NURSING PROCESS

Nursing process is a systematic, step by step, goal oriented, patient centred method of care that
forms the framework for nursing practice. The nursing process is a scientific method used by
nurses to ensure the quality of patient care. This approach can be broken down into separate
steps.

A process is a series of steps or acts that lead to accomplishment of some goals or purpose.
Nursing process: is a systemic method for providing care to clients. The purpose is to provide
individualized, holistic, effective client care efficiently. Although the steps of nursing process
build on each other, each step overlaps with the previous and subsequent steps.

PURPOSES OF NURSING PROCESS

 Providing professional, quality nursing care.

 Directs nursing activities for health promotion, health protection, and disease prevention
and is used by nurses in every practice setting and specialty.
 Provides the basis for critical thinking in nursing.

PHASES OF THE NURSING PROCESS:

 Assessment (of patient's needs).

 Diagnosis (of human response needs that nurses can deal with).
 Planning (of patient's care)
 Implementation (of care)
 Evaluation (of the implemented care).
1. ASSESSMENT:

Is the first step in the nursing process and includes

 Systemic collection,
 Verification, organization,
 Interpretation (analysis), and
 Documentation of data.
The completeness and correctness of the information obtained during assessment are directly
related to the accuracy of the steps that follow. Assessment involves several steps:

a. Data collection from a variety of sources.

b. Data validation.
c. Organizing the data.
d. Data interpretation (Data analysis).
e. Making initial inferences or impressions.
f. Recording or reporting data.

PURPOSE OF ASSESSMENT:

a. Organize a database regarding a client physical, psychological, and emotional health.

b. Identified of health promoting behaviours and actual or potential health problems.

c. The nurse can ascertain of the clients about: A Functional abilities, Absence or the presence of
dysfunction, Normal activities of daily living, and Lifestyle pattern.

d. Identifying the client strengths gives the nurse information about the abilities, behaviour, and
skills the client can use during the treatment and recovery process.

e. Provides an opportunity to form a therapeutic interpersonal relationship with clients.

f. The client can discuss health care concerns and goals with the nurse.

TYPE OF ASSESSMENT:

The information needed for assessment is usually determined by health care setting and needs of
the clients.

Three types of assessment include:

 Comprehensive assessment:
 Provide baseline of client data including a complete health history and current needs
assessment.
 Usually completed upon admission to health care agency.
 Changes in the client’s health status can be measured against this database.
 Includes of clients physical and psychological health, perception of health, presence of
health risk factors, and coping patterns.
 Focused assessment:
 Is limited to potential health care risks, a particular need, or health care concern.
 There are not as detailed as comprehensive assessment.
 Often used when short stays are anticipated (e.g., outpatient surgery and emergency
departments).
 Used in specialty areas such as mental health settings and delivery.
 Used in screening for specific problems or risk factors.
 Ongoing assessment:
 Follow up, or monitoring of specific problems.
 Broadens the database and allow the nurse to confirm the validity of data obtained during
the initial assessment.
 Systematic monitoring allows the nurse to determine the client’s response to nursing
interventions and to identify any other problems.

Sources of Data collection by assessment methods:

A. Primary sources: the client should be considered the primary source of data. As much
information as possible should be gathered from the client, using both interview
techniques and physical examination skills.
B. Secondary sources: data source from other than the client are considered secondary
sources (family members, other health care providers, and medical records).

Types of Data collection by assessment methods:

A. Subjective data (also called symptoms): are data from the client’s point of view
(provided verbally by the patient) and include feelings, perceptions, and concerns.
Interview is the primarily method of collecting subjective information.

STEPS OF COLLECTING SUBJECTIVE DATA:

a. Begin with the patient’s main concern (chief complain).

b. Reason of seeking health care.
 c. The question, “What happened that made you decide to come to the hospital.
d. Use the letters of the “WHAT’S UP?” questioning format to remember questions to ask
the patient,
1. Obtain a patient history by asking the patient and family questions about patient’s past
and present health problems, including specific questions about each body system,
family health problems, and risk factors for.
2. Health problems. The patient’s medical record may also be consulted for background
history information.

Examples of subjective information:

a. I have had pains in my legs for three days ago.

b. I have had headache, nausea, vomiting, dizziness for three hours ago.
c. I have had anxiety from surgery.

WHAT’S UP? Guide to Symptom Assessment

W—where is it?

H—how does it feel? Describe the quality.

A—Aggravating and alleviating factors. What makes it worse? What makes it better?

T—Timing. When did it start? How long does it last?

S—Severity. How bad is it? This can often be rated on a scale of 0 to 10.

U—Useful other data. What other symptoms are present that might be related?

P—Patient’s perception of the problem.

The patient often has an idea about what the problem is, or the cause, but may not believe that
his or her thoughts are worth sharing unless specifically asked.

B. OBJECTIVE DATA (ALSO CALLED SIGNS): are observable and measurable data
that are obtained through both physical examination and the result of laboratory and
diagnostic tests. The primary method of collecting objective information is the physical
examination, which provides information about the function of body systems. Inspection,
palpation, percussion, and auscultation techniques are used to collect objective data.
 Examples of objective information include:
a. Temperature (37.3°C), Pulse rate (100 b/m), Respiration (18 T/m), Blood pressure
(130/76 mm/hg).
b. Positive bowel sounds.
c. Flushed face.

