nurses are to initiate on the basis of their knowledge and skills Includes physical care, ongoing assessment, emotional support and comfort, teaching counseling, environmental management, making referrals to other health care professionals.

Collaborative Interventions Are actions the nurse carries out in collaboration with other health team members, such as physical therapists, social workers, dieticians, and physicians. Its nursing activities reflect the overlapping responsibilities of, and collegial relationships between, health personnel.

Dependent Interventions Are activities carried out under the physician s orders or supervision, or according to specified routines. Physician s orders completed to nurse o Medication o Intravenous therapy o Diagnostic tests o Treatments o Diet o Activity

EVALUATION
Is a planned, ongoing, purposeful activity in which clients and healthcare professionals determine:

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Client s progress toward achievement of goals/outcomes Effectiveness of the nursing plan

*During the evaluation step the nurse collects data for the purpose of comparing it to preselected goals and judging the effectiveness of the nursing care. *The act of assessing (data collection) is the same; the differences lie in: y y When the data are collected How the data are used

Comparing data with outcomes If the first two parts of the evaluation process have been carried out effectively, it is relatively simple to determine whether a desired outcome has been met. When determining whether the goal has been achieved, the nurse can draw one of three possible conclusions 1. The goal was met; that is, the client response is the same as the desired outcome 2. The goal was partially met; that s, either a short-term goal was achieved but the long-term was not. 3. The goal was not met. Evaluation Statement Parts: 1. Conclusion - is a statement that the goal/desired outcome was met, partially met, or not met. 2. Supporting data are the list of client responses that support the conclusion. Quality Assurance (QA) Program is an ongoing, systematic, process designate to evaluate and promote excellence in the health care provided to clients. Requires evaluation of Three Components: 1. Structure evaluation focuses on the setting in which care is given - Answers the question what effect does the setting have on the quality of care? 2. Process evaluation - Focuses on how the care was given. - Standards focus on the manner in which the nurse uses the nursing process. - Answers the question is the care relevant to the client s needs? 3. Outcome evaluation - Focuses on demonstrable changes in the client s health status as a result of nursing care. - Are written in terms of client within the nursing process.

Follows client care rather than organizational structure, focuses on process rather than individuals, and uses a systematic approach with the intention of improving the quality of care rather than ensuring the wualty of care.

Nursing Audit Audit means the examination or review of records Retrospective audit is the evaluation of a client s record after discharge from and agency. Retrospective means relating to the past events. Concurrent audit is the evaluation of a client s health care is still recieving care from the agency. *These evaluations use interviewing, direct observation of nursing care, and review if clinical records to determine whether the specific evaluative criteria have been met. Peer Review another type of evaluation of care. Types: 1. Individual peer review focuses on the performance of an individual nurse. 2. Nursing Audit focuses on evaluating nursing care through the review of records.

DOCUMENTING AND REPORTING OF CARE OF PLAN

Discussion is an informal oral consideration of a subject by two or more health care personnel to identify a problem or establish strategies to resolve a problem. Report is oral, written, or computer-based communication intended to convey information to others. Record is written or computer-based. *The process of making an entry on a client record is called recording, charting, or documenting. Clinical record (Chart or client record) care Purposes of Client Records 1. 2. 3. 4. 5. 6. Communication Planning client care Auditing care health agencies Research Education Reimbursement is a formal legal document that provides evidence of a client s

7. Legal Documentation 8. Health care analysis Documentation Systems 1. Source-orientated record traditional client record. In this type of record, information on about a particular problem is distributed throughout the record. 2. Narrative charting traditional part of the source-oriented record. It consists of written notes that include routine care, normal findings, and client problems. There is no right or wrong order of information, but chronological order is frequently used. Problem-oriented medical record (POMR) or Problem-oriented record (POR) - established by Lawrence Weed, the data are arranged according to the problems the client has rather than the source of the information. Components: 1. Database consist of information 2. Problem List derived from the database. Serves as an index to the numbered entries in the progress notes. 3. Plan of care initial list of orders or plan of care with reference to the active problems 4. Progress notes is a chart made by all health professionals. SOAP format is used to correspond the problems. S Subjective data consists of information from what the client says. O Objective data consists of information that is measured or observed by the senses A - Assessment is the interpretation or conclusions drawn about the subjective and objective data. P Plan is a plan of care designed to resolve the stated problem. Focus Charting is intended to make the client concerns and strengths the focus of care. Three columns for recording: 1. Focus may be a condition, a nursing diagnosis, a behavior, a sign or symptom, and acute change in the client s condition, or client strength. 2. Data reflects the assessment phase of the nursing process and consists of observations of the client status and behaviors, including data from flow sheets. 3. Action - reflects planning and implementation and includes immediate and future nursing action. *Response category reflects the evaluation phase of the nursing process and describes the nursing client s response to any nursing and medical care.