Chapter 2
Nursing Process
DEFINITION: process is a set of actions leading to a particular goal. Nursing process
is an organized sequence of problem-solving steps used to identify and to manage the
health problems of clients. The nursing process is the framework for nursing care in
all health care settings. When nursing practice follows the nursing process, clients
receive quality care in minimal time with maximal efficiency.
See FIGURE 2-1•The steps in the nursing process, P. 17
Characteristics of Nursing process:
1. Within the legal scope of nursing; the midwife can apply components of
nursing process and solve the health problems independently. Nurses can
diagnose and treat human responses to actual or potential health problems.
2. Based on knowledge; every step in diagnosing and treating the health problem
should has a rational and should be based on knowledge. Critical thinking
helps midwives select appropriate nursing interventions for achieving
predictable outcomes.
3. Planned; The steps of the nursing process are organized and systematic. One
step leads to the next in an orderly fashion. For example: assessment should
be done before diagnosis.
4. Client-centered; the nursing process helps to formulate a comprehensive and
unique plan of care for each client. The client is expected to be active in the
application of the care.
5. Goal-directed; the client and the nursing/midwifery team must cooperate to
achieve desired outcomes.
6. Prioritized; the midwife should classify the health problems according to their
importance and urgency. She must resolve the problems that represent the
greatest threat to health first.
7. Dynamic; because the health status of any client is usually changing, the
nursing process acts like a continuous loop. Evaluation, the last step in the
nursing process, involves data collection, beginning the process again.
The nursing process include:
1.Assessment2.Diagnosis3.Planning4.Implementation5.Evaluation
I. Assessment: the first step
It is a systematic collection of data. It begins from the first minute you contact with
the client and continues as long as a need for health care exists. The midwife
collects information to determine areas of abnormal function, risk factors that may
lead to health problems, and the client strengths. Both subjective and objective data
should be included. Objective data are observable and measurable facts and are
referred to as signs of a disorder. An example is a client’s blood pressure
measurement. Subjective data consist of information that only the client feels and
can describe, and are called symptoms. An example is pain.
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Sources for Data: The primary source for information is the client. But you may
collect the data from other secondary sources including: family, reports, test results,
information in current and past medical records, and discussions with other health
care workers.
Types of Assessments: There are two types of assessments: a data base assessment
and a focus assessment (Table 2-1, p. ).
A.
DATA BASE ASSESSMENT. It focuses on initial information about the
client’s physical, emotional, social, and spiritual health. It consumes long
time and comprehensive. The midwife obtains data base information
during the admission interview and physical examination. These
information serve as a reference for comparing all future data and provides
the evidence used to identify the client’s initial problems. Comparisons of
continuous assessments with baseline data help determine whether the
client’s health is improving, deteriorating, or remaining unchanged.
B.
FOCUS ASSESSMENT. A focus assessment is information that provides
more details about specific problems and expands the original data base.
For example, if the client tells you that she always has constipation during
the data base assessment, more questions follow. You need to ask about
her dietary habits, level of activity, fluid intake, any drugs, frequency of
bowel elimination, and stool characteristics. This type of assessment is
short and focusing on a specific aspect.
Organization of Data: Interpreting data is easier if information is organized.
Organization involves grouping related information. Using knowledge and past
experiences, midwives cluster related data (Box 2-3, p. ). Data organized into small
groups is easier to analyze and takes on more significance than when the midwife
considers each fact separately or examines the entire group at once.
II. Diagnosis: the second step
It is the identification of health-related problems. Analyzing collected data and
determining whether they suggest normal or abnormal findings, result in nursing
diagnosis. A nursing diagnosis is a health issue that can be prevented, reduced,
resolved, or enhanced through independent nursing measures. It is an exclusive
nursing responsibility. Nursing diagnoses are categorized into five groups: actual,
risk, possible, syndrome, and wellness(Table 2-2, p. ).
DIAGNOSTIC STATEMENTS. An actual nursing diagnostic statement contains
three parts:
1.Name of the health-related issue or problem as identified in the NANDA list
2.Etiology (its cause)
3.Signs and symptoms.