Objective Data is obtained by 6 major means:

o Chart (EHR) review ○ Consultation with the physician/ healthcare provider

o Observation
o Palpation
o Percussion
o Auscultation
 Nurse is responsible for being able to recognize “red flags”; need to know normal values
and recognize deviations from those values.
 Also accountable for recognizing discrepancies b/w what is known to be an evidence
based therapeutic dosage of medication and what is transcribed as an order; required
tolerate concerns about theses discrepancies so that physician can either confirm or
change order.
 Updated info on patient status.
 Data also obtained through observation (noting what is seen); identify what doesn’t look
normal; awareness of patient’s immediate surroundings (making sure patient is
dressed/covered, enough drinking water, call bell in reach, bed positioned properly)
 Obtain vitals; vital signs are essential to the assessment process: considered objective
data; usually refer to temperature, pulse, respirations, BP.
 Palpation feeling/touching; allows nurse to determine arterial pulsations,
swelling/enlargement of organs, areas sensitive to pain, muscle strength
 When there is swelling in the area, physician should be notified; sometimes when in the
lower extremities, it results in a phenomenon called pitting oedema - depressions (pits)
remain on skin following the application of pressure
 Percussion is “thumping” as if striking a drum - performed by placing the middle finger
of one hand over an area and striking that finger with the tip of the middle finger of the
other hand; usually done to determine if the swelling is related to tissue or fluid; results in
a dull thud which indicates it is occurring over a solid tissue such as organ or bone; when
it results in a tympanic/resonance indicates presence of fluid.
 Auscultation is listening, usually with stethoscope (listen to sounds of heart, lungs,
abdomen) ; through the stethoscope, the nurse can determine the rate, regularity and
strength of the flow of blood through the heart ; when there is a “rush” in sound, usually
indicates a bruit and evidences an insufficient closure of one of the valves in the heart ;
murmur occurs when there is an irregularity in the intensity of flow of blood through the
heart ; may be related to a minor constriction/irregular pulsation but COULD be normal ;
in Normal lungs, there is a rush of air going in and out l with infection there may be
crackles (gurgling or popping of fluid mixed with air) that indicate blockage of passage
of air ; asthma, nurse may hear wheezing (whistling) on exhalation (indicates constriction
of airway) ; Normal bowel sounds should be gurgling (digestive process is active) ;
absent bowel sounds indicative of possible blockage.
 Nurse also determines BP through stethoscope to hear the pressure range of pulsations in
large arteries; accomplished with the use of a sphygmomanometer (BP cuff).
 Assessment which is one of the most critical steps in nursing process; incorporates hands
on assessment skills, listening skills, observation skills, focusing skills, technical skills,
therapeutic communication skills, general health history, obtaining an inventory of
medications patient is taking.

Validating the data:

 Objective information may add to or validate subjective information.

 Validation is a critical step in data collection to avoid omissions, prevent
misunderstandings, and avoid incorrect inferences and conclusions.

Organizing the data:

  Data that are collected must be organized to be useful to the health care professional
collecting the data as well as others involved with the client’s care.

Data should be organised through:

I. Data clustering (admission assessment format): Is the process to put the data together
in order to identify areas of the client problems and strengths?

Assessment model: is a framework providing a systematic way to organize data such as:

1. Hierarchy of needs: proposes that individual basic needs (physiological) must be meet
before higher level can be meet.
2. Body system model: organizes data according to tissue and organ function in the various
body systems.
3. Functional health pattern: cluster information about client habitual pattern and any
change to determine if the client’s current response is functional or dysfunctional
4. Theory of self-care: based on the client ability to meet self-care needs and identifying
existing self-care deficits.
II. Interpreting the data:

When data are placed in clusters the nurse can:

a. Distinguish between relevant and irrelevant data.

b. Determine whether and where there are gaps in the data.
c. Identify patterns of cause and effect.
d. Documenting the data:

Assessment data must be recorded and reported. The nurse must make a judgment about
which data are to be reported immediately and which data need only to be recorded at that
time.

Data that reflect a significant deviation from the normal (for example, rapid heart rate with
irregular rhythm, severe difficulty in breathing, or high levels of anxiety) would need to be
reported as well as recorded. Examples of data that need only to be recorded at the time
include a report that prescribed medication has relieved a headache and a determination that
an abdominal dressing is dry and intact.
 NOTE: Assessment does not end with the initial interview and physical examinations.
Assessment is dynamic and continues with each nurse-client interaction.

2. DIAGNOSIS PHASE:

Involves further analysis and synthesis of the data that have been collected. According to the
North American Nursing Diagnosis Association (NANDA), a nursing diagnosis: Is a clinical
judgment about individual, family, or community responses to actual or potential health
problems / life processes. The nursing diagnoses provide the basis for client care delivered
through the remaining steps. Clients receive both medical and nursing diagnoses.

 A medical diagnosis: Is a clinical judgment by the physician that identifies or

determines a specific disease, condition, or pathological state.
 Medical Diagnosis Focuses on illness, injury, or disease process while Nursing Diagnosis
Focuses on client’s responses to actual or potential health problems or life processes.
 Medical diagnoses Remains constant until a cure is effected or client dies.
 Nursing diagnosis Changes as the client’s response and/or the health problem changes.
 Medical diagnosis Recognizes conditions the physician is licensed and qualified to treat.
Example: (Lung cancer, Congestive heart failure, Brain tumour, exploratory surgery,
Appendectomy, Bronchial asthma).
 Nursing diagnosis recognizes situations that the nurse is licensed and qualified to
intervene. Example: (Nausea, Acute pain, Anxiety, Impaired physical mobility,
Ineffective breathing pattern, Risk for imbalanced fluid volume)

TYPES of Nursing Diagnoses:

1. Actual Nursing Diagnosis (Actual problems):

Indicates that a problem exists Composed of (diagnostic label, related factors, and signs and
symptoms). Example (Impaired Skin Integrity related to prolonged pressure on bony
prominence as manifested by stage II pressure ulcer over coccyx, 3 cm in diameter).

2. Risk Nursing Diagnosis (Potential problems):

Indicates that a problem does not yet exist, but special risk factors are present. A risk diagnosis
is composed of the diagnostic label preceded by the phrase “risk for” with the specific risk
factors listed. An Example of a risk diagnosis is: (Risk for Impaired Skin Integrity related to
inability to turn self from side to side in bed).

3. A possible (Potential) nursing diagnosis indicates a situation in which a problem could

arise unless preventive action is taken.

A possible diagnosis is composed of the diagnostic label and related factors. An example of a
possible diagnosis is: (Possible Self-Esteem Disturbance related to recent retirement and
relocation). The nurse may not yet have enough data to confirm this diagnosis or a more specific
one. However, this diagnosis will alert other nurses to collect data that will either confirm this or
another diagnosis, verify a risk diagnosis, or rule out the existence of a problem.

