Nursing Process

The Nursing process is an organized, systematic, dynamic method of giving individualized nursing care that focuses on identifying and treating unique responses of individuals or groups, to actual or potential alterations in health. (Nursing procedure Manual, 2015)

OR:

The nursing process is defined as a systematic, rational method of planning that guides all nursing actions in delivering holistic and patient-focused care.

Outline the CHARACTERISTICS of the nursing process

1. Cyclic and Dynamic: It is an ongoing continuous process throughout the stages of illness and treatment and ends with the cease of the illness.
2. Goal directed and Client oriented: The nursing process is intended to treat the patient and is in the best interest of the patient.
3. Interpersonal and Collaborative: This goes to explain the amount of interaction that might be necessary between nurses, patients of similar illnesses and the medical team.
4. Universally applicable: This process is universally standard and no matter what the institution it may be, the process remains the same.
5. Scientific and Systematic: Every symptom or sign is a result of a scientific fact which leads to scientific methods of treatment and follow-ups. It is systematic and goes from step to step as in the phases mentioned below.
6. Requires critical thinking: The use of the nursing process requires critical thinking which is a vital skill required for nurses in identifying client problems and implementing interventions to promote effective care outcomes.

Explain the components of the nursing process

1. Assessment
2. Diagnosis
3. Planning
4. Implementation
5. Evaluation

ASSESSMENT PHASE

The first phase of the nursing process is assessment. It involves collecting, organizing, validating, and documenting the clients’ health status. Assessment involves data collection which is the process of gathering information regarding a client’s health status. The main methods used to collect data are health interviews and physical examination.

Types of data collected

• Subjective data or symptoms: This is information obtained from the patient through an interview. It also includes symptoms felt by the patient only. It is only the patient who can tell you information e.g. present complaints, past medical history, past surgical history etc.
• Objective data or signs: This is the information that is measurable, tangible data collected via the senses, such as sight, touch, smell, or hearing e.g. vomiting, distended abdomen, presence of edema, lung sounds, crying, skin color, and presence of diaphoresis.

NURSING DIAGNOSIS PHASE

A nursing diagnosis is a clinical judgment concerning a human response to health conditions/life processes, or a vulnerability to that response, by an individual, family, group, or community.

Differences between Nursing Diagnosis and Medical Diagnosis

• Focus: Nursing diagnosis centers on the patient's holistic response to actual or potential health problems, encompassing physical, emotional, social, and spiritual aspects. Medical diagnosis, conversely, identifies and labels diseases, injuries, or conditions based on their etiology and pathology.
• Scope: Nursing diagnoses provide a framework for nursing care and interventions, guiding nurses in developing individualized care plans. Medical diagnoses, on the other hand, guide medical treatment and interventions, often involving pharmacological or surgical approaches.
• Orientation: Nursing diagnoses are patient-oriented and dynamic, changing as the patient's responses evolve. Medical diagnoses are disease-oriented and tend to be more static, remaining the same as long as the disease is present.
• Nomenclature: Nursing diagnoses use standardized terminology developed by organizations like NANDA International (e.g., "Acute Pain," "Impaired Skin Integrity"). Medical diagnoses use standard medical classifications such as ICD-10 (e.g., "Appendicitis," "Type 2 Diabetes Mellitus").

Types of the nursing diagnosis:

1. Actual nursing diagnosis

• These are presenting response to current health condition.
• The actual nursing diagnosis has three parts i.e. Diagnosis, relation to (pathophysiology) and evidence.

Scenario A: A patient complaining of fevers, on thermometer reading it indicates 38°C.
From NANDA 2024 – 2026 fevers have hyperthermia i.e.
Hyperthermia related to increased leukocyte activity evidenced by the thermometer reading of 38°C.

