Nursing Process • • • • • • Objectives: Introduce the history of nursing process Discuss purpose of nursing process Including philosophy Discuss nursing models in relation to assessment Discuss defensible documentation Criticism of process Summary
Summary Nursing Process n n
Assessment n n
Planning n n
Implementation n n
Evaluation
Evaluation The Nursing Process The term ““ Nursing Process
Nursing Process ” came to the UK in the 1970
in the 1970 ’’ s and came to be understood as: n n A form of documentation n n As a means of organising work, that is patient allocation or primary nursing n n As an educational tool to help achieve patient centred nursing n n As a philosophy to help nursing attain professional status by offering an alternative to the medical model.
alternative to the medical model. 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
the patient and their family ”” Nursing Models All models have 4 core components, nThe person, nTheir environment, nHealth and nNursing (but all have different emphasis)
(but all have different emphasis) The Person n n
Body (physical/ biological) Activities of daily living n n
n n
Genetic make
Genetic make ­­ up – gender n n
Nature/ Nurture
Nature/ Nurture Mind (psychological) Healthy, impaired or damaged n n Intellect n n Attitudes n n Effect of illness
Effect of illness ­ stress, fears, memories n n Emotional support
Emotional support n n
Social Family and friends Work Play Effects of illness (e.g. financial)
Effects of illness (e.g. financial) Spirit Belief systems about the meaning of life, death, hope, suffering, n n it may involve organised religion, other customs or ““ New age
New age ” spirituality.
spirituality. n n
Environment Home, neighbours, neighbourhood, work, social activities, town, county, country and political factors
and political factors Health “ The complete state of physical, psychological and social well
psychological and social well ­­ being
being ” World health organisation 1946 Health care continuum (liked to age) Optimum health Ill health Independence Dependence Adaptation Maladaption Self
Reliance on others
Self ­­ care Reliance on others Human Needs Model: Roper Logan & Tierney
& 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 n socio
socio ­­ cultural, n n politico
politico ­­ economical n n and environmental.
and environmental. There are 12 activities, some of which are essential such as breathing and others that which enhance the quality of life.
quality of life. It should be carried out: n n By or under the supervision of the ““ Named Nurse
Named Nurse ” n n With the agreement and co
With the agreement and co ­ operation of the patient n n Be evidence based and follow National and Trust Policy and guidelines n n Must use the NMC
NMC ’’ s ““ Standards for record keeping
record keeping ” and ““ Code of professional conduct
professional conduct ”” The purpose of care planning It is a legal document n 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
assessment to the final evaluation n n
Assessment What components are needed for a successful assessment n n Good communication n n A systematic approach to data collection n n Interpretation
Interpretation ­­ based on nursing knowledge Objective (scientific Quantitative) n n Empirics
Empirics ­ measurement of knowledge with scientific fact Subjective (Art, Qualitative) n n Aesthetics
Aesthetics ­­ gained through empathy and is how a nurse becomes sensitive to a patient
nurse becomes sensitive to a patient ’’ s pain, worry or joy n n Ethics
Ethics ­ concerned with motivation, morality, human rights and law n n Personal knowledge
Personal knowledge ­ awareness that the nurse has an impact on patient care
has an impact on patient care Sources of Data 1. Non verbal observation n n
n n
n n
n n
Sight
Sight ­ Physical, psychological (and social) Touch
Touch ­ Skin temp, hydration, pulse/BP Sound
Sound ­ Breath
Breath ­ wheeze, stridor Smell
Smell ­ breath body fluids infections, gangrene 2. Verbal Communication n n
n n
n n
n n
n n
Patients/ clients Family and friends (Meaningful others) Nursing colleagues Medical colleagues Other members of multidisciplinary team 3. Written records n n
n n
G.P Letter Transfer letter Communication Why are good communication skills required? n n To establish and maintain a relationship with patients and their families n n To encourage patients to describe all relevant aspects of their problems n n To get and give accurate information n n To use time and opportunity effectively n n To improve patient satisfaction with the care given n n To improve thrust and cooperation with the care n n To reduce negative emotions and fear
To reduce negative emotions and fear Guide to a successful assessment Prepare adequately n n Introduce yourself
Introduce yourself ­ prepare patient n n Use non
Use non ­­ verbal communication n n Be courteous n n Use sensitivity, compassion and empathy n n Use focused questions (opened and closed) n n Listen n n Clarify n n Summarise what they describe n n Make notes n n reflect
reflect n n
Planning Effective planning depends on the quality and comprehensiveness of the assessment n n Determine the problems n n Establish the risks and priorities
Establish the risks and priorities ­ How ill are they? n n Can they breath adequately (safe airway?) n n Are they in pain? (physical/ psychological) n n Can they maintain a safe environment? If not why not? (Drugs, drink, mental or psychological problem?) n n Non
Non ­­ compliance with medical advice
compliance with medical advice Writing a care plan (s) Think about n n Who is it for ?(The patient and other members of nursing team) n n What are the short
What are the short ­­ term and long term goals? n n How can you determine that you have reached the goals? (measurable) n n How will the patient know he/she has achieved the goals? (realistic) n n Who is involved in the delivery of the care? (The patient (and family), yourself, the nursing team, medical staff, multidisciplinary team, labs, investigations, procedures etc) n n How quickly is the problem likely to change
How quickly is the problem likely to change ­ How soon will you need to re
soon will you need to re ­­ evaluate the plan?