4. Wellness nursing diagnosis (Wellness conditions):

Indicates the client’s expression of a desire to attain a higher level of wellness in some area of
function. Composed of the diagnostic label preceded by the phrase “potential for enhanced.” For
example, a client who is neither overweight nor underweight tells the nurse that she knows she
could improve her diet in some ways. She expresses a desire to know more about how to
improve her diet. The nurse would make a wellness diagnosis of Potential for Enhanced
Nutrition.

5. Collaborative problems: Are defined as physiologic complications monitored by nurses

to assess changes in client status.

Usually collaborative problems involve alterations in organ and/or system function or structure
(e.g., myocardial infarction, duodenal ulcer). Collaborative problems begin with the label
potential complication followed by the situation. For example, respiratory distress are the
specific collaborative problems of potential complication: hypoxemia.
In nursing diagnosis, data obtained during assessment from all sources are then sorted and re-
grouped according to priority needs; theses need are then specified according to an identifiable
classification base known as the North American Nursing Diagnosing Association International
(NANDA International).

 ANA (2012) described nursing as the “diagnosis and treatment of human responses to
actual and potential health problems”; also states that health problems are either actual or
potential nurses should be forever mindful of what may follow, whether it may be a
potential physiologic complication or potential psycho-social crisis.
 NANDA International recommends that nursing diagnosis be written in a 3part format:
o What the patients’ response is (pain, anxiety, immobility, loss of appetite, tiredness)
o What the contributing or associated cause of the response is (is usually the medical
diagnosis such as surgical incision, insufficient circulation, etc.) .
o The symptoms that the patient is exhibiting that validate the selection of the nursing
diagnosis.

Maslow’s Hierarchy of Needs - used to determine priority diagnoses for patients; there
is a ranking of what needs to be addressed first.

o Physiological needs = 1st priorities

o Safety/ Security
o Love/Belonging
o Self-Esteem
o Self-Actualization (Patient- centred Goals)
3. OUTCOME IDENTIFICATION AND PLANNING PHASE:

Includes the formulation of guidelines that establish the proposed course of nursing action in the
resolution of nursing diagnoses and the development of the client’s plan of care. The planning of
nursing care occurs in three phases:

a. Initial planning: Developed by the nurse who performs the admission assessment and
gathers the comprehensive admission assessment data.
b. Ongoing planning: Updating of the client’s plan of care.
 c. Discharge planning: Critical anticipation and planning for the client’s needs after
discharge.

The planning phase involves several tasks:

a. Establishing priorities of nursing diagnoses.

b. Setting goals and developing expected outcomes (outcome identification).

c. Planning nursing interventions (with collaboration and consultation as needed).

d. Record the entire nursing care plan in the client record.

There are a number of frameworks used to prioritize nursing diagnoses; however, those
diagnoses involving life-threatening situations are given the highest priority.

A goal: is an aim, intent, or end. Goals are broad statements that describe the intended or desired
change in the client’s behaviour.

Goals should be identified as outcomes that can be objectively measured and should also include
a realistic time frame; a measurable goal is one that identifies the criteria that evidences progress
Patient either met goal or not.

 Short term goals - usually evidence based progress w/in a very short period of time (end
of shift, 24hr)
 Long Term goals- evidenced based progress over a longer period of time (time of
discharge)

Expected outcomes: are specific objectives related to the goals and are used to evaluate the
nursing interventions. They must be measurable, have a time limit, and be realistic.

4. IMPLEMENTATION/INTERVENTION PHASE:

The implementation phase of the nursing process is when the nurse puts the treatment plan into
effect. It involves action or doing and the actual carrying out of nursing interventions outlined in
the plan of care. This typically begins with the medical staff conducting any needed medical
interventions.
 Interventions should be specific to each patient and focus on achievable outcomes. Actions
associated with a nursing care plan include monitoring the patient for signs of change or
improvement, directly caring for the patient or conducting important medical tasks such as
medication administration, educating and guiding the patient about further health management,
and referring or contacting the patient for a follow-up.

Implementation Involves the execution of the nursing care plan derived during planning phase.
It consists of performing nursing activities that have been planned to meet the goals set with the
client. The implementation phase of the nursing process requires cognitive (intellectual),
psychomotor (technical), and interpersonal skills.

The nurse must continue to assess the client’s condition before, during, and after the nursing
intervention. Nursing implementation activities include:

a. Ongoing assessment.
b. Establishment of priorities.
c. Allocation of resources.
d. Initiation of nursing interventions.
e. Documentation of interventions and client response.

Nursing Intervention Categories

Nursing interventions are grouped into three categories according to the role of the healthcare
professional involved in the patient’s care:

1. Independent Nursing Interventions

A registered nurse can perform independent interventions on their own without the help or
assistance from other medical personnel, such as:

 Routine nursing tasks such as checking vital signs.

 Educating a patient on the importance of their medication so they can administer it as
prescribed.
2. Dependent Nursing Interventions

A nurse cannot initiate dependent interventions alone. Some actions require guidance or
supervision from a physician or other medical professional, such as:
  Prescribing new medication
 Inserting and removing a urinary catheter
 Providing diet
 Implementing wound or bladder irrigations
3. Interdependent Nursing Interventions

A nurse performs as part of collaborative or interdependent interventions that involve team

members across disciplines.

 In some cases, such as post-surgery, the patient’s recovery plan may require
prescription medication from a physician, feeding assistance from a nurse, and
treatment by a physical therapist or occupational therapist.
 The physician may prescribe a specific diet to a patient. The nurse includes diet
counselling in the patient care plan. To aid the patient, even more, the nurse enlists
the help of the dietician that is available in the facility.
5.EVALUATION PHASE:

Involves determining whether the goals have been met, partially met, or not met.

1. If the goal has been met, the nurse must then decide whether nursing activities will stop
or continue in order for status to be maintained.
2. If the goal has been partially met or not been met, the nurse must re-assess the situation
and change the plan of care accordingly. New problems may be identified at this stage,
and thus the process will start all over again.

There are a number of possible reasons that goals are not met or are only partially met,
including:

a. The initial assessment data were incomplete.

b. The goals and expected outcomes were not realistic.
c. The time frame was too optimistic.
d. The goals and/or the nursing interventions planned were not appropriate for the client.

