chapter 4

Copyright © 2011 F.A. Davis Company

Nursing Process and Decision Making


Nursing Process TerminologyNursing process

Decision-making framework Nursing diagnosis

Labels a problem resulting from medical diagnosis

Nursing goalsOverall direction to improve a problem

Expected outcomesStatements of measurable patient actions


Care PlanDocumented plan of care

Nursing diagnosisGoalPhysician ordered interventionsNursