Nursing Process. Assessment. Planning. Implementation. Evaluation

(1)

Nursing Process

Objectives: Objectives: • • Introduce the history of nursing process Introduce the history of nursing process • • Discuss purpose of nursing process Discuss purpose of nursing process Including philosophy Including philosophy • • Discuss nursing models in relation to Discuss nursing models in relation to assessment assessment • • Discuss defensible documentation Discuss defensible documentation • • Criticism of process Criticism of process • • SummarySummary

(2)

Nursing Process

n n

Assessment

n n

Planning

n n

Implementation

n n

Evaluation

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The Nursing Process

The term

The term ““ Nursing ProcessNursing Process ” ” came to the UK came to the UK in the 1970

in the 1970’’ s and came to be understood s and came to be understood as: as: n n A form of documentation A form of documentation n n As a means of organising work, that is As a means of organising work, that is patient allocation or primary nursing patient allocation or primary nursing n n As an educational tool to help achieve As an educational tool to help achieve patient centred nursing patient centred nursing n n As a philosophy to help nursing attain As a philosophy to help nursing attain professional status by offering an professional status by offering an alternative to the medical model. alternative to the medical model.

(4)

The nursing process is

“

An organised,

systematic and deliberate approach

to nursing with the aim of improving

standards in nursing care

standards in nursing care”

”

Rush S,

Fergy

S &

Weels

D (1996)

It uses a systematic, holistic, problem

solving approach in partnership with

the patient and their family

”

(5)

Nursing Models

All models have 4 core components,

n n

The person,

n n

Their environment,

n n

Health and

n n

Nursing

(but all have different emphasis)

(6)

The Person

n n

Body (physical/ biological)

n n

Activities of daily living

n

Genetic make

up

–

gender

n

(7)

Mind (psychological)

n n

Healthy, impaired or damaged

n n

Intellect

n n

Attitudes

n

Effect of illness

stress, fears,

memories

n

(8)

Social

Family and friends

Work

Play

Effects of illness (e.g. financial)

(9)

Spirit

n n

Belief systems about the meaning of

life, death, hope, suffering,

n n

it may involve organised religion,

other customs or

“

New age

”

spirituality.

(10)

Environment

Home, neighbours,

neighbourhood, work, social

activities, town, county, country

and political factors

(11)

Health

“

“ The complete state of physical, The complete state of physical, psychological and social well

psychological and social well beingbeing ” ” World World health organisation 1946

health organisation 1946

Health care continuum (liked to age)

Optimum health

Optimum health Ill health Ill health Independence

Independence Dependence Dependence Adaptation

Adaptation Maladaption Maladaption Self

(12)

Human Needs Model: Roper Logan

& Tierney

’

s Model (1980) (activities

of daily living

This is the main one used in Britain

and has 5 dimensions:

n n

Physiological,

n n

psychological,

n

socio

cultural,

n

politico

economical

n

(13)

There are 12 activities, some of

which are essential such as breathing

and others that which enhance the

quality of life.

(14)

It should be carried out:

n n

By or under the supervision of the

“

Named Nurse

”

n n

With the agreement and co

operation of the patient

n n

Be evidence based and follow

National and Trust Policy and

guidelines

n

Must use the

NMC

’

s

“

Standards for

record keeping

”

and

“

Code of

professional conduct

(15)

The purpose of care planning

n

It is a legal document

n

Shows accountability

“

The care plan

is a document that identifies the care

to be given, and a record that shows

who planned and gave that care

n n

It should guide the work of others

and be a basis for continuity of care

n n

Should show a logical and systematic

flow of ideas through from the initial

assessment to the final evaluation

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Assessment

What components are needed for a successful assessment What components are needed for a successful assessment n n Good communication Good communication n n A systematic approach to data collection A systematic approach to data collection n

n InterpretationInterpretation based on nursing knowledgebased on nursing knowledge

Objective (scientific Quantitative)

n

n EmpiricsEmpirics measurement of knowledge with measurement of knowledge with scientific fact

scientific fact

Subjective (Art, Qualitative)

n

n AestheticsAesthetics gained through empathy and is how a gained through empathy and is how a nurse becomes sensitive to a patient

nurse becomes sensitive to a patient’’ s pain, s pain, worry or joy

worry or joy

n

n EthicsEthics concerned with motivation, morality, concerned with motivation, morality, human rights and law

human rights and law

n

n Personal knowledgePersonal knowledge awareness that the nurse awareness that the nurse has an impact on patient care

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Sources of Data

1.

1. Non verbal observation Non verbal observation

n

n SightSight Physical, psychological (and social) Physical, psychological (and social)

n

n TouchTouch Skin temp, hydration, pulse/BP Skin temp, hydration, pulse/BP

n

n SoundSound BreathBreath wheeze, wheeze, stridor stridor

n

n SmellSmell breath body fluids infections, gangrene breath body fluids infections, gangrene

2. 2.

Verbal Communication

n n Patients/ clients Patients/ clients n n Family and friends (Meaningful others) Family and friends (Meaningful others) n n Nursing colleagues Nursing colleagues n n Medical colleagues Medical colleagues n n Other members of multidisciplinary team Other members of multidisciplinary team 3. 3.

Written records

n n G.P Letter G.P Letter n n Transfer letter Transfer letter n n Old notesOld notes

(18)

Communication

Why are good communication skills required? Why are good communication skills required? n n To establish and maintain a relationship with To establish and maintain a relationship with patients and their families patients and their families n n To encourage patients to describe all relevant To encourage patients to describe all relevant aspects of their problems aspects of their problems n n To get and give accurate information To get and give accurate information n n To use time and opportunity effectively To use time and opportunity effectively n n To improve patient satisfaction with the care To improve patient satisfaction with the care given given n n To improve thrust and cooperation with the care To improve thrust and cooperation with the care n n To reduce negative emotions and fearTo reduce negative emotions and fear

(19)

Guide to a successful assessment

n

n Prepare adequately Prepare adequately

n

n Introduce yourselfIntroduce yourself prepare patient prepare patient

n

n Use nonUse non verbal communication verbal communication

n n Be courteous Be courteous n n Use sensitivity, compassion and empathy Use sensitivity, compassion and empathy n n Use focused questions (opened and Use focused questions (opened and closed) closed) n n Listen Listen n n Clarify Clarify n n Summarise what they describe Summarise what they describe n n Make notes Make notes n n reflectreflect

(20)

Planning

Effective planning depends on the quality Effective planning depends on the quality and comprehensiveness of the assessment and comprehensiveness of the assessment n n Determine the problems Determine the problems n

n Establish the risks and prioritiesEstablish the risks and priorities How ill How ill

are they? are they? n n Can they breath adequately (safe airway?) Can they breath adequately (safe airway?) n n Are they in pain? (physical/ psychological) Are they in pain? (physical/ psychological) n n Can they maintain a safe environment? If Can they maintain a safe environment? If not why not? (Drugs, drink, mental or not why not? (Drugs, drink, mental or psychological problem?) psychological problem?) n

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Writing a care plan (s)

Think about Think about n n Who is it for ?(The patient and other members of Who is it for ?(The patient and other members of nursing team) nursing team) n

n What are the shortWhat are the short term and long term goals? term and long term goals? n n How can you determine that you have reached How can you determine that you have reached the goals? (measurable) the goals? (measurable) n n How will the patient know he/she has achieved How will the patient know he/she has achieved the goals? (realistic) the goals? (realistic) n n Who is involved in the delivery of the care? (The Who is involved in the delivery of the care? (The patient (and family), yourself, the nursing team, patient (and family), yourself, the nursing team, medical staff, multidisciplinary team, labs, medical staff, multidisciplinary team, labs, investigations, procedures etc) investigations, procedures etc) n

n How quickly is the problem likely to changeHow quickly is the problem likely to change How How

soon will you need to re

(22)

n n

How many problems are there

Which order of priority?

n n

How can you prove that they are

evidence based (what resources do

you need?) (core care plans Vs

individualised ones)

(23)

Implementing

a)

a) At the start of the shift, during handover and At the start of the shift, during handover and when you first meet them, think about whether when you first meet them, think about whether the oral report matches the patients actual the oral report matches the patients actual condition condition b) b) Compare this to what you already know of the Compare this to what you already know of the patient and to the existing care plans patient and to the existing care plans c) c) Has anything changed for better or worse Has anything changed for better or worse d) d) Decide: Decide: What are the priorities for looking after this What are the priorities for looking after this patient? patient? • • Is their condition stable? What observations Is their condition stable? What observations need doing

need doing how often how often • • Are they going off the ward tests/investigations/ Are they going off the ward tests/investigations/ operations operations • • Are they being discharged? When are they Are they being discharged? When are they going? Is every thing ready? going? Is every thing ready?