Scenario B: A patient complained of headache of the forehead since the last 2 days after a minor head injury following a fight. On examination the pain was at 3 on a 0 – 5 pain scale.
From NANDA 2024 – 2026 headache is described as Acute pain since it has been present less than 3 months.
- Acute pain related to trauma to the head evidenced by the patient’s verbalization of feeling headache of 3 on a 0 – 5 pain scale.

2. Potential Nursing diagnosis:

• This is an issue that could occur incase the current symptoms is not properly managed.
• The potential nursing diagnosis has two parts that is the nursing diagnosis and the relation (pathophysiology) only.

Scenario: A patient reported vomiting for 1 day after ingesting chips and chicken. On examination the patient had no signs of dehydration.
From NANDA 2024 – 2026 vomiting does not have an actual nursing diagnosis it only has a potential nursing diagnosis which is risk for inadequate fluid volume.
– Risk for inadequate fluid volume related to vomiting.

PLANNING PHASE

The planning stage is where goals and outcomes are formulated that directly impact patient care. Planning phase is divided into:

1. Goals
2. Expected outcomes

Goals

• These are the aims of the nursing interventions to be provided.
• Therefore they should be smart.

Goals should be:

1. Specific or on point
2. Measurable or Meaningful
3. Attainable or Action-Oriented
4. Realistic: it should represent things in a way that is accurate and true to life
5. Timely or Time-Oriented

Goals are divided into 3 categories i.e.

1. Short term goals: these are goals having time limit ranging from minutes to 5 days.
2. Intermediate goals: these are goals having time limit ranging from 5 days to 30 days.
3. Long term goals: these are goals having time limit ranging from 30 days to years.

Expected Outcome

This what a nurse expects the patient to present after provision of the nursing interventions. Its divided into 2 i.e. short term and long term outcomes.

IMPLEMENTATION PHASE

The implementation phase of the nursing process is when the nurse puts the treatment plan into effect. It involves action or doing and the actual carrying out of nursing interventions outlined in the plan of care.

The implementation phase is divided into two parts:

1. Nursing Interventions
2. Rationale

Nursing Interventions

Nursing interventions are specific actions or treatments that nurses perform to help patients achieve the outcomes identified in the care plan. These interventions are based on scientific knowledge, clinical judgment, and the nurse's skills. They are designed to:

• Promote health and prevent illness.
• Restore health and facilitate recovery.
• Alleviate suffering and provide comfort.
• Assist with coping and adaptation to health problems.

Nursing interventions can be categorized in various ways, such as:

• Direct Care Interventions: These are actions performed directly with the patient, such as administering medications, performing wound care, assisting with activities of daily living, or providing emotional support.
• Indirect Care Interventions: These are actions performed away from the patient but on their behalf, such as documenting care, collaborating with other healthcare professionals, managing the patient's environment, or advocating for the patient's needs.
• Independent Nursing Interventions: These are actions that nurses can initiate and perform on their own, based on their scope of practice and clinical judgment, without a physician's order (e.g., providing health education, repositioning a patient to prevent pressure ulcers).
• Dependent Nursing Interventions: These are actions that require a physician's order or supervision (e.g., administering prescription medications, initiating intravenous fluids).
• Collaborative Interventions: These are actions that nurses carry out in collaboration with other healthcare team members, such as physical therapists, dietitians, or social workers.

Rationale

The rationale in the implementation phase refers to the scientific reason or justification behind each nursing intervention. It explains *why* a particular intervention is chosen and *how* it is expected to achieve the desired patient outcomes. Providing a clear rationale for interventions is crucial for several reasons:

• Evidence-Based Practice: It ensures that nursing care is based on current best evidence and research, rather than tradition or guesswork.
• Critical Thinking: It promotes critical thinking by requiring nurses to understand the underlying principles and expected effects of their actions.
• Accountability: It provides a basis for accountability, as nurses can explain and justify their interventions to patients, families, and other healthcare professionals.
• Learning and Education: It serves as an educational tool for nursing students and less experienced nurses, helping them understand the principles of effective nursing care.
• Patient Safety: Understanding the rationale helps nurses to identify potential risks and complications associated with interventions and to take appropriate precautions.

