Nursing Process1

The purpose of the nursing process is to identify a client's health status and his/her actual or potential health care problems or needs, to establish plans to meet the identified needs, and to deliver specific nursing interventions to meet these needs. The client may be an individual, a family or a group.

The use of nursing process in clinical practice gained additional legitimacy in 1973 when it was included in the American Nurses Association's (ANA), Standards of Clinical Nursing Practice. The standards of care include the five phases of nursing process: Assessment, diagnosis, planning, implementation, and evaluation. The different phases of nursing process are closely interrelated and each phase affects the others. For example, if inadequate data are obtained during assessing, the nursing diagnosis will be incomplete or incorrect; and the inaccuracy will also be reflected in the planning, implementing and evaluating phases.

The nursing process is a systematic, rational method of planning and providing nursing care. The nursing process is cyclical; that is, its components follow a logical sequence, and more than one component may be involved at one time. At the end of the cycle, care may be terminated if goals are achieved, or the cycle may continue with reassessment, or the plan of care may be modified.

There are four types of assessments; initial assessment, problem-focused assessment, emergency assessment and time-lapsed assessment. Assessments vary according to their purpose, time available and client status.

Client data should include past history as well as current problems. For example, a history of an allergic reaction to penicillin and chronic diseases are important historical data. Current data relate to present circumstances, such as pain, nausea and sleep patterns.

A complete database of both subjective and objective data provides a baseline for comparing the client's responses to nursing and medical interventions.

The best source of data is usually the client, unless the client is too ill, young, or confused to commun-icate clearly. The client can provide subjective data that no one else can offer. Family members, friends and care givers who know the client well often can supplement or verify information provided by the client. Support people are especially important source of data for a client who is very young, unconscious, or confused.

Client records serve as good source of data. They contain data regarding the client's occupation, religion, and marital status. Type of client records include medical records, records of therapies and laboratory records. Medical records are often a source of a client's present and past health and illness patterns. These records can provide nurses with information about the client's coping behaviors, health practices, previous illnesses and allergies.

Records of therapies provided by other health professionals such as social workers, nutritionists, dietitians or physical therapists help the nurse obtain relevant data not expressed by the client.

Laboratory records also provide pertinent health information. For example, the determination of blood glucose level allows health professionals to monitor the administration of hypoglycemic agents.

Reports from other health care professionals serve as other potential sources of information about a client's health. Nurses, social workers, physicians and physiotherapists may have information from either previous or current contact with the client. Both verbal and written reports of health care professionals add to data regarding client.

Review of nursing and related literature, such as professional journals, and reference texts can provide additional information for the database.

Although nurses observe mainly through sight, most of the senses are engaged during careful observations.

Observation has two aspects (a) noticing data and (b) selecting, organizing and interpreting the data. A nurse who observes that a client's face is flushed must relate that observation to, for example, body temperature, activity, environmental temperature and blood pressure. Nursing observations must be organized so that nothing significant is missed.

During a non-directive interview, or rapport-building interview, by contrast, the nurse allows the client to control the purpose, subject matter and pacing. Rapport is an understanding between two or more people. A combination of directive and non-directive approach is usually appropriate during the information-gathering interview.

To build an accurate database, nurses must validate assumptions regarding the client's physical or emotional behavior. For example, a nurse seeing a man holding his arm to his chest might assume that he is experiencing chest pain, when in fact he has a painful hand.

The identification and development of nursing diagnoses began formally in 1973, when two faculty members of Saint Louis University, Kristine Gebbie and Mary Ann Lavin, perceived a need to identify nurses' roles in an ambulatory care setting. The first National 6Conference to identify nursing diagnoses was sponsored by the Saint Louis University School of Nursing in 1973. Subsequent national conferences occurred in 1975, 1980 and every 2 years thereafter.

International recognition came with the first Canadian Conference in Toronto in 1977 and the international nursing conference in May 1987 in Calgary, Alberta, Canada. In 1982, the conference group accepted the name “North American Nursing Diagnosis Association (NANDA)”, recognizing the participation and contributions of nurses in the United States and Canada.

The purpose of NANDA is to define, refine, and promote a taxonomy of nursing diagnostic terminology for general use by professional nurses. Taxonomy is a classification system or set of categories arranged on the basis of a single principle or set of principles. The group has currently approved more than 150 nursing diagnosis labels for clinical use.

In 1990, NANDA adopted an official working definition of nursing diagnosis; “a clinical judgment about individual, family, or community responses to actual and potential health problems or life processes. Nursing diagnosis provides the basis for selection of nursing interventions to achieve outcomes for which the nurse is accountable”. This definition implies the following:

To be clinically useful, diagnostic labels need to be specific when the word specify follows a NANDA label. The nurse states the area in which the problem occurs, for example, Deficient Knowledge (Medications) or Deficient Knowledge (Dietary Modifications)

A medical diagnosis is made by physician and refers to a condition that only a physician can treat. Medical diagnoses refer to disease processes specific pathophysiologic responses that are fairly uniform from one client to another. In contrast, nursing diagnoses describe a client's physical, socio-cultural, psychological and spiritual responses to an illness or a health problem.

