Foundations of Nursing (III)
Subtopic:
The nursing process
The nursing process is a systematic, organized, and dynamic approach to providing individualized patient care. It guides nurses in identifying and addressing the unique responses of individuals or groups to actual or potential health problems. It is a cyclic and goal directed problem solving approach.
Characteristics of the Nursing Process
Cyclic and Dynamic: The nursing process is ongoing and continuous, adapting to the patient’s changing needs throughout the course of illness and treatment.
Goal-Directed and Patient-Centered: The process is focused on achieving specific patient goals and providing care tailored to the individual’s needs.
Interpersonal and Collaborative: It involves interaction and collaboration among nurses, patients, families, and the healthcare team.
Universally Applicable: The nursing process is a standardized framework used by nurses in all settings.
Systematic: It follows a logical, step-by-step approach.
Requires Critical Thinking: Nurses must use critical thinking skills to analyze patient data, identify problems, develop interventions, and evaluate outcomes.
Components of the Nursing Process
The nursing process consists of five sequential phases:
1. ASSESSMENT PHASE
The first phase involves systematically collecting, organizing, validating, and documenting data about the patient’s health status.
Data Collection Methods:
Patient Interviews: Gathering information directly from the patient about their health history, symptoms, and concerns (subjective data).
Physical Examination: Assessing the patient’s physical condition using techniques like inspection, palpation, percussion, and auscultation (objective data).
Types of Data:
Subjective Data: Information provided by the patient, reflecting their perceptions, feelings, and experiences (e.g., pain, nausea, anxiety).
Objective Data: Observable and measurable data obtained through physical examination, diagnostic tests, and observations (e.g., vital signs, lab results, wound appearance).
2.DIAGNOSIS PHASE
The nursing diagnosis is a clinical judgment about the patient’s response to actual or potential health problems or life processes. It provides the basis for selecting nursing interventions to achieve outcomes for which the nurse is accountable.
Note: A nursing diagnosis differs from a medical diagnosis. A medical diagnosis identifies a specific disease or medical condition, while a nursing diagnosis describes the patient’s response to that condition.
Types of Nursing Diagnoses
Nursing diagnoses are categorized based on the nature of the patient’s response to a health condition:
Actual Nursing Diagnosis:
Describes a current health problem or response that is present at the time of assessment.
Three-Part Structure:
Problem (Diagnosis): The specific nursing diagnosis label from the NANDA-I list (e.g., Hyperthermia, Acute Pain).
Etiology (Related to): The cause or contributing factors related to the diagnosis (e.g., “related to inflammatory process,” “related to surgical incision”).
Defining Characteristics (As Evidenced By): The signs and symptoms that support the diagnosis (e.g., “as evidenced by temperature of 38.5°C,” “as evidenced by patient’s report of pain 8/10”).
Example 1:
Scenario: A patient has a fever, and their temperature reading is 38°C.
Nursing Diagnosis: Hyperthermia related to increased leukocyte activity as evidenced by a temperature reading of 38°C.
Example 2:
Scenario: A patient reports a headache for the past two days following a minor head injury. The pain is rated as 3 on a 0-5 pain scale.
Nursing Diagnosis: Acute pain related to head trauma as evidenced by patient’s verbal report of headache and pain score of 3/5.
Risk Nursing Diagnosis (Potential Nursing Diagnosis):
Describes a potential problem that the patient is vulnerable to developing based on their current health status or risk factors.
Two-Part Structure:
Problem (Diagnosis): The specific nursing diagnosis label from the NANDA-I list (e.g., “Risk for Infection,” “Risk for Falls”).
Risk Factors (Related to): The factors that increase the patient’s vulnerability to the problem (e.g., “related to surgical incision,” “related to impaired mobility”).
Example:
Scenario: A patient has been vomiting for one day after eating contaminated food but shows no signs of dehydration yet.
Nursing Diagnosis: Risk for fluid volume deficit related to active fluid loss secondary to vomiting.
3. PLANNING PHASE
The planning phase involves establishing priorities, setting goals, and determining expected outcomes to guide nursing care.
1. Goals
Definition: Broad statements that describe the desired changes in a patient’s condition or behavior. They are the aims of nursing interventions.
SMART Criteria: Goals should be:
Specific: Clearly defined and focused.
Measurable: Able to be evaluated objectively.
Achievable/Attainable: Realistic and within the patient’s capacity.
Relevant/Realistic: Meaningful and important to the patient.
Time-bound: Having a specific timeframe for achievement.