STEPS IN EVALUATION

1. Collecting Data

The nurse recollects data so that conclusions can be drawn about whether goals have been
fulfilled. It is usually vital to collect both objective and subjective data. Data must be
documented concisely and accurately to facilitate the next part of the evaluating process.

2. Comparing Data with Desired Outcomes

 The documented goals and objectives of the nursing care plan become the standards or
criteria by which to measure the client’s progress whether the desired outcome has been met,
partially met, or not met.

 The goal was met, when the client response is the same as the desired outcome.
 The goal was partially met, when either a short-term outcome was achieved but the
long-term goal was not, or the desired goal was incompletely attained.
 The goal was not met.
3. Analysing Client’s Response Relating to Nursing Activities

It is also very important to determine whether the nursing activities had any relation to the
outcomes whether it was successfully accomplished or not.

4. Identifying Factors Contributing to Success or Failure

It is required to collect more data to confirm if the plan was successful or a failure. Different
factors may contribute to the achievement of goals. For example, the client’s family may or may
not be supportive, or the client may be uncooperative to perform such activities.

5. Continuing, Modifying, or Terminating the Nursing Care Plan

The nursing process is dynamic and cyclical. If goals were not sufficed, the nursing process
begins again from the first step. Reassessment and modification may continually be needed to
keep them current and relevant depending upon general patient condition. The plan of care may
be adjusted based on new assessment data. Problems may arise or change accordingly. As clients
complete their goals, new goals are set. If goals remain unmet, nurses must evaluate the reasons
these goals are not being achieved and recommend revisions to the nursing care plan.

6. Discharge Planning

Discharge planning is the process of transitioning a patient from one level of care to the next.
Discharge plans are individualized instructions provided as the client is prepared for continued
care outside the healthcare or for independent living at home. The main purpose of a discharge
plan is to improve the client’s quality of life by ensuring continuity of care together with the
client’s family or other healthcare workers providing continuing care.
The following are the key elements of IDEAL discharge planning according to the Agency
for Healthcare Research and Quality:

 Include the patient and family as full partners in the discharge planning process.
 Discuss with the patient and family five key areas to prevent problems at home:
 Describe what life at home will be like
 Review medications
 Highlight warning signs and problems
 Explain test results
 Schedule follow-up appointments
 Educate the patient and family in plain language about the patient’s condition, the
discharge process, and next steps throughout the hospital stay.
 Assess how well doctors and nurses explain the diagnosis, condition, and next steps in the
patient’s care to the patient and family and use teach back.
 Listen to and honour the patient’s and family’s goals, preferences, observations, and
concerns.

HANDING OVER NURSING DUTY WHO SHOULD BE INVOLVED?

 Each hospital/unit needs to identify the key people who need to attend handover. Clinical
Handover is equally important to all members of the medical team, both junior and
senior. The ideal model includes all grades of staff from each included specialty,
subspecialty or ward as appropriate. The nurse clinical coordinator should be involved in
the major handover, usually the morning one.
 Ideally, teams from all units should attend to ensure that they receive necessary patient
information and make timely decisions about patient care and transfer. The multi-
disciplinary or multi-specialty approach requires the greatest change in culture, but has
the potential for the greatest benefits.
 The involvement of senior clinicians is essential. This ensures that appropriate level
management decisions are made and that handover forms a constructive part of medical
education conveying the seriousness with which the organisation takes this process.
  There will always be work that is ongoing during the handover time, especially in the
evening. Virtually all aspects of care can wait for 30 minutes to ensure continued safety
overnight. It is essential that individuals be allowed to attend, subject to emergency cover
being defined.
 The handover leader needs to ensure the team is aware of any new or locum members of
the team and that adequate arrangements are in place to familiarize them with local
systems and hospital geography to ensure attendance at morning handover.

WHEN SHOULD HANDOVER TAKE PLACE?

 Handover should be at a fixed time and of sufficient length

 The handover period should be known to all staff and designated ‘pager-free’ except for
immediately life threatening emergencies
 Shifts for all staff involved must be coordinated to allow them to attend in working time.
This is particularly important for the handover to, and from, the night team
 Main handover is generally held in the morning; however, handover is also needed at the
change of other shifts (for example 5pm in some ward settings). Morning handover
allows the team to discuss overnight patient admissions, gives them a head start with their
morning rounds and plan the day’s work 12
 In addition to the larger, more formal handover there will inevitably be smaller local
handovers occurring daily (such as on ICU or admissions unit).
 As well as handover between shifts, doctors must conduct a thorough handover to ensure
patient care is maintained if they are absent for extended periods, i.e. over weekends or
while they are away on holidays.

WHERE SHOULD HANDOVER TAKE PLACE?

 Ideally this should be close to the most used areas of work (such as DEM or Admissions
Unit)
 It should be large enough to comfortably allow everyone to attend.
 This should be free from distraction and not used by others at this time.
  It should have access to lab results, X-rays, clinical information, the internet/intranet,
and telephones Distractions that can disturb the handover process include pagers,
telephones, relatives, nurses and other doctors.

HOW SHOULD HANDOVER HAPPEN? The style of handover will vary depending on local
need – whole hospital handovers, local handovers on specific units, community-based specialties
or those covering several sites. However, all types need a predetermined format and structure to
ensure adequate information exchange.

 Handovers often miss out important aspects of care and information

 Handover should be supervised by the most senior clinician present and must have clear
leadership
 Information presented should be succinct and relevant
 Ideally, this can be supported by information systems identifying all relevant patients
 Regular review of the system, for example at clinical governance meetings, appraisal
meetings, through surveys, and monitoring incident reports, is required.
 The relevant senior consultant or the medical director, should have responsibility for
ensuring handover happens as expected The Royal College of Physicians has published
guidance on handover, relevant to general medical staff. Included in this document is an
example of a handover sheet that can be used to facilitate effective information transfer
between colleagues.

WHAT SHOULD BE HANDED OVER?

