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    Thursday, 20 July 2017


    Nursing is a profession with independent practice which focuses on holistic client care. A nurse plays a clinical role among other roles in promoting and maintaining the health of the individual and family within the community. To achieve this goal of nursing, there is need for an organized framework or sequence of problem solving steps that guides nursing practice.

    At the end of this session, participants should be able to:
    ü Define Nursing Process
    ü Identify the Steps of Nursing Process
    ü Identify the Concepts of Nursing Diagnosis, Nursing Outcome Classification (NOC) and Nursing Intervention Classification (NIC)
    ü Link Up the Identified Nursing Diagnoses With NIC And NOC

    Nursing process is an organised framework for professional nursing practice (Ackley and Ladwig 2011).
    American Nurses Association 2007 defined nursing process as an organized sequence of problem-solving steps used to identify and manage the potential and actual health problems of clients.
    Nwonu (2002) defined Nursing Process as a systematic and goal directed set of activities which are interrelated and dynamic, used by the nurse to determine, plan and implement individualized nursing care which is aimed at helping the patient achieve integration of his whole being or optimal level of wellness.

    §  Systematic.
    §  Goal directed set of Activities.
    §  Interrelated.
    §  Dynamic.
    §  Determine, plan and implement.
    §  Individualized nursing care.
    §  Integration of a whole being/optimal level of wellness.

    Characteristics of the Nursing Process:
    §  Nursing process is systematic and organized with specific components.
    §  Nursing process is cyclic, with each phase leading logically to the next. Each phase is dependent on the accuracy of the preceding one. Each step overlaps with the previous and subsequent step.
    §  It is purposeful and goal-directed. The goal is to provide quality, individualized, client-centered care.
    §  It is dynamic to meet the ever changing needs of the client.
    §  It is interactive because it involves reciprocal interpersonal relationships between the nurse and the client, family, significant others and other health team members.
    §  Nursing process is theoretically based as it is grounded in knowledge of sciences and humanities. There are some theories that are applicable to Nursing process some of which are Gordon Marjorie’s functional health pattern model which applies to assessment phase; Maslow’s hierarchy of need theory which applies to planning phase etc. The nurse must incorporate knowledge from many areas in order to deliver holistic care, that is, to meet the total needs of the client.
    §  Nursing process is flexible and can be used effectively in all levels of health care setting. It is appropriate for use with individual clients, families, groups, or communities. It can be used with the acutely or chronically ill patients. Nurses can utilize the nursing process with clients of any age and at any developmental level.

    Importance of Nursing Process
    §  Provides individualized care
    §  Client is an active participant
    §  Promotes continuity of care
    §  Provides more effective communication among nurses and healthcare professionals
    §  Develops a clear  and efficient plan of care
    §  Provides personal satisfaction as you see client achieve goals
    §  Professional growth as you evaluate effectiveness of your interventions

    The steps have been changing over the years. Initially, it was a three step process. Later became four then five. Currently, it is a six phase process which includes:
    ·        Assessment
    ·        Nursing Diagnosis
    ·        Outcome Identification
    ·        Planning
    ·        Implementation
    ·        Evaluation

    This is the first phase in the nursing process. It is a time of data collection or information gathering about the individual patient, family or community. Data gathering include physiological, socio-cultural and environmental information about the patient, family or community. Information gathered is verified, organized, interpreted, and documented. The completeness and correctness of the information obtained during assessment are directly related to the accuracy of the steps that follow. Assessment provides information that could be subjective or objective which forms the client database.

    Subjective data are data from the client’s point of view and include feelings, perceptions, and concerns. The patient’s history, embodying a personal perspective of problems and strength, provides subjective date (Ralph & Taylor, 2011). It is an essential data source in the assessment phase.

    Objective data are observable and measurable data that are obtained through both standard assessment techniques performed during the physical examination and diagnostic tests.

    Sources of information
    The primary source of data is the client. The client is an individual, family, community or group/organization.
    Secondary source: physical examination, nursing history, team members, laboratory reports, diagnostic tests.

    Activities carried out during nursing assessment
    -         History taking (client interview).
    -         Physical examination.
    -         Review of relevant documents/reports.
    -         Diagnostic and laboratory investigation.

    (1) History taking
    This is one of the major tools the nurse uses in nursing assessment. It provides the necessary information from which to develop a written record about the client and identify existing and potential problems of the client. It allows the nurse to plan and modify nursing actions in accordance with the client’s desires, values and patterns of daily living.

    1. History taking has three types and the history which the nurse collects is determined by the nature of the patient’s contact with the health agency, the patient’s current health condition and the particular health settings. The types are;
    -         Initial complete history - Enough information is gathered by the nurse to assess the general health status of the patient as an individual. It serves as the basis for future comparison.
    -         A health complaint history or emergency history – it focuses on immediate problem, events that led to the problems, home or emergency treatment and its effect.
    -         Update or interim or time lapse history – it focuses on health a problem that arises after the clients’ last contact the nurse.

    Nursing history is obtained mainly through interview. The interview focuses on emotionally charged areas since these are likely to be the areas where the patient is having difficulty in adapting. Health history interview is a conversation with a purpose. Skill is required in health history such as communication and interaction skills. The interview sessions are;
    -         Introduction phase or join phase.
    -         Working phase.
    -         Termination phase
    Introduction phase
    The nurse and patient establish rapport and trust in this phase. Identification data such as name, age, address, marital status, religion, educational status, etc are obtained. This phase helps in forming a base for continued rapport necessary for a good directed interaction.
    Working phase
    Information related to history and assessment of the patient’s problem is collected.
    Termination phase
    This focuses on the closure of the interview. Summarizes the discussion so that the client can validate the nurse’s perception of what has occurred and decisions made.
    2. Physical examination
    Physical examination constitutes objective data that is observable or measurable and can be verified by more than one person. It helps the nurse to validate the client’s complaints/information got during history taking. The data are obtained using senses of touch, smell, vision and hearing (Nwonu, 2002).
    Techniques used in physical examination
    -         Inspection.
    -         Palpation.
    -         Percussion
    -         Auscultation.
    3. Review of relevant documents and reports
    The relevant reports and records include x-ray reports, admission records, ultrasound reports.
    4. Diagnostic and laboratory investigation
    Tests like haemoglobin, pack cell volume estimation (PCV), blood grouping, and routine urinalysis can be ordered by the nurse to form baseline data. The nurse should know the normal values in order to identify deviations from the normal.

    Types of Assessment
    There are four types namely:
    1.     Initial assessment: this is performed shortly after patient’s admission to a health facility.
    2.     Problem focused assessment: in this case, the nurse gathers data about a specific problem that has already been identified.
    3.     Emergency assessment: Here the nurse performs emergency assessment on a physiological or psychological crisis to identify the life threatening problems. It focuses on the few essential health patterns and is not comprehensive.
    4.     Time-lapsed assessment (Ongoing): This assessment is done to compare a patient’s current status with initial assessment. Nurses perform time-lapsed reassessment (e.g. periodic output, patient clinic visits, home health visits,
    health and developmental screening).

    Nursing Diagnoses
    According to Nwonu (2002), Nursing Diagnosis is a concluding statement based on the analysis and interpretation of systematically collected data, describing the actual or potential health problems or the client’s response to these for which the professional nurse is qualified and licensed to intervene.
    NANDAdefined nursing diagnosis as a clinical judgment concerning a human response to health conditions/life processes, or vulnerability for that response, by an individual, family, group or community. A nursing diagnosis provides the basis for selection of nursing interventions to achieve outcomes for which the nurse has accountability. (Approved at the ninth NANDA conference; amended in 2009 and 2013.)
    Nursing diagnosis is a clinical judgment about individuals, family, or community responses to actual or potential health problems/life processes (Herdman, 2012).
    There are four types of nursing diagnosis.
    1.     Problem focused diagnosis (this was formerly called Actual diagnosis) – this is a clinical judgment concerning an undesirable human response to a health condition / life processes that exist in an individual, family, group and community (Herdman ad Kamitsuru, 2014). The problem focused diagnosis has a label, definition, defining characteristics and related factors. Example.
    Label – Ineffective Breathing Pattern
    Definition – Inspiration and /or expiration that does not provide adequate ventilation.