evaluate the plan? How many problems are there
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)
individualised ones) n n
Implementing At the start of the shift, during handover and when you first meet them, think about whether the oral report matches the patients actual condition b) Compare this to what you already know of the patient and to the existing care plans c) Has anything changed for better or worse d) Decide: What are the priorities for looking after this patient? a) • Is their condition stable? What observations need doing
need doing ­ how often • Are they going off the ward tests/investigations/ operations • Are they being discharged? When are they going? Is every thing ready?
going? Is every thing ready? Repeat this process for all the patients you are looking after. f) g) h) i) j) What routine work must be done and when should this be done Who is going to do this work
Who is going to do this work ­ are you on your own or do you have a Clinical support worker with you? How will they give you feedback? Who is available to give you help or advice if needed? (senior nurse
advice if needed? (senior nurse ­­ medical team) How are you going to organise the work TIME MANAGEMENT What resources do you need?
What resources do you need? Evaluation. n n
MENTAL
MENTAL ­­ On going throughout implementation n n
WRITTEN (this should preferably be done with the patient present in order to get accurate feedback) Must be carried out at least twice in 24 hours n n And whenever any incident occurs. (date, time signature) n n Write a general statement about patient
Write a general statement about patient ’’ s condition (better, same, worse) n n Evaluate each care plan in turn and by number
Evaluate each care plan in turn and by number n n
Personalise
Personalise ­ use patient
use patient ’’ s own words appropriate n n State what care you have given “
“ Care of planned
planned ” or any variation/ comment e.g. ““ pressure area care given skin slightly red on …
… sacrum
sacrum ” n n Amend the care plan if circumstances have changed n n Discontinue care plans if the goal(s
goal(s ) have been reached n n Legally
Legally ­ if the care given has not been recorded than it hasn
recorded than it hasn ’’ t occurred!
t occurred! n n
Criticisms of the nursing process & Roper Logan & Tierney
Roper Logan & Tierney ’’ s Model Assessment n n It is only a “
“ snap shot
snap shot ”” ­ and is often not referred to after the initial assessment or updated n n There is the danger of a “
“ reductionist
reductionist ” approach in which patients are made to ““ fit
fit ” into the boxes rather than allowing flexibility n n It is only one among several nursing assessment tools (
tools ( waterlow
waterlow , moving & handling, nutrition, pain etc) in addition to other medical. Paramedical records n n Patients may lie or conceal “
“ incriminating
incriminating ” or embarrassing information n n Psychological, sexual, spiritual or issues surrounding death may not be mentioned
surrounding death may not be mentioned Planning and Giving Care The patient
The patient ’’ s may not be consulted, empowered to cooperate, or complient in their care n n With increasing skill mix CSW
CSW ’’ s now provide most of the physical care, But the often have not been taught (or expected) to read care plans, may not report back (or realise the significance of) changes to the RN who is writing the evaluation and may or may not document the care they have given n n Patient care is fragmented “
“ task nursing
task nursing ” rather than holistic nursing
rather than holistic nursing n n
Evaluation There is not enough time n n It is just paper work that takes nurses away from hands
away from hands ­­ on
on ­­ care n n We are bad at reading: so care plans are not consulted
not consulted ­ nurses rely on verbal handovers and their notes. (But these are only as good as the individuals memory and continuity of care n n Evaluation tends to concentrate on objective measurable activity
objective measurable activity ­ it may not be appropriate to describe ““ therapeutic
therapeutic ” care interventions or set measurable goals
care interventions or set measurable goals n n
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 n Maslow (1970) “
“ Hierarchy of needs
Hierarchy of needs ” n n Burford Nursing Development Unit
Nursing Development Unit ?
Any
Questions
Further Reading: Bowman G.S, Thompson D & Suttin T (1983) Nurses attitudes towards the nursing process Journal of Advanced Nursing 8(2) p.125
8(2) p.125 ­­ 129 Braden S (1998) Evaluating nursing interventions: A theory driven approach Sage publications London Cohen E, Gesta T (2001) Nursing case management from essential to advanced practice application 3rd edition Mosby USA Faulkner A (2000) Nursing: The reflective approach to adult practice 2nd Edition Bailliere Tindall Cheltenham Hincliff S, Norman S, Schober J (1998) Nursing practice and health care: A foundation text 3rd edition Arnold Oxford
3rd edition Arnold Oxford n n
n n
n n
n n
Kowalak J & Hughes A et al (2002) Best practices a guide to excellence in nursing care Lippincott Williams & Wlikins Leahy J, Kizilay P (1998) Foundtions of nursing practice: A nursing process approach Saunders Philadelphia Littlejohn C,(2002) Are nursing models to blame for low morale? Nursing Standard Vol 16(17) p.39
p.39 ­­ 41 Mason C (1999) Guide to practice or ““ load of rubbish
rubbish ”” ? The influence of care plans on nursing practice in five clinical areas in Northern Ireland Journal of Advanced Nursing Vol 29(2) P.380
29(2) P.380 ­­ 387
387 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
Hutchinson ’’ s clinical methods 21st edition Saunders Ediburgh Walsh M (2001) Models and critical pathways in clinical nursing Bailliere Tindall Cheltenham
Cheltenham