The information and level of detail that is included in a clinical handover session depends on
several factors including the severity of the patient’s illness and whether they are pending results
of investigations and require prompt follow-up. The type and level of handover conducted is also
influenced by the time of the day and week it is occurring (e.g. weekday vs weekend, night vs
morning), the doctor to patient ratio and workflow. Priorities need to be set to ensure that the
essential information is communicated and understood

Written (or IT based) handover should include:

 Current inpatients
  Accepted and referred patients due to be assessed
 Accurate location of all patients
 Operational matters directly relevant to clinical care such as ICU bed availability
 Information to convey to the following shift
 Patients brought to the attention of the critical care outreach team (where appropriate)
 Patients who are unstable or whose clinical status is deteriorating The following, as well
as being included in the written handover, should be discussed within the handover
meeting. All verbal and written handover should follow a similar structure and cover the
essential information. This verbal handover is vital to highlight:
 Patients with anticipated problems, to clarify management plans and ensure appropriate
review
 Outstanding tasks and their required time for completion

DEVELOPING THE NURSING CARE PLAN

IMPORTANCE OF A NURSING CARE PLAN

 Care plans play a vital role in the treatment of a patient.

 They clearly define guidelines along with the nurse’s role in patient care and help them
create and achieve a solid plan of action.
 This equips nurses to provide focused care without overlooking important steps. Nursing
care plans also promote:

Collaboration

 A well-documented care plan ensures the patient’s entire care team (doctors, nurses, etc.)
can access the same information, give input, and join forces to provide the best care
possible.

Compliance
  Care plans help nurses uphold the nursing code of ethics and provide a record that they
did so in case of lawsuits or accusations that they failed to adhere to care standards.

Continuity

 A care plan is a communication tool for patient care between nurses. When nurses
change
shifts they’re able to reference the patient’s care plan to ensure the same quality care and
interventions are being executed.
 Without nursing care plans, nursing staff might have to rely on verbal communication
and patient information could become more easily scattered or lost, all of which could
result in improper patient care.

How to Write a Nursing Care Plan

Nursing care plans follow a five-step process: assessment, diagnosis, outcomes, implementation,
and evaluation.

1. Assess the patient.

The first step to writing a care plan is performing a patient assessment. This includes reviewing
your patient’s medical history, diagnosis, lab values, and medications. This step is critical to
creating an effective and accurate care plan for either short term or long term care.

2. Make a diagnosis.

Nursing diagnoses differs from a medical diagnosis in that it’s based on the patient’s response to
an illness, rather than the illness itself. Simply put, a nursing diagnosis is focused on patient care
rather than treatment.
According to NANDA (North American Nursing Diagnosis Association), a good nursing care
plan should not only list each diagnosis but define it as well. For example, acid reflux should be
described as: "Ineffective airway clearance related to gastroesophageal reflux as evidenced by
retching, upper airway congestion, and persistent coughing.”

3. Set goals and outcomes.

Once you’ve completed an assessment and diagnosis, it’s time to write down goals and a desired
health care outcome for your patient. These describe what you hope to achieve in the short- and
long-term future, provide direction for planning interventions, and serve as criteria for evaluating
progress. Goals are documented in the patient’s care plan so that other nurses and health
professionals caring for the patient have access to it.

4. Determine nursing interventions.

At this point in the care plan, you’ll list all planned nursing interventions and document any that
you’ve performed. You’ll write down things such as client responses to care, pain scale
responses, medications given and their dosages, vital signs, etc. This communicates what nursing
orders were implemented, what still needs to be done, and if the patient is ready to be discharged.

5. Evaluate the plan.

Evaluation is necessary in a patient care plan to determine whether to continue, adjust, or

terminate the plan of care. It measures the degree to which goals and outcomes are achieved and
provides evidence for what factors positively or negatively impacted those goals.
ETHICS IN NURSING PROCESS

 Since nurses’ work mainly focuses on patients, ethics in nursing offers a framework to
help them ensure the safety of patients and their fellow healthcare providers. The
nationally accepted guide is the Code of Ethics for Nurses with Interpretive Statements,
or The Code, issued by the American Nurses Association.
 The preface contains an explanation of the purpose of The Code: “The Code of Ethics for
Nurses with Interpretive Statements (the Code) establishes the ethical standard for the
profession and provides a guide for nurses to use in ethical analysis and decision-
making. The Code is non-negotiable in any setting.”
 In short, The Code contains the framework for ethical decision-making and analysis for
nurses in all roles, at levels and in all settings.
 In 1953, the International Council of Nursing was the first to adopt Code of Ethics for
Nurses. Like The Code, the ICN’s code has been revised to reflect the current healthcare
environment.
  Both codes make the patient the focus of the nurses’ work, ensuring they provide
compassionate patient care and ease or prevent suffering. These guidelines help nurses
with challenging decision-making.

Importance of ethics in nursing

Nurses encounter situations almost every day that require a strong understanding of ethics.
Education and guides like. The Code help them decide the right thing to do.

Here are situations nurses face almost every day:

 Obtain informed consent. Unless the patient is unconscious, the nurse has a responsibility
to obtain a patient’s consent prior to any treatment or procedure. Sometimes the patient
will refuse treatment. Nurses ensure the staff follows the patient’s wishes.
 Maintain patient confidentiality. While not everyone on the staff needs to know about the
patient’s history or situation, nurses must decide who needs to know without violating
confidentiality.
 Tell the truth. Most patients trust nurses, which is one of the reasons the profession has
the highest rating for ethics and honesty. Nurses must remain truthful even when
reporting news, the patient does not want to hear. They also depend on patients to share
correct information about their medicines, conditions and other issues.
 Deal with beliefs that conflict with empirical knowledge. Patients and their families may
refuse standard treatment that has been proven effective. For example, some religions
forbid blood transfusions. Should the nurse explain the benefits of the recommended
treatment? Or should the nurse respect the patient’s decision?
 Ethical guidelines help nurses work through difficult situations and provide them with a
moral compass to do their jobs fairly. At the same time, these guidelines promote high
levels of care and attention.

Ethical guidelines for nurses

Nurses may not always find the answers they need in The Code. In fact, “Everyday Ethics:
Ethical Issues and Stress in Nursing Practice” has found that everyday ethical issues can be
stressful for nurses.
The study has identified the following five most stressful ethical topics for nurses:

 Protecting patients’ rights.