Categories:
Short-Term Goals: Achievable within a short period, typically from minutes to a few days.
Intermediate Goals: Achievable within a longer timeframe, typically from a few days to a month.
Long-Term Goals: Achievable over a longer period, ranging from weeks to months or even years.
2. Expected Outcomes
Definition: Specific, measurable criteria used to evaluate whether goals have been met. They describe observable patient behaviors or responses that demonstrate progress toward the goal.
Types:
Short-Term Outcomes: Describe early expected benefits of nursing interventions.
Long-Term Outcomes: Describe benefits expected to be seen after discharge or in the long term.
4.IMPLEMENTION PHASE
This phase represents the action-oriented stage of the nursing process, where the care plan is put into practice. It encompasses the actual performance of the nursing interventions designed to achieve patient goals.
This phase is structured into two key components:
Nursing Interventions: This involves the direct application of planned nursing actions. It is the “doing” part of the implementation phase, where nurses execute the specific interventions detailed in the care plan.
Rationale: This component explains the scientific basis or reasoning behind each nursing intervention. It clarifies why a particular nursing action is being implemented, linking it back to the patient’s needs and desired outcomes.
5.EVALUTION
Evaluating is the fifth step of the nursing process. This final phase is vital to achieving a positive patient outcome. Once all nursing intervention actions have taken place, the team evaluates what was done beforehand to learn what works and what doesn’t. This is the past tense of the outcome if they have been achieved.
Importance of Using a Nursing Process:
Effective Care: The nursing process allows the nurse to provide effective care by prioritizing meaningful interventions based on their assessments and clinical diagnosis of the patient.
Standard of Care: It creates a standard of care where the nurse develops a nursing diagnosis and care plan based on their assessment of the patient.
Patient-Centered Care: The nursing process provides care that is centered around the individual patient, reducing the time the client spends in the health care facility and optimizing their health by minimizing complications in care.
Goal Setting: 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.
SOIN BRIEF
Assessment
Subjective Data (Symptoms): Patient reports feeling feverish.
Objective Data (Signs): Oral temperature reading of 38°C obtained.
Diagnosis
Actual Nursing Diagnosis: Hyperthermia related to increased leukocyte activity, as evidenced by a thermometer reading of 38°C.
Potential Nursing Diagnosis: Risk for fluid volume deficit secondary to possible vomiting.
Planning (Goals/Expected Outcomes)
Goals:
Short Term: Temperature will be reduced and maintained between 36.0°C – 37.4°C within a 30-minute timeframe.
Intermediate Term: [Specify if needed – e.g., Maintain normal temperature for the next 2 hours]
Long Term: [Specify if needed – e.g., Identify and manage the underlying cause of hyperthermia]
Expected Outcomes:
Patient will express a subjective improvement in thermal comfort and state they no longer feel feverish.
Temperature measurement will be within the normal range of 36.0°C to 37.4°C.
Implementation
Initiated tepid sponging as per protocol. [You can add more specific interventions here if needed, e.g., “Administered antipyretic medication as prescribed.”]
Rationale
Tepid sponging is implemented to facilitate heat dissipation through evaporative cooling mechanisms.
Evaluation
Patient reported feeling less feverish and more comfortable. Re-assessment of temperature after 30 minutes indicated a reading of 36.7°C.
Sample Nursing Care Plan for a Patient with Malaria
Assessment
Fever: Elevated body temperature noted.
Headache: Patient reports pain in the head.
Myalgias: Patient experiencing muscle aches.
Nausea: Patient reports feeling sick to their stomach.
Vomiting: Episodes of emesis observed.
Diarrhea: Frequent watery bowel movements reported.
Dehydration Risk: Potential for fluid loss due to diarrhea, nausea, and vomiting.
Diagnosis
Hyperthermia: Elevated body temperature related to the body’s response to infection, as indicated by a temperature of 39°C.
Acute Pain: Headache associated with malaria infection, as reported by the patient.
Impaired Physical Mobility: Difficulty moving due to muscle pain and weakness.
Nausea: Feeling of sickness related to changes in usual eating patterns.
Imbalanced Nutrition: Less than body requirements, possibly related to vomiting and reduced intake.
Risk for Deficient Fluid Volume: Potential for dehydration secondary to diarrhea, nausea, and vomiting.
Risk for Imbalanced Nutrition: Less than body requirements, due to reduced food intake and diarrhea.