The name of the nursing diagnosis is linked to the etiology with the phrase “related
to,” and the signs and symptoms are identified with the phrase “as manifested(or
evidenced) by” (Box 2-4).
Different types of diagnoses have different stems:
Risk diagnoses start with the term “risk for,” as in Risk for Impaired Skin
Integrity related to inactivity.
The word “possible” is used in a diagnostic statement to indicate uncertainty
(for example,.
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Wellness diagnoses start with the phrase “Potential for enhanced.”
Risk and possible nursing diagnoses just consist of two parts. There are no
signs or symptoms.
Syndrome diagnoses and wellness diagnoses are one-part statements.
III. Planning: the third step
Planning includes prioritizing nursing diagnoses, identifying measurable goals or
outcomes, selecting appropriate interventions, and documenting the plan of care.
Setting Priorities: Not all clients’ problems can be resolved quickly. Therefore, it is
important to determine which problems require the most immediate attention. This is
done by setting priorities. Prioritization involves ranking from those that are most
serious or immediate to those of lesser importance. The midwife usually uses
Maslow’s Hierarchy of Human Needs to prioritize the problems.
Problems interfering with physiologic needs have the first priority (Table 2-4). When
the health problem is resolved, the midwife starts to resolve the next one.
Establishing Goals: A goal (expected or desired outcome) helps the midwives team
know if the care is suitable for managing the client’s diagnoses. It is important that the
goal statement contains the criteria or objective evidence for verifying that the client
has improved. In the acute setting, midwives use short term goals.
SHORT-TERM GOALS: refer to goals can be achieved in a few days to 1 week.
Short-term goals have the following characteristics (Box 2-6, p. ):
Developed from the problem portion of the diagnostic statement; the client
temperature will decreased to 36C
Client-centered, reflecting what the client will accomplish, not the midwife;
the client will consume
Measurable, identifying specific criteria that provide evidence of goal
achievement; the client will have two bowel movements
Realistic, to avoid setting unattainable goals, which can be frustrating
Time limited, the predicted time when the goal will be met.
Planning should involve the measures that the client and nurse will use to accomplish
identified goals. Midwifery interventions are directed at eliminating the etiologies.
They selects strategies based on the knowledge. Whatever interventions are planned,
they must be safe, within the legal scope of nursing practice, and compatible with
medical orders. Initial interventions generally are limited to selected measures with
the potential for success. Nurses should reserve some interventions in case a client
does not accomplish the goal.
Documenting the Plan of Care: Plans of care can be written by hand, standardized
forms, computer generated, or based on an agency’swritten standards or clinical
pathways. Nursing orders(directions for a client’s care) identify the what, when,
where, and how for performing nursing interventions. They provide specific
instructions so that all health team members understand exactly what to do for the
client (Box 2-7). Nursing orders are also signed to indicate accountability. The plan of
care is a permanent part of the client’s medical record. It is placed in the client’s chart,
kept separately at the client’s bedside, or located in a temporary folder at the nurses’
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station for easy access. Wherever it is located, each nurse assigned to the client refers
to it daily, reviews it for appropriateness, and revises it according to changes in the
client’s condition.
IV. Implementation: the fourth step
It means carrying out the plan of care. The nurse implements medical orders as well
as nursing orders, which should complement each other. Implementing the plan
involves the client and one or more members of the health care team. The medical
record is legal evidence that the plan of care has been more than just a paper trail.
Midwives are accountable to carry out midwifery/ nursing orders as well as they are
for physician’s orders. The midwife should document interventions that have been
provided, and the quantity and quality of the client’s response. She may use some
quotes of the clients to show evidence of care effectiveness.
In short, appropriate documentation maintains open lines of communication among
members of the health care team, and ensures the client’s continuing progress,
V. Evaluation: the fifth and final step
It is the way by which midwives determine whether a client has reached a goal.
Although this is considered the last step, the entire process is ongoing. By analyzing
the client’s response, evaluation helps to determine the effectiveness of nursing care
(Table 2-5). The midwife determine if the goal has been achieved totally or partially.
Before revising a plan of care, it is important to discuss any lack of progress with the
client. Several reasons for incomplete achievement are showed in the table below.
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