(24)

Repeat this

process for all the

patients you are looking after.

f) f) What routine work must be done and What routine work must be done and when should this be done when should this be done g)

g) Who is going to do this workWho is going to do this work are you on are you on

your own or do you have a Clinical your own or do you have a Clinical support worker with you? How will they support worker with you? How will they give you feedback? give you feedback? h) h) Who is available to give you help or Who is available to give you help or advice if needed? (senior nurse

advice if needed? (senior nurse medical medical team)

team)

i)

i) How are you going to organise the work How are you going to organise the work

TIME MANAGEMENT

j)

(25)

Evaluation.

n

n MENTALMENTAL On going throughout On going throughout

implementation implementation n n WRITTEN (this should preferably be done WRITTEN (this should preferably be done with the patient present in order to get with the patient present in order to get accurate feedback) accurate feedback) n n Must be carried out at least twice in 24 hours Must be carried out at least twice in 24 hours n n And whenever any incident occurs. (date, time And whenever any incident occurs. (date, time signature) signature) n

n Write a general statement about patientWrite a general statement about patient ’’ s condition s condition

(better, same, worse)

n

(26)

n

n PersonalisePersonalise use patientuse patient ’’ s own words s own words

appropriate

appropriate n

n State what care you have given State what care you have given ““ Care of Care of

planned

planned” ” or any variation/ comment e.g. or any variation/ comment e.g. “

“pressure area care given skin slightly red pressure area care given skin slightly red on

on …… sacrumsacrum ” ”

n

n Amend the care plan if circumstances Amend the care plan if circumstances

have changed

have changed n

n Discontinue care plans if the Discontinue care plans if the goal(sgoal(s ) have ) have

been reached

been reached n

n LegallyLegally if the care given has not been if the care given has not been

recorded than it hasn

(27)

Criticisms of the nursing process &

Roper Logan & Tierney

’

s Model

Assessment

n

n It is only a It is only a ““ snap shotsnap shot ”” and is often not referred and is often not referred to after the initial assessment or updated

to after the initial assessment or updated

n

n There is the danger of a There is the danger of a ““ reductionistreductionist ” ” approach approach in which patients are made to

in which patients are made to ““ fitfit ” ” into the boxes into the boxes rather than allowing flexibility

rather than allowing flexibility

n

n It is only one among several nursing assessment It is only one among several nursing assessment tools (

tools (waterlowwaterlow , moving & handling, nutrition, , moving & handling, nutrition, pain etc) in addition to other medical.

pain etc) in addition to other medical.

Paramedical records

n

n Patients may lie or conceal Patients may lie or conceal ““ incriminatingincriminating ” ” or or embarrassing information embarrassing information n n Psychological, sexual, spiritual or issues Psychological, sexual, spiritual or issues surrounding death may not be mentioned surrounding death may not be mentioned

(28)

Planning and Giving Care

n

n The patientThe patient ’’ s may not be consulted, s may not be consulted,

empowered to cooperate, or

empowered to cooperate, or complient complient in in their care

their care n

n With increasing skill mix With increasing skill mix CSWCSW ’’ s s now now

provide most of the physical care, But the provide most of the physical care, But the often have not been taught (or expected) often have not been taught (or expected) to read care plans, may not report back to read care plans, may not report back (or realise the significance of) changes to (or realise the significance of) changes to the RN who is writing the evaluation and the RN who is writing the evaluation and may or may not document the care they may or may not document the care they have given have given n

n Patient care is fragmented Patient care is fragmented ““ task nursingtask nursing ” ”

rather than holistic nursing

(29)

Evaluation

n n There is not enough time There is not enough time n n It is just paper work that takes nurses It is just paper work that takes nurses away from hands

away from hands onon care care

n

n We are bad at reading: so care plans are We are bad at reading: so care plans are

not consulted

not consulted nurses rely on verbal nurses rely on verbal

handovers and their notes. (But these are handovers and their notes. (But these are only as good as the individuals memory only as good as the individuals memory and continuity of care and continuity of care n n Evaluation tends to concentrate on Evaluation tends to concentrate on objective measurable activity

objective measurable activity it may not it may not be appropriate to describe

be appropriate to describe ““ therapeutictherapeutic ” ”

care interventions or set measurable goals

(30)

Other Models

These include

n n

Nightingale (1859)

n n

Medical model

n n

Henderson (1966)

n n

Systems model: used in USA

n n

Development models

n

Maslow

(1970)

“

Hierarchy of needs

”

n

(31)

?

Any

Questions

(32)

Roper W, Logan W, & Tierney A (1990)

The elements of nursing based on a

model of living

3rd edition Churchill,

Livingston London

Swash M (2002)

Hutchinson

’

s clinical

methods

21st edition Saunders

Ediburgh

Walsh M (2001)

Models and critical

pathways in clinical nursing

Bailliere

Tindall