A client's medical diagnosis remains the same for as long as the disease process is present, but nursing diagnosis changes as the client's responses change. Nurses have responsibilities related to both medical and nursing diagnoses. Nursing diagnoses relate to the nurse's independent functions, that is, the areas of health care that are unique to nursing and separate and distinct from medical management.

The two parts are joined by the words related to rather than due to. The phrase due to implies that one 8part causes or is responsible for the other part. By contrast, the phrase related to, merely implies a relationship. Examples of two-part nursing diagnosis are:

Some NANDA labels contain the word specify. For these, the nurse must add words to indicate the problem more specifically. For example: Noncompliance (specify). Noncompliance (Diabetic diet) related to denial of having disease.

Actual nursing diagnoses can be documented by using the three-part statement because the signs and symptoms have been identified. The format cannot be used for risk diagnoses because the client does not have signs and symptoms of the diagnosis.

In addition to using the correct format, nurses must consider the content of their diagnostic statements. The statements should, for example, be accurate, concise, descriptive, and specific. The nurse must always validate the diagnostic statements with the client and compare the clients' signs and symptoms to the NANDA defining characteristics. For risk factors, the nurse compares the client's risk factors to NANDA risk factors.

NANDA has specified that any new wellness diagnoses will be developed as one-part statements beginning with the words Readiness for enhanced followed by the desired higher level wellness. For example, Readiness for Enhanced Parenting.

Currently the NANDA list includes several wellness diagnoses. Some of these are: Spiritual Well Being, Effective Breast Feeding, Health Seeking Behaviours, and Anticipatory grieving. These are usually accepted as one-part statements, but may be made more explicit by adding a descriptor, for example, Health Seeking Behaviours (Low Fat Diet).

Planning is a deliberate, systematic process that involves decision-making and problem solving. In planning, the nurse refers to the client's assessment data and diagnostic statements for direction in formulating client goals and designing the nursing interventions required to manage the clients' health problems.10

A nursing intervention is any treatment, based on clinical judgment and knowledge that a nurse performs to enhance patient/client outcomes.

Although planning is basically a nurse's responsibility, input from the client and support person (family members) is essential if a plan is to be effective. Nurses do not plan for the client, but encourage the client to participate actively to the extent possible. In a home setting, the client's family members and caregivers are the ones who implement the plan of care, thus its effectiveness depends largely on them.

Nurses use the formal care plan for direction about what needs to be documented in client's progress notes and as a guide for delegating and assigning staff to care for clients.When nursing diagnoses are used to develop goals and nursing interventions, the result is a holistic, individualized plan of care that will meet the client's unique needs.

Care plans include the actions nurses must take to address the client's nursing diagnoses and produce the desired outcome. The nurse begins the plan when the client is admitted to the hospital and constantly updates it throughout the client's stay in response to changes in the client's condition and evaluations of goal achievement.

The complete plan of care for a client is made up of several different documents that:

Standardized care plans are pre-printed guides for the nursing care of a client who has a need that arises frequently in the agency (e.g. specific nursing diagnosis or all nursing diagnoses associated with a particular medical condition). They are written from the perspective of what care the client can expect.

Problem → Desired outcomes / goals → Nursing interventions → Evaluations

Like standardized care plans, protocols are pre-printed to indicate the actions commonly required for a particular group of clients. For example, a hospital may have a protocol for admitting a client to the intensive care unit, for administering magnesium sulphate to a client with pre-eclampsia/eclampsia or for caring for a client receiving continuous epidural analgesia. Protocols may include both physician's orders and nursing interventions.

Policies and procedures are developed to govern the handling of frequently occurring situations. For example, a hospital may have a policy specifying the number of visitors a patient may have. Some policies and procedures specify what is to be done, for example, in the case of cardiac arrest. If a policy covers a situation pertinent to client care, it is usually entered in the care plan (e.g. make social service referral according policy manual). Policies are institutional records and do not become a part of the permanent record.

A standing order is a written document about policies, rules, regulations or orders regarding client care. Standing orders give nurses the authority to carry out specific actions under certain circumstances, often when a physician is not immediately available. In a hospital critical care unit, a common example is the administration of emergency antiarrythmic medications when a client's cardiac monitoring pattern changes.

Regardless of whether care plans are handwritten, computerized or standardized, nursing care must be individualized to fit the unique needs of each client. In hospitals/health care settings when nursing process is followed for providing holistic care to clients, care plans usually consist of both preprinted and handwritten sections. The nurse uses standardized care plans for predictable, commonly occurring problems and handwrites an individual plan for unusual problems or problems needing special attention. For example, a standardized care plan for all “clients with a medical diagnosis of pneumonia” would probably include a nursing diagnosis of deficient fluid volume, and direct the nurse to assess the client's hydration status. On a respiratory or medical unit, this would be a common nursing diagnosis and the nurse may incorporate it in her care plan for the client. However, a nursing diagnosis, risk for interrupted family process would not be common to all patients with pneumonia, it is true only to certain clients. Therefore the goals and nursing interventions for that diagnosis would need to be handwritten by the nurse.

