The Nursing Process: A Comprehensive Guide

Posted on Aug 15, 2024 in Psychology and Sociology

Recovery

Assessment of health status requires the collection and interpretation of clinical data. This process falls into several classes:

  • Beginner: Collection is organized in a logical sequence.
  • Oriented: Information focuses on defining critical features of a previous problem.
  • Emergency: Addresses a life-threatening episode.
  • New Assessment: Aimed at previously identified problems and assessing changes in functional patterns.

Collection and Data Collection: Practical information is gathered for diagnosis and planning. Three instruments are used for data production: interview, observation, and exploitation. Sources may be primary (the user) or secondary (family).

Types of Data

  • Subjective: Personal view, including perceptions and feelings.
  • Objective: Observable and measurable data.
  • Current: Present situations.

First Appraisal

Objectives: To assess health status, identify functional patterns that may present problems, and help establish a therapeutic relationship. This involves nursing or history review, observation, and examination. Nursing history is gathered through interviews and questionnaires, which should be oriented towards specific areas of interest. This facilitates the relationship with the patient.

Four key elements to provide: Support, empathy, peace, and quiet.

Stages
  • Introduction: Begins the therapeutic relationship and explains the purpose of evaluating factors affecting the interview.
  • Body: The conversation focuses on specific areas.
  • Closing: Addresses additional information or concerns (treatment plan, problems).
Techniques

Fluid conversation is key. Types of techniques include:

  • Verbal Questioning: Frequently Asked Questions (FAQs).
  • Reflection: Repeating or rephrasing information.
  • Additional Sentence: Providing a stimulus for the patient to continue.
  • Examination: Observation and exploration.

Classification of Data

Information is categorized to enable specific categorization.

Inferences

Inferential reasoning is the process by which unknown significance is predicted from known data. It is temporary.

Inference Types

  • Analytical: The process of reasoning and analysis with observation that leads to a trial.
  • Intuitive: Understanding the whole situation of the individual and their environment. Requires verification and validation.

Validation Data

Validity and reliability are the most important characteristics. A fact is valid if it enables correct judgments. This is achieved through direct interaction with the user and consultation with other professionals.

Documentation and Recording

Data must be recorded. Objectives of documentation include facilitating information exchange between team members, permitting the establishment of diagnoses, objectives, and evaluation; providing legal proof; and supporting teaching and research.

Features of documentation: Objective, specific facts; avoids generalizations; descriptive and concise annotations.

Diagnosis

A diagnosis is a trial about individual responses, health problems, processes, or potential risks. Judgments are opinions issued after analyzing and synthesizing information.

Nursing Diagnosis

Describes a human response that is dynamic and informs nursing practice. It can be applied collectively and reflects how the user perceives their health status.

Collaborative Problems

Triple Nursing Disclaimer:

  • Detect and report signs and symptoms of complications that require early intervention prescribed by the physician or other professional.
  • Perform physician-prescribed interventions: medication, probes, suction.
  • Initiate interventions within the home to handle the problem: Postural drainage, risk prevention, teaching moving and coughing.

Nursing Diagnosis

Addresses unhealthy responses to treatment, signs and symptoms related to a definitive diagnosis, detection and treatment of liability issues, and the beginning of a treatment plan. Identifies health problems from the user’s perspective.

Diagnosis Process Elements

  • Collection of information
  • Data validation
  • Interpretation
  • Clustering of information
  • Nomination of the group (set of data)

Identification and Problem Types

  • Real: Human responses that exist in an individual.
  • Risk: Responses that may develop.
  • Health Promotion: Responding to health standards.

Diagnosis as Health Problems

  • Ensure a proper assessment has been completed.
  • Determine if the individual is normal, altered, or at risk of alteration.
  • Study groups and identify key areas of impaired functioning and risk.
  • Look for signs and symptoms often associated with the problem.
  • Name the problem and confirm the diagnosis is correct.
  • Identify the cause and risk factors.
  • Explain problems and ask if they include anything more.

Characteristics of a Nursing Diagnosis

  • Exhibits the problem of who is being evaluated.
  • Addresses health problems and drawn conclusions.
  • Includes jointly verifiable signs and symptoms.
  • Expresses a nursing trial.
  • Uses authorized nursing themes.
  • Addresses spiritual, physical, psychological, and sociocultural aspects.
  • Is brief and concise.
  • Must be valid.

Developing a Diagnosis

  • 1 Part: Syndrome Diagnosis
  • 2 Parts: Risk Diagnosis
  • 3 Parts: Actual Diagnosis (signs and symptoms) PES

The diagnosis category specifies the problem identified during assessment. Accuracy is crucial as it conditions the plan and its evaluation. Factors will be etiological or risk-related. Actual factors influence the change, while risk factors increase the individual’s vulnerability.

Writing a Diagnosis

Guidelines:

  • Describes a functional or dysfunctional pattern.
  • The term “R/C” (Related to) should be used. Signs and symptoms are not causative factors.
  • Use terminology within the nursing field.
  • Write the diagnosis with legally desirable terms, avoiding value judgments.