 Informed consent for treatment.
 Staffing patterns.
 Advanced care planning.
 Surrogate decision-making.

Health organizations hold ethics-related interventions for today’s complex healthcare issues.
Some organizations may have their own ethics committees and guidelines. These committees
allow nurses to discuss dilemmas and acquire resources.

NB: In 2014, the National Nursing Ethics Summit attempted to break the barriers between
nursing organizations and other groups such as educational organizations, policymakers and
professional nursing non-profit organizations.

The result is Blueprint for 21st Century Nursing. This lists steps on how to prepare and
support nurses for practice.

 Nurses spend more time with patients than almost any other healthcare provider.
 They often understand what the patient and family want more than others.
 Healthcare staff depend on nurses’ knowledge and skills, which both play a large role in
the ethical care of patients.
 The fact that nurses consistently receive the highest ratings for honesty and ethics shows
they play a valuable role in healthcare.

ANA CODE OF ETHICS

ANA describes the nursing code of ethics as “non-negotiable in any setting.” The code serves as
the foundation for “nursing theory, practice, and praxis” in expressing the “values, virtues, and
obligations that shape, guide, and inform nursing as a profession.”

1. Compassion

Nurses recognize the dignity, worth, and uniqueness of all people. They understand that the right
to healthcare applies to everyone, and they respect at all times their patients, co-workers, and
everyone else they interact with
 2. Commitment

Nurses’ primary commitment is to their patients. They have a duty to recognize and address
potential conflicts of interest that may jeopardize their commitment to their patients. This
commitment extends to individuals, families, groups, and communities.

3. Advocacy

Nurses promote and protect patients’ rights, health, and safety by understanding privacy
guidelines, consent, and the need for full disclosure and honesty when dealing with patients.
Misconduct or other threats to patients’ well-being must be reported in a timely manner.

4. Responsibility

Nurses are accountable for the care they provide their patients. They must ensure that their care
aligns with professional guidelines, ethical concerns, and patients’ rights.

5. Self-Regard

Nurses must apply the same care standards their patients receive to self-care. Their responsibility
to promote health and safety extends beyond the workplace to their homes and other settings.
They have a duty to improve and adapt to maintain competence and grow in their profession.

6. Safety

Nurses have a duty to maintain a safe work environment that promotes quality care to all
patients. Institutions are responsible for outlining safety standards and enforcing ethical
obligations of care to ensure optimal patient outcomes.

7. Healthcare Advancement

In all the roles they play, nurses are charged with advancing the profession through research,
development of professional standards, and creation of nursing and health policy. They must
ensure that professional practice standards evolve as new healthcare approaches are developed.

8. Human Rights
In collaboration with other healthcare professionals, nurses protect human rights, foster health
diplomacy, and address healthcare inequities. As part of this process, nurses are obliged to
commit to constant learning and preparation to respond appropriately to novel and unusual
situations.

9. Social Justice

Social justice principles must be integrated into a nurse’s practice and advocacy for equitable
healthcare policies. By taking part in organizations and committees that acknowledge and
address ethics issues, nurses strengthen their voices in calling for social justice.

A Nurse’s Core Values and Commitments

ANA describes the nursing code of ethics as “self-reflective, enduring, and distinctive.”

 It restates the nursing profession’s fundamental values and commitments.

 It identifies the boundaries of duties and loyalty.
 It explains how nurses’ roles extend beyond individual patient interactions.
 It addresses the many relationships nurses have with other healthcare professionals,
patients’ families, and the public.
 It makes nurses more aware of the socio-political, economic, and environmental context
of their profession.
 Identifying Duty and Loyalty Boundaries
 The fourth, fifth, and sixth principles in the nursing code of ethics address the boundaries
that nurses must identify in their work.
 Limits are applied in their personal relationships with patients and co-workers.
 The boundaries can be difficult to maintain because nurses become involved in their
patients’ lives at very stressful times.
 Nurses have a duty to ask co-workers and supervisors for help when unsure how to
respond to situations that threatens professional boundaries.
 A Nurse’s Duties Beyond Patient Care

Ethical Dilemmas Facing Nurses

Even the most extensive code of ethics can’t account for all the potential dilemmas that nurses
may encounter in their work. That’s the reason that one of the duties stated in the nursing code of
ethics is to seek the advice and counsel of others whenever a nurse is uncertain about a medical
decision’s ethical aspects.

Even with a code of ethics in place, nurses may still encounter scenarios that make adhering to
these principles difficult. It’s important for nurses to recognize the potential for the following
situations, so they’re prepared to make the most ethically sound decisions possible: protecting a
patient’s rights, receiving fully informed consent to treatment, patient confidentiality breaches,
respecting a patient’s cultural or religious beliefs, and life event decision-making.

 Informed Consent

Nurses must obtain a patient’s informed consent before any medical procedure. As Medical
Records Info explains, in addition to explaining all of a procedure’s risks and benefits, nurses
must ensure that the patient is sufficiently competent to grant informed consent. Even being
medicated can impair a patient’s ability to understand a medical decision’s consequences, which
usually means the patient’s family or caretaker will decide on the patient’s behalf.

 Protecting Patients’ Rights

Sometimes the advocacy role nurses perform becomes second nature. However, this can cause
problems if nurses are overworked or unprepared, despite their best intentions. Advocacy
extends to the duty of healthcare administrators to ensure that nurses are working in an
environment that allows them to provide patients with the quality care they deserve.

 Breaches of Patient Confidentiality

Often a nurse may inadvertently breach patient confidentiality by misunderstanding an action’s

consequences. Nurses have a duty to protect sensitive health information, such as medical
history, and in the course of dealing with family members, co-workers, and law enforcement
officials, they must preserve patient autonomy and avoid oversharing personal information.

 Cultural Competency and Nursing Ethics

In recent years, much more attention has been paid to the need for nurses to understand the
cultural implications of their interactions with patients. Nurse Advisor highlights the many
benefits nurses realize by improving their cultural competence.

They pay closer attention to the verbal and nonverbal messages that patients and their families
send. The more contact nurses have with people from different cultures and socioeconomic
backgrounds, the higher quality care they can provide as they come to understand new social
norms and belief systems.