Planning (Goals/Expected Outcomes)
Hyperthermia:
Short-Term Goal: Achieve a body temperature between 36°C and 37°C within 30 minutes.
Acute Pain (Headache):
Short-Term Goal: Experience a reduction in headache intensity within 40 minutes.
Impaired Physical Mobility:
Long-Term Goal: Demonstrate improved mobility and decreased muscle discomfort within 5 days.
Nausea:
Short-Term Goal: Report a decrease in nausea within 1 hour.
Vomiting:
Expected Outcome: Patient will exhibit normal bowel sounds upon auscultation.
Diarrhea:
Long-Term Goal: Achieve optimal nutritional intake despite diarrhea.
Risk for Deficient Fluid Volume:
Expected Outcome: Maintain adequate hydration status, evidenced by stable vital signs, good skin turgor, and balanced intake and output.
Implementation/Rationale
Hyperthermia:
Intervention: Administer prescribed antipyretic medication.
Intervention: Encourage increased oral fluid consumption.
Intervention: Apply external cooling techniques such as tepid sponging.
Rationale: Antipyretics help reduce fever. Adequate fluids combat dehydration. Cooling measures promote heat loss.
Acute Pain (Headache):
Intervention: Administer prescribed analgesic medication.
Intervention: Ensure a calm and dimly lit environment.
Intervention: Promote relaxation exercises like deep breathing.
Rationale: Analgesics alleviate pain. Reduced stimuli can lessen headache intensity. Relaxation techniques can enhance comfort.
Impaired Physical Mobility:
Intervention: Encourage gentle range-of-motion and stretching exercises.
Intervention: Administer prescribed analgesic medications.
Intervention: Apply warm compresses to affected muscle areas.
Rationale: Gentle exercise improves muscle flexibility and reduces pain. Analgesics help manage pain. Warmth promotes muscle relaxation.
Nausea:
Intervention: Administer prescribed antiemetic medication.
Intervention: Recommend small, frequent meals.
Intervention: Provide oral hygiene care, especially after vomiting.
Rationale: Antiemetics reduce nausea. Small meals are easier to digest. Oral hygiene promotes comfort and well-being.
Vomiting:
Intervention: Administer prescribed antiemetic medication.
Intervention: Monitor and document fluid intake and output.
Intervention: Offer oral rehydration solutions as necessary.
Rationale: Antiemetics control vomiting. Intake and output monitoring helps assess hydration status. Rehydration solutions restore fluid balance.
Diarrhea:
Intervention: Administer prescribed antidiarrheal medication.
Intervention: Advise a bland, easily digestible diet.
Intervention: Monitor and record the frequency and characteristics of bowel movements.
Rationale: Antidiarrheals help manage diarrhea. Bland diets are gentler on the digestive system. Bowel movement monitoring assesses intervention effectiveness.
Risk for Deficient Fluid Volume:
Intervention: Administer intravenous fluids if prescribed.
Intervention: Offer foods with high water content, such as soups.
Intervention: Administer antiemetics as needed to control vomiting and reduce fluid loss.
Rationale: IV fluids replace fluid deficits. Water-rich foods aid rehydration. Antiemetics help minimize fluid loss from vomiting.
Evaluation
Hyperthermia: Fever reduced to 37°C within the specified timeframe.
Acute Pain (Headache): Headache intensity lessened within 40 minutes, with patient reporting a pain level of 1/10 on a pain scale.
Impaired Physical Mobility: Improved mobility and reduced muscle pain reported after 5 days.
Nausea: Patient verbalized a reduction in nausea after 1 hour.
Vomiting: Bowel sounds assessed and found to be within normal limits.
Diarrhea: Optimal nutritional intake achieved.
Risk for Deficient Fluid Volume: Patient maintained hydration as evidenced by stable vital signs, good skin turgor, and balanced intake and output.
Expected Outcomes Summary
Patient will exhibit normal bowel sounds during abdominal assessment.
Patient will demonstrate improved dietary tolerance without experiencing nausea, vomiting, abdominal discomfort, bloating, or feeling full quickly.
Patient will maintain adequate nutritional status, free from signs of malnutrition.
Patient will regain or maintain a healthy body weight appropriate for their age and sex.
Patient will describe at least two methods to alleviate nausea and enhance comfort.
Patient will report increased comfort, reflected in improved sleep and mood.
Patient will express relief from nausea.
Patient will be able to demonstrate strategies to prevent or manage nausea.
Patient will maintain proper hydration, indicated by adequate fluid intake and output, stable vital signs, and healthy skin turgor.
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