Assignment of Nursing Process Final - Latest

NURSING PROCESS APPROACH


INTRODUCTION
Nursing process is a systematic problem-solving approach used to identify, prevent and treat actual
orpotential health problems and promote wellness. Asystematic way to plan, implement and
evaluate care for individuals, families, groups and communities.
Practice of nursing is caring which is directed by the way the nurses view the client, the client’s
environment, health and the purpose of nursing. To nurses the nursing process provides a useful
description of how nursing should be performed.
As nurses remain in constant interaction with their clients, professional colleagues, medical and
health care team members, they have the best opportunity to assess the patient’s needs and provide
evidence-based care.


HISTORY OF 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.
In 1967, yura and walsh added assessment to the three steps and described a four phase process.
In the mid-1970s an addition of diagnostic phase resulted into a five step process.
The use of nursing process in clinical practice was started in 1973 by the american nurses
association (ANA ) in standards of nursing practice.
After 1980 the nursing process was added to the general nursing curriculum in India.


DEFINITIONS
The two words of nursing process are significant - nursing and process.
NURSING - Caring the clients during times of illness and assisting the client to achieve maximum
health potential throughout the life cycle.
PROCESS - A series of rational thoughts, decisions and acts to achieve a goal. It implies a
movement which has beginning, middle and an ending.
DEFINITION OF NURSING PROCESS
1. The nursing process is systematic, goal directed, client-centered method for structuring the .
delivery of nursing care.”

2. Nursing process is defined as a systematic, continuous and dynamic method of providing
care to clients. It comprises series of sequential phases built upon the preceding step. Each
phase logically leads to the next. As one step leads to the next step it results into ultimate
achievement of mutually determined nursing outcomes/goals.
1

,CHARACTERISTICS OF NURSING PROCESS
1. Interactive, Purposeful and systematic ..
2. Client-centered.
3. Goal-directed, outcome focused .
4. Within the legal scope of nursing
5. Prioritizing the needs.
6. The steps are interrelated and dependent on the accuracy of each of the preceding steps .
7. It is used to identify, diagnose, and treat human responses to health and illness .

PURPOSE OF NURSING PROCESS
 General objectives
 To help the nurse provide goal-directed, client-cantered care
 Specific objectives
 To identify a client’s health status; his actual/present and potential/possible health problems
or needs.
 To establish a plan of care to meet identified needs.
 To provide nursing interventions to meet those needs.
 To provide an individualized, holistic, effective and efficient nursing care.


COMPONENTS OF NURSING PROCESS:




2

,PHASES OF NURSING PROCESS-
Phase Title Description

1 Assessment Collecting subjective and Objective data.

2 Diagnosis Analysis subjective and objective data to make nursing diagnosis.

3 Planning Determining outcome criteria and developing a plan.

4 Implementation Carrying out a plan.

5 Evaluation Assessing whether outcome criteria have been met and revising the plan
as necessary.



1.HEALTH ASSESSMENT
It is systematic and continuous collection, validation and communication of client data as compared
to what is the standard/norm. It includes the client's perceived needs, health problems, related
experiences, health practices, values and life styles.

DEFINITION
Assessment is the systematic and continuous collection, organization, validation, and
documentation of data (information).

PURPOSE
 To establish a data base (all the information about the client):
 Nursing health history.
 Physical assessment.
 The physician's history & physical examination.
 Results of laboratory & diagnostic tests.
 Material from other health personnel

TYPES OF ASSESSMENT
The four different types of assessments are;
1. Initial nursing assessment
2. Problem-focused assessment
3. Emergency assessment
4. Time-lapsed reassessment

1. INITIAL NURSING ASSESSMENT:

3

,  Performed within specified time after admission.
 To establish a complete database for problem identification. Eg: nursing admission
assessment

2. PROBLEM-FOCUSED ASSESSMENT:
 To determine the status of a specific problem identified in an earlier assessment. Eg: hourly
checking of vital signs of fever patient

3. EMERGENCY ASSESSMENT:
 During emergency situation to identify any life threatening situation. Eg: rapid assessment
of an individual’s airway, breathing status, and circulation during a cardiac arrest.

4. TIME-LAPSED REASSESSMENT:
 Several months after initial assessment.
 To compare the client’s current health status with the data previously obtained.


COMPONENTS OF A HEALTH ASSESSMENT-
HEALTH HISTORY-
Taking a nursing history prior to the physical examination allows a nurse to establish a rapport with
the patient and family.
Elements of the history include:
 Health status.
 Course of present illness including symptoms.
 Current management of illness.
 Past medical history including family's medical history.
 Social history.
 Perception of illness.
PSYCHOLOGICAL AND SOCIAL EXAMINATION-
The psychological examination may include: -
 Client's perception (why they think they have been referred are being assessed; what they
hope to gain from the meeting).
 Emotional health (mental health state, coping styles etc).
 Social health (accommodation, finances, relationships, genogram, employment status, ethnic
back ground, support networks etc).
 Physical health (general health, illnesses, previous history, appetite, weight, sleep pattern,
diurinal variations, alcohol, tobacco, street drugs; list any prescribed medication with
comments on effectiveness).
 Spiritual health (is religion important? If so, in what way? What/who provides a sense of
purpose?). Intellectual health (cognitive functioning, hallucinations, delusions,
concentration, interests, hobbies etc).


4