By communicating more clearly with patients from diverse backgrounds, nurses engender a
sense of trust that allows patients to feel more confident in opening up to healthcare providers.

As the pace of societal change increases, nurses are better equipped to adapt and modify the care
they provide to meet the ever-changing needs of their patients.

How Ethics Shape a Nurse’s Daily Responsibilities

Nurses must be aware of the breadth of their responsibilities, and they must determine their
readiness to accept those responsibilities. Collegian presents a framework of nurses’
responsibilities where seven domains are intended to promote safety and quality in healthcare.

 Promotion of safety
 Evidence-based practice
 Medical/technical competency
 Person-centred care
 Positive interpersonal behaviours
 Clinical leadership and governance
 Patient perceptions of quality

To validate the domains, researchers solicited nurses’ descriptions of their responsibilities for
safe and high-quality care to ensure that nurses’ perceptions match the expectations of their
organization and profession.

AREAS OF POTENTIAL LIABILITIES IN NURSING

Nursing Liability
Nurses are responsible for providing safe, competent, legal, and ethical care to clients and
families. Nurses are expected to meet standards of care, meaning the care that they provide to
clients meets set expectations and is what any nurse in a similar situation would do. Standards of
care are developed from professional standards

Code of ethics was adopted in 1950, It has been revised several times by: The International
Council of Nurses’ Code was revised in 1973 and again in 2000.

Includes the following area:

 Nurses and People

 Nurses and Practice
 Nurse & Profession
 Nurse & Co-workers
 The nurse carries personal responsibility and accountability for nursing practice and for
maintaining competence by continual learning.
 The nurse maintains a standard of personal health such that the ability to provide care is
not compromised.
 The nurse uses judgment regarding individual competence when accepting and delegating
responsibilities.
 The nurse at all times maintains standards of personal conduct that reflect well on the
profession and enhance public confidence.
 The nurse, in providing care, ensures that use of technology and scientific advances are
compatible with the safety, dignity and rights of people.
Nurses and People

The nurse’s primary responsibility is to people requiring nursing care. In providing care, the
nurse promotes an environment in which the human rights, values, customs and spiritual beliefs
of the individual, family and community are respected. The nurse ensures that the individual
receives sufficient information on which to base consent for care and related treatment. The
nurse holds in confidence personal information and uses judgment in sharing this information.
The nurse shares with society the responsibility for initiating and supporting action to meet the
health and social needs of the public, in particular those of vulnerable populations. The nurse
also shares responsibility to sustain and protect the natural environment from depletion,
pollution, degradation and destruction.

Nurses and the Profession

The nurse assumes the major role in determining and implementing acceptable standards of
clinical nursing practice, management, research and education. The nurse is active in developing
a core of research-based professional knowledge. The nurse, acting through the professional
organization, participates in creating and maintaining equitable social and economic working
conditions in nursing.

Nurses and Co-workers

The nurse sustains a cooperative relationship with co-workers in nursing and other fields.
The nurse takes appropriate action to safeguard individuals when their care is endangered
by a co-worker or any other person.
Legal Liability

You likely chose the nursing profession because you enjoy helping others. Words like ''liability,''
''negligence,'' and ''malpractice'' probably never entered your mind. However, nurses are
increasingly finding that legal issues are an everyday part of nursing practice. Studies show that
more nurses are being sued for on-the-job behaviours and actions than ever before. Recent issues
like nursing shortages and hospital cost-cutting initiatives have placed extra burdens on nurses,
increasing their workloads and the margin for error.

Nurses can be found legally liable, or responsible for mistakes made, due a variety of different
reasons. Perhaps they did not do something they were supposed to do, or they did something they
should not have done.

Negligence
 In order to be found legally liable, it's generally necessary to show that the nurse acted
negligently, or acted in the way they shouldn't have, which can occur even when a nurse has
good intentions. A nurse can be found to be negligent if these three standards are present:

1. The nurse owed a ''duty of care'' to the patient, or was obligated to care for the patient

2. The nurse ''breached'' that duty of care, or failed to properly care for the patient

3. The breach resulted in ''measurable damage'', which is simply injury or harm to the patient
When determining whether or not a nurse owed a duty of care, and whether or not that duty was
breached, the court will consider the standard of care appropriate for a nurse with similar
education, training, and experience when encountering the same or a similar situation. A nurse in
her first weeks of work will not be held to the same standard as one with years of experience.
Also, a nurse will not be held to the same standard of care as a surgeon who worked on the same
patient.

Malpractice

When a nurse is found to have acted negligently, that nurse has committed malpractice.
Malpractice simply means the nurse failed to uphold his or her legal and professional
responsibilities. All nurses must be licensed, and through that process nurses pledge to maintain
certain standards.

The standards include knowing and following all laws and ethical rules applicable to their
practice, including the state's nurse practice act (NPA). Each state has an NPA enacted in order
to protect public health and ensure the safe practice of nursing. When a nurse is not practicing
within the NPA's laws, that nurse is committing malpractice.

Liability

There are three forms of liability:

1. Civil liability

A patient claims compensation for damage or injury. The court may order the payment of
damages.

2. Criminal liability
The authorities prosecute punishable offences such as the causing of serious personal injury or
culpable homicide. The court may impose a punishment (e.g. a fine).

3. Disciplinary liability

On the initiative of a patient or his/her family (or e.g. the Healthcare Inspectorate), a disciplinary
tribunal assesses whether the staff member(s) concerned has/have acted negligently. If this is
found to be the case, the tribunal can impose a measure such as a warning, reprimand or fine.
The most severe penalty is removal from the BIG Register (register of healthcare professionals).

Areas of Liability

Let's take a look at some specific areas that are ripe for legal liability in nursing. There are
situations in which nurses must be particularly careful in order to avoid negligent behaviour. A
few of these include: patient’s treatment, patient’s privacy, handling patient’s property,
confidentiality.