When documenting nursing interventions, it is often best practice to include a concise rationale, either explicitly or implicitly through the choice of evidence-based actions, to demonstrate the thoughtful and purposeful nature of nursing care.

EVALUATION

Evaluating is the fifth step of the nursing process. This final phase of the nursing process is vital to a positive patient outcome. Once all nursing intervention actions have taken place, the team now learns what works and what doesn’t by evaluating what was done beforehand. This is the past tense of the outcome if they have been achieved.

Explain the importance of using a nursing process

1. The nursing process allows the nurse to provide effective care by prioritizing meaningful interventions based on their assessments and clinical diagnosis of the patient.
2. At the end of the nursing process, the nurse evaluates the success of their care to ensure that effective care is being prioritized.
3. It creates a standard of care where the nurse develops a nursing diagnosis and care plan based on their assessment of the patient.
4. The nursing process provides care that is centered around the individual patient which reduces the time the client spends in the health care facility, and optimizes their health by minimizing complications in care.
5. By setting defined goals with a clear timeline in the nursing process, the nurse can evaluate the effectiveness of the care they are providing and make changes to the care plan as needed.

SO IN BRIEF

Assessment:

• Subjective Data (Symptoms): Patient complaining of fevers.
• Objective Data (Signs): Thermometer reading indicates 38°C.

Diagnosis:

• Actual Nursing Diagnosis: Hyperthermia related to increased leukocyte activity evidenced by the thermometer reading of 38°C.
• Potential Nursing Diagnosis: Risk for fluid volume deficit related to vomiting.

Planning (Goals/Expected Outcomes):
Goals:

• Short Term: Reduce temperature to between 36.0°C to 37.4°C within 30 minutes.
• Intermediate Term: [Specify a goal if needed]
• Long Term: [Specify a goal if needed]

Expected Outcomes:
The patient will verbalize that he no longer feels feverish. Thermometer reading will be between 36.0°C to 37.4°C.

Implementation:

• [Specify nursing interventions here, e.g., tepid sponging.]

Rationale:

• [Explain why you did the intervention, e.g., To allow evaporative cooling.]

Evaluation:

• Patient verbalized that he no longer feels feverish, and the thermometer reading was 36.7 degrees Celsius after 30 minutes

Sample Nursing Care Plan for a patient with Malaria

Expected outcomes while managing a patient with glomerulonephritis: Came as a Question in 2023

Defining Expected Outcomes

Expected outcomes, also known as patient outcomes or desired outcomes, are measurable, observable, and achievable goals that a patient is expected to attain as a result of nursing care. They represent the desired changes in a patient's health status, behaviors, or perceptions. Expected outcomes are crucial components of the planning phase of the nursing process, as they provide a benchmark against which the effectiveness of nursing interventions can be evaluated.

Tense Used in Expected Outcomes

Expected outcomes are always written in the future tense. This is because they describe what the patient will do or will achieve after the nursing interventions have been implemented. The future tense emphasizes that these are goals to be reached, rather than current states. Examples include phrases like "patient will demonstrate," "patient will exhibit," "patient will regain," or "patient will verbalize."

1. Patients will demonstrate bowel sounds within normal limits.
2. Patients will exhibit normal eating habits without experiencing nausea, vomiting, abdominal discomfort, dyspepsia, bloating, and early satiety.
3. Patient will exhibit balanced nutrition as evidenced by the absence of malnutrition
4. Patient will regain and maintain adequate body weight for age and gender
5. Patient will verbalize two strategies to reduce nausea and improve comfort.
6. Patient will express improved comfort as evidenced by improved sleep and mood.
7. Patient will verbalize relief from nausea
8. Patient will be able to demonstrate strategies that prevent nausea
9. Patient will maintain hydration as evidenced by adequate intake and output, vital signs, and skin turgor