Student care plans are more lengthy and detailed as it is a learning activity as well as plan of care. They usually have an additional column for “rationale” after nursing orders column. To help students learn to write care plans, these are often handwritten as required by the educators. A rationale is a scientific principle given as the reason for selecting a particular nursing intervention. Students may also be required to cite supporting literature for their stated rationale.

It is not necessary to resolve all high-priority diagnoses before addressing others. The nurse may partially address a high-priority diagnosis and then deal with a diagnosis of lesser priority. Further, because the clients usually have several problems, the nurse often deals with more than one diagnosis at a time.

When it is not possible to change the etiologic factors, the nurse chooses interventions to treat the signs and symptoms or the defining characteristics in NANDA terminology. Examples of this situation would be pain related to surgical incision and anxiety related to unknown etiology.

Interventions for risk nursing diagnosis should focus on measures to reduce the client's risk factors, which are also found in the second clause. Correct identification of the etiology during the diagnosing phase provides the framework for choosing successful nursing interventions. For example, the diagnostic label Activity Intolerance may have several etiologies: pain, weakness, sedentary lifestyle, anxiety, or cardiac arrhythmias. Interventions will vary according to the cause of the problem.

In the nursing process, implementing is the phase in which the nurse implements the nursing interventions. Implementing consists of doing and documenting activities that are specific nursing actions needed to carry out nursing orders. The nurse performs or delegates the nursing activities for the interventions that were developed in planning step and then conclude the implementing step by recording nursing activities and the resulting client responses. The degree of participation depends on the client's health status. For example, an unconscious person is unable participate in his care and therefore needs to have care given to him. By contrast, an ambulatory client may require very little care from the nurse and carry out health care activities independently.

While implementing nursing orders, the nurse continues to assess the client at every contact, gathering data about the client's responses to the nursing activities and about any new problems that may develop. A nursing activity on the client's care plan may read “Auscultate lungs q4h”. When performing this activity, the nurse is both carrying out the intervention (implementing) and performing an assessment.

Some routine nursing activities are, themselves, assessments. For example, while bathing an elderly client, the nurse observes a reddened area on the client's sacrum. Or, when emptying a urinary catheter bag, the nurse measures 200 ml of strong-smelling, brown urine.

The cognitive skills (intellectual skills) include problem solving, decision-making, critical thinking and creativity. They are crucial to safe, intelligent nursing care.

Technical skills are “hands on” skills such as manipulating equipment, giving injections and bandaging, moving, lifting and repositioning clients. The skills are also called as tasks, procedures, or psychomotor skills.

Technical skills require knowledge and manual dexterity. The number of technical skills expected of a nurse has increased in the recent years because of the increased use of technology, especially in acute care hospitals.17

At times new data may indicate a need to change the priorities of care or nursing activities.

Nursing activities are communicated verbally as well as in writing. When client's health is changing rapidly, the head nurse and/or the physician may want to be kept up to date with verbal reports. Nurses also report 18client status at change of shifts or on client's discharge to another unit or institution, in person, in writing, or via a voice recording.

To evaluate means to judge or appraise. It is a planned, ongoing, purposeful activity in which clients and health care professionals determine (a) the client's progress toward achievement of outcomes/goals (b) the effectiveness of the nursing care plans. Evaluation is an important aspect of the nursing process because conclusions drawn from the evaluation determine whether the nursing interventions should be terminated, continued or changed.

Evaluation is continuous and when carried out during or immediately after implementing a nursing order/directive, enables the nurse to make on-the-spot modifications in an intervention. Evaluation performed at specific intervals (e.g. once a week for a home care client), shows the extent of progress toward achievement of outcome and enables the nurse to correct any deficiencies and modify the care plan as needed. Evaluation continues until the client achieves the health goals or is discharged from nursing care. Evaluation at discharge includes the status of goal achievement and the client's self-care abilities with regard to follow-up care.

Through evaluating, nurses demonstrate responsibility and accountability for their actions, and indicate interest in the results of the nursing activities carried out.

The evaluating and assessing phases overlap as assessment (data collection) is ongoing and continuous at every client contact. However, data are collected for different purposes at different points in the nursing process. During the assessment phase the nurse collects data for the purpose of making diagnoses. During the evaluation step, the nurse collects data for the purpose of comparing it to pre-selected goals and for judging the effectiveness of the nursing care.

After determining whether a goal has been met, the nurse writes an evaluative statement in the nurse's notes. An evaluative statement consists of two parts; a conclusion and a supporting data.

The conclusion is a statement that the desired outcome was met or not. The supporting data are the list of client responses that support the conclusion.

For example, goal met: oral intake at 300 ml more than output; skin turgor good, mucous membrane moist. In practice (in hospital units), care plans usually do not have a column for evaluation statements; rather, these are recorded in the nurse's notes.

When goals have been partially met or when goals have not been met the nurse may conclude on one of the following:

In addition to evaluating goal achievement for individual clients, nurses are also involved in evaluating and modifying the overall quality of care given to groups of clients. This is an essential activity of professional accountability.