ROLE OF THE NURSE IN HYGIENE AND ASEPSIS

Hand hygiene is a cornerstone in health care settings. The term includes several actions intended
to decrease colonization with transient flora The World Health Organization (WHO) has
defined hand hygiene as a general term for referring to any action of hand cleansing whose
purpose is to physically or mechanically remove dirt, organic material or microorganisms. In
other words, hand hygiene covers both hand washing (using plain or antimicrobial soap and
water) and hand disinfection (using alcohol-based rub).

It is the single most important intervention to prevent the spread of health care associated
infections.

Asepsis means the absence of microorganisms that cause infections. Aseptic technique is when
the possibility of transferring microorganisms from one place to another is decreased.
Aseptic technique is “a set of specific practices and procedures performed under carefully
controlled conditions with the goal of minimizing contamination by pathogens”. It is important
to point out that the contamination has to be minimized on both human (i.e. hands) and on
environmental level (i.e. surfaces, equipment).

Hand washing, surgical scrub, barriers (equipment), patient preparation, maintaining a sterile
field and a safe environment in the procedure area are good examples practices.

Hand hygiene is an aseptic technique, the goals of which are to reduce a patient’s risk of
exposure to microorganisms, to protect the patient from infection and to prevent the spread of
pathogens by eliminating microorganisms from hands and objects.

Hand hygiene non-compliance is a major cause of nosocomial infection. Good hand hygiene
plays a major role in reducing and eliminating the spread of germs and infections from patient-to
patient. Research has shown that while healthcare workers state largely favourable attitudes
towards hand-cleaning practices, observed compliance rates are below 30%. A reason given by
professionals for the lack of compliance to hand-cleaning practices highlights several
explanatory factors, including: work conditions (lack of time), infrastructures (lack of
equipment), and training (inadequate), human environment (superiors, colleagues, unscrupulous
patients) and the health of medical and nursing staff (skin irritations caused by frequent hand
cleaning). Infection prevention and infection control have always been serious topics, but this is
particularly true today, with the spread of the swine flaunt associated infections.

Good personal hygiene plays a major part in reducing and eliminating the spread of germs and
infections from person-to person. It also helps in reducing the spread of infectious illnesses,
including colds, flu and other upper respiratory illnesses. A big part of personal hygiene is hand
hygiene and incorporating safety measures in developing habits that will stave off illnesses can
help to further reduce the spread of germs and infections. Ensuring that today's medical
professionals make hand washing a priority is essential. Simple activity of frequent handwashing
has the potential to save more lives than any single vaccine or medical intervention. It is one of
the most effective and inexpensive ways to prevent diarrheal diseases and pneumonia, which
cause more than 3.5 million deaths worldwide in children under the age of 5 every year.
Although people around the world clean their hands with water, very few use soap to wash their
hands.
 MEDICAL PRESCRIPTION

Nurses application: application of medical prescription. The second and third themes, named
“collaborative approach” and “nurse’s knowledge”, respectively, provide an overview to the
physician-nurse interaction and to the role of nurse’s knowledge in the prescription decision.
Application of medical prescription

The essential nursing role is a part of medication administration, monitoring its effects, and
providing patient advice on medications. In addition, the nurse is involved in drafting and
development of policies and guidelines for the use of drugs.

Collaborative approach

The nurse shares the medical-prescribing decision with the doctor; she retains the medication in
certain situations and recommends treatments to prescribing doctors. Thus, the nurse can
influence decision making by prescribers through encouraging drug compliance, monitoring
prescription decisions and reducing prescribing errors. In fact, the participation of nurses in
antimicrobial management activities could provide an opportunity to discuss antimicrobial
treatment and duration with the attending physicians and pharmacists. Indeed, direct
communication among health professionals, including nurses, about the use of medicines would
promote best practice; thereby reducing patient’s morbidity and its costs, as well as reducing the
length of hospital stay

CRITICAL THINKING

The practice of nursing requires critical thinking and clinical reasoning. Critical thinking is the
process of intentional higher level thinking to define a client’s problem, examine the evidence-
based practice in caring for the client, and make choices in the delivery of care. Clinical
reasoning is the cognitive process that uses thinking strategies to gather and analyse client
information, evaluate the relevance of the information, and decide on possible nursing actions to
improve the client’s physiological and psychosocial outcomes.

Thinking Model provides a visual representation of critical thinking abilities and promotes
making meaningful connections between nursing research and critical thinking and practice.
Critical thinking is an essential skill needed for the identification of client problems and the
implementation of interventions to promote effective care outcomes.

Effective critical thinking requires synthesis of knowledge, experience, information gathered

from patients, critical thinking attitudes, and intellectual and professional standards. Clinical
judgments require you to anticipate the information necessary to analyse data and make
decisions regarding care. A patient’s condition is always changing, requiring ongoing critical
thinking. During assessment consider all elements that build toward making appropriate nursing
diagnoses. Apply the elements of critical thinking as you use the nursing process to meet
patients’ hygiene needs.

Integrate nursing knowledge with knowledge from other disciplines. For example, the patient
with diabetes mellitus has special needs for nail and foot care. Knowledge about the
pathophysiology of diabetes and its potential effects on his or her peripheral circulation and
sensory status provides the scientific knowledge base needed to implement safe and effective
foot care. In addition, integrate knowledge about developmental and cultural influences as you
identify and meet hygiene needs.

Be aware of the impact of critical thinking attitudes as you plan and implement care. For
example, think creatively to help patients adapt existing hygiene practices or develop new
hygiene practices when illness or loss of function impairs self-care abilities. Be non-judgmental
and confident when providing care. Because of variations in individual patients’ physical status
and hygiene practices, you need to approach care with an attitude of flexibility.

For example, when caring for a patient who is fatigued, you pace activities and plan rest periods
during hygiene care to prevent exhaustion. Draw on your own experiences as you assist with
your patients’ hygiene care. Reflect on times when you helped family members or others close to
you with their hygiene. Usually an early clinical experience involves providing or assisting with
hygiene care for a patient. Finally rely on professional standards such as those for skin and foot
care from the American Diabetes Association (ADA) and specialty nursing groups such as
Wound Ostomy Continence Nurses (WOCN) when planning care to meet a patient’s hygiene
needs. As your experience and knowledge grow, your comfort and expertise in meeting the
individualized hygiene needs of your patients increase.