Planning

Planning involves identifying objectives and interventions that are achievable within a timeframe. It develops a care plan for solving a problem based on its cause.

Components

  • Prioritization
  • Setting goals
  • Defining specific activities

Properties

  • Facilitates communication
  • Directs care
  • Provides a post-registration assessment or investigation

Principles for Priority Setting

  • Use a method of assigning priorities (e.g., Maslow’s Hierarchy of Needs).
  • Address issues that are or may be the source of others.
  • Use a scale of priorities, understanding that it will be influenced by: user perception of priorities, the nurse’s understanding of the general situation, general health, length of stay, and guidelines of the healthcare center.

Objectives

  • Serve as a measuring instrument for the care plan.
  • Direct interventions.
  • Provide motivation.

Types of Objectives

  • Short-term
  • Long-term
  • Discharge planning objectives: Care plan, resource mobilization, and user support.

Expected Results

Objectives are generally phrased as questions followed by “evidenced by” and the desired result. They must state what must be done, who will do it, when, how, where, and to what extent. Interrelated problems should be addressed with separate objectives.

Verbs to Use

Use verbs that describe measurable or exact behavior, such as: Go, Get, Describe, Demonstrate, Do, Communicate.

Classification of Expected Results

  • Functional Domain: Body functions
  • Affective Domain: Changes in attitudes and feelings
  • Cognitive Domain: Knowledge acquisition
  • Psychomotor Domain: Skill development

Wording of Objectives

Guidelines:

  • User-centric
  • Brief and clear
  • Measurable and observable
  • Time-bound
  • Realistic and reflective of the current situation
  • Jointly decided with the user

Planning Interventions

Interventions are a combination of specific nursing activities performed to:

  • Monitor health status
  • Prevent, cure, or control a problem
  • Help perform daily activities
  • Promote independence and maximize health

Interventions encompass assessment, teaching, counseling, consultation, and specific interventions.

Features of Interventions

  • Consistent with the care plan
  • Based on scientific principles
  • Individualized
  • Provide safe and therapeutic use of resources
  • Appropriate for the situation

Application of the Scientific Method

  • Define the problem or diagnosis.
  • Identify alternatives (hypotheses).
  • Select alternatives. Brainstorming or using computer tools can stimulate the creation of alternatives.

Record of Proceedings

The record must include the user profile, discharge goals, major problems, expected results, intervention orders, and evaluation reviews. Annotations should be included as needed.

Implementation

Implementation involves putting the care plan into action. It includes interventions aimed at modifying factors contributing to the existence of problems.

Five Stages

  1. Assessment and Reassessment: Collect information to ratify, change, or add to the diagnosis; assess the need for intervention; monitor user responses; identify post-intervention responses.
  2. Setting Priorities for the Day: According to Alfaro, this involves studying medical and nursing records, evaluating critical issues, identifying problems requiring immediate solutions, listing interdependent problems, distinguishing interventions, determining user autonomy and providing support, and creating a personal sheet of daily tasks.
  3. Preparation: Review nursing performance, knowledge, and skills; analyze practice; check for existing protocols; identify potential problems; identify and obtain necessary resources. Consider legal and ethical aspects (user rights, nursing ethics) and involve the user.
  4. Intervention: This stage addresses the individual’s basic needs and includes undertaking, aiding, supervising, providing nursing education, offering advice on choices, and controlling risk factors. Common elements include continuous assessment, planning to revise or discontinue the action, and education (informing users about the performance).
  5. Recording and Reporting: Documentation must be completed after performing interventions. Commonly used systems include source-oriented records, problem-oriented medical records, and multi-disciplinary records where all professionals annotate on the same document.

Evaluation

Evaluation is a planned and systematic comparison between the user’s health status and the expected results.

Focus Areas

  • Organization: Focuses on the ability to provide care. Includes care services, equipment and administration, center policies, admission procedures, and personnel skills. All these factors influence the context of care delivery.
  • Process: Covers what has been done and the patient’s response. It is continuous.
  • Expected Results: Reviews the status and capabilities of users.

Objectives

  • Evaluate the achievement of results.
  • Identify factors affecting achievement.
  • Decide on the modification, continuation, or termination of the plan and execute the decision.

Assessment of Achievements

  • Consider previous assessments and reassessments to determine health status and achievement of results.
  • Compare current health status with expected results.
  • Identify issues and address them accordingly.
  • Record data and results of the evaluation.

Identifying Variables

  • Were interventions realistic?
  • Were they performed correctly?
  • Are there new problems?
  • What factors are affecting the process?
  • Review the user’s progress towards achieving the goals.

Continuation, Modification, or Completion of the Plan

  • Continuation: If no influencing factors are detected.
  • Modification: Check the accuracy of the problem list; delete inappropriate problems and add new ones; establish expected results; revise interventions; incorporate the results of the modification; set a reassessment date.
  • Completion: If the expected results have been achieved.

Evaluation and Feedback

This is an automatic process triggered after a disturbance to provide corrective action. It provides information to each factor involved in any stage of the nursing process.