     Defining characteristics
    • Dyspnea
    • Orthopnea
    • Shortness of breath
    • The pressure drop of inspiration / expiration
    • Decreased air exchange per minute
    • Using the additional respiratory muscles
    • Nasal flaring
    • Respiratory rata-rata/minimal
      • Infants: less than 25 or more than 60
      • Ages 1-4: less than 20 or more than 30
      • Age 5-14: less than 14 or more than 25
      • Age over 14: less than 11 or more than 24
    Related factors –
    ·        Hyperventilation
    ·        Chest wall deformity
    ·        Fatigue of respiratory muscles
    ·        Hypoventilation syndrome
    ·        Pain
    ·        Anxiety
    ·        Neuromuscular Dysfunction

    2. Risk diagnosis– This is a clinical judgment concerning the vulnerability of an individual, family, group and community for developing an undesirable human response to a health condition / life processed (Herdman and Kamitsuru, 2014). Risk diagnosis has a label, definition and related factors but no defining characteristics.
    Example –
    Label: Risk for Infection
    Definition: At increased risk for being invaded by pathogenic organisms
    Risk Factors –
    ·        Invasive procedures;
    ·        Insufficient knowledge regarding avoidance of exposure to pathogens; 
    ·        Tissue destruction and increased environmental exposure; 
    ·        Pharmaceutical agents (e.g., immunosuppressants); 
    ·        Malnutrition; 
    ·        Increased environmental exposure to pathogens;
    ·        Immunosuppression;
    ·        Inadequate primary defenses (e.g., broken skin, traumatized tissue, decrease in ciliary action, stasis of body fluids, change in pH secretions, altered peristalsis); 
    3. Health promotion diagnosis: This is a clinical judgment concerning motivation and desire to increase well being and to actualize human health potential. These responses are expressed by a readiness to enhance specific health behaviours, and can be used in any health state. Health promotion responses may exist in an individual, family, group or community. (Herdman and Kamitsuru, 2014). The health promotion diagnosis has a label, definition and defining characteristics to establish the positive health behaviours. It does not have related factors.
    Example –
    Label: Readiness for Enhanced Community Coping
    Definition: Is a pattern of community activities for adaptation and problem solving for meeting the demands or needs of the community, which can be strengthened.
    Defining characterisits –
    ·        Expresses desire to enhance availability of community recreation programmes
    ·        Expresses desire to enhance availability of community relaxation programmes
    ·        Expresses desires to enhance community planning for predictable stressors
    ·        Expresses desire to enhance community resources for managing stressors
    ·        Expresses desire to enhance problem solving for identified issues
    4. Syndrome diagnosis: this is a clinical judgment concerning a specific cluster of nursing diagnosis that occur together and are best addressed together and through similar interventions (Herdman and Kamitsuru, 2014). It si a problem focused diagnosis. It has a label, definition, defining characteristics and related factors.
    Lable: Rape – Trauma Syndrome
    Definition: Sustained maladaptive response to a forced, violent, sexual penetration against the victim’s will and consent.
    Defining characteristics –
    Aggression                     Agitation                       Alteration in sleep pattern
    Anger                                      Anxiety                          Change in relationship(s)
    Confusion                      Denial                            Dependency
    Depression                     Disorganization             Dissociative identity disorder

    Outcome Identification
    After the appropriate priority of nursing diagnoses is determined, outcomes are developed.
    In the opinion of Moorehead, Johnson and Maas (2004), outcomes are variable concepts that can be measured along a continuum, which means the outcomes are stated as concepts that reflect a patient, family caregiver, or community actual state rather than expected goals. Development of outcomes can be done through two ways: using the Nursing Outcome Classification (NOC) or writing an outcome statement ((Ackley & Ladwig, 2006).
    Using NOC.
    E.g. Nursing diagnosis (Hopelessness).        Impaired physical mobility
    Using NOC- Outcome    (Hope.)                                  Mobility.
    Using Outcome Statement.
              Patient’s physical mobility will improve within the period of hospitalization.
    Outcome Criteria:
    The outcome criteria are specific conditions under which the outcomes are expected to occur.

    Characteristics of Outcome Criteria
    S-      SPECIFIC
    A -     ATTAINABLE
    R-      REALISTIC
    T-      TIME – FRAMED
    Outcome identification can be short term or long term goal.
    If possible, the nurse should involve the client in determining appropriate outcomes

     According to Nwonu (2002), planning is the act of determining things to do to ensure that client is assisted to achieve restoration, maintenance and promotion of health. Planning promotes continuity of care.  For planning to be effective, individuals, families and communities has to be involved.

    Steps in planning nursing care
      Setting priority – Here the diagnoses are arranged in order of importance taking into consideration the life-threatening needs, health-threatening needs and patient’s concerns. Maslow’s need theory is useful in prioritizing diagnoses.
      Setting objectives – The objectives should be client centred, stating what the client should be able to do or exhibit by the end of nursing intervention. They should be measureable, achievable and time bound.
      Selecting appropriate nursing intervention – Nursing interventions that will assist the client to achieve the set objectives should be selected taking into consideration the client’s preferences.
      Writing a care plan – All the actions in the preceding three steps are pooled and written as a care plan that should guide the implementation of care.
    The use of standardized nursing language is important in writing a nursing care plan. The relevant standardized languages here are NOC and NIC.

    Nursing Outcome Classification (NOC)
    The Nursing Outcomes Classification describes an individual, care-giver, family, or community state, behaviour or perception that is measured along a continuum in response to a nursing intervention(s) (Moorhead, Johnson, Mass and Swanson, 2013). It is also a comprehensive, standardized classification of patient/client outcomes developed to evaluate the effects of nursing interventions. Each NOC outcome has a label name, a definition, a list of indicators to evaluate the patient current status in relation to the outcome, a five-point Likert scale to measure patient status.
    Each NOC has: Label name: Community Risk Control: Unhealthy cultural traditions.
    Definition: Community actions to promote customs, beliefs, values and laws that support members’ health and lifestyle modifications within the culture. Measurement scale(s): 1 (poor) 2 (fair) 3 (good) 4 (very good) and 5 (excellent).
    The nurse rates the client using the indicators listed below on this measurement scale at every stage to evaluate progress.
    ·        Systemic assessment of cultural practices within the community
    ·        Mobilization of community members to identify harmful cultural practices
    ·        Educational programmes to reinforce healthy cultural practices
    ·        Treatment of members with conditions related to harmful practices
    ·        Promotion of laws against harmful practices
    ·        Availability of referral systems for counseling
    ·        Capacity of the community to monitor harmful practices
    ·        Modifications of harmful cultural practices to make them safe
    ·        Reinforcement of healthy cultural practices

    Nursing Intervention Classification (NIC)
    Nursing intervention is any treatment, based upon clinical judgment and knowledge that a nurse performs to enhance patient/client outcomes (Bulechek, Butcher, Dochterman and Wagner, 2013). When diagnoses are identified, there must be interventions to resolve the identified diagnoses. Unlike nursing diagnosis or patient outcome in which the focus of concern is the patient, the focus of concern with nursing intervention is nursing behaviour which is the nursing actions that assist the patient toward a desired outcome. Nursing intervention classifications (NIC) were developed to give a label, definition and standard to our activities as nurses. From a list of 10 to 30 activities per intervention, the nurse selects the activities most appropriate for the specific individual, family or community. The nurse can add new activities if needed however, all modifications and additions should be congruent with the definition of the intervention
    Each NIC has label, definition and the activities to be performed by the nurse.
    Definition: Thermometric reading above normal body temperature of 37.20c.
    ·        Tepid sponge the patient
    ·        Open nearby windows
    ·        Fan the patient
    ·        Expose the patient but maintain privacy
    ·        Give prescribed antipyretic drug.

    ·        Means putting nursing care plan into ACTION!
    ·        To help client attain goals and achieve optimal level of health.
    ·        Requires: Knowledge, Technical skills, Communication skills.
    ·        During implementation, all the previous phases of the nursing process are integrated.
    ·        While giving the actual care, you must continue to assess, validate concerns, modify the plan and identify priorities as needed.
    ·        The nursing interventions should be client-centred and goal-oriented; with careful attention to the safety needs of the client.
    ·        It is important to ensure active involvement of the client and family while implementing care.
    ·        During delivery of care, the nurse should continue to assess the behaviours of the client while giving nursing care.
    ·        It is also important to note the client’s responses to nursing interventions

    Evaluation in nursing process is the planned, systematic comparison of the client’s health status with the goals/expected outcomes. It is an ongoing activity, done on a day -to-day basis, which involves the client, the nurse, and other health team members. It is an on-going activity and involves the client, the nurse and other members of the team. Nursing Outcome Classification should be used as guide when writing evaluation.

    Evaluation is carried out with the aim to:
    ·        Determining the status of the client
    ·        Determining the client’s progress toward achievement of the stated goals/expected outcomes.
    ·        Judging the effectiveness of the nursing orders, strategies, and care plan.
    N: B-Expected outcomes identify the exact client behaviors to be achieved.
    Steps in evaluation
    ·        Select evaluation criteria
    ·        Observe client for evidence
    ·        Make a judgment

    Four Possible Judgments are:
    ·        The goal was completely met.
    ·        The goal was partially met.
    ·        The goal was completely unmet.
    When a goal is partially met or not met, the nurse reassesses the situation.
    Ineffective breathing pattern
    Definition: – Inspiration and /or expiration that does not provide adequate ventilation.

    Defining characteristics:
    • The pressure drop of inspiration / expiration
    • Decreased air exchange per minute
    • Using the additional respiratory muscles
    • Nasal flaring
    • Dyspnea
    • Orthopnea
    • Shortness of breath
    • Respiratory rata-rata/minimal
      • Infants: less than 25 or more than 60
      • Ages 1-4: less than 20 or more than 30
      • Age 5-14: less than 14 or more than 25
      • Age over 14: less than 11 or more than 24
    Related factors:
    • Hyperventilation
    • Chest wall deformity
    • Fatigue of respiratory muscles
    • Hypoventilation syndrome

    • Respiratory status: Ventilation
    • Respiratory status: Airway patency
    • Vital sign Status

    Criteria Results:
    • Demonstrate effective cough and breath sounds are clean, no cyanosis and dyspnoea (capable of removing sputum, able to breathe easily, no pursed lips)
    • Indicates a patent airway (the client does not feel suffocated, breath rhythm, respiratory frequency in the normal range, there is no abnormal breath sounds)
    • Vital signs are within normal range (blood pressure, pulse, respiration)

    Airway Management
    • Open the airway, using chin lift technique or jaw thrust if necessary
    • Position the patient to maximize ventilation
    • Identify the patient's need for the installation of an artificial airway devices
    • Place the mayo if needed
    • Perform chest physiotherapy if necessary
    • Remove secretions by coughing or suction
    • Auscultation of breath sounds, record the presence of additional noise
    • Perform suction on the mayo
    • Give bronchodilators if necessary
    • Adjust intake to optimize fluid balance.
    • Monitor respiration and oxygenation status

    Oxygen therapy
    • Clean the mouth, nose and trachea secret
    • Maintain a patent airway
    • Set oxygenation equipment
    • Monitor the flow of oxygen
    • Maintain the position of the patient
    • Observe for signs of hypoventilation
    • Monitor the patient's anxiety to oxygenation

    Vital sign monitoring
    • Monitor blood pressure, pulse, temperature, and respiratory rate
    • Note the presence of fluctuations in blood pressure
    • Monitor vital signs while the patient is lying down, sitting, or standing
    • Auscultation of blood pressure in both arms and compare
    • Monitor blood pressure, pulse, respiratory rate, before, during, and after activity
    • Monitor the quality of the pulse
    • Monitor respiratory rate and rhythm
    • Monitor lung sounds
    • Monitor abnormal breathing pattern
    • Monitor the temperature, color, and skin moisture
    • Monitor peripheral cyanosis
    • Monitor the existence of Cushing's triad (a widened pulse pressure, bradycardia, increased systolic)
    • Identify the causes of changes in vital signs

    Ackley, B. J. & Ladwig, G. B. (2011). Nursing Diagnosis Handbook: A Guide to  Planning Care. Phildelphia: Mosby-Elsevier.
    Bulechek, G.M.,Butcher, H.K.Dochterman, J.M. & Wagner, C.(2013). Nursing Interventions Classification (NIC), 6th Ed; Canada: Elservier.
    Herdman, T.H. & Kamitsuru, S. (2014). North American Nursing Diagnosis Association-International. Nursing diagnoses: Definitions and classification, 10th Ed; Chichester: Wiley-Blackwell.
    Moorhead, S., Johnson, M., Maas, M.L., & Swanson, E. (2013). Nursing Outcomes Classification (NOC), Measurement of Health Outcomes. 5th Ed; Philadelphia: Elsevier
    NANDA –I (2013): NANDA International Nursing Diagnosis Glossary available from http://www.nanda.org/nanda-international-glossary-of-terms.html. Accessed 24th March 2017.
    Nwonu E. (2002): Nursing Process: Concept and Practice, 1st Ed; Enugu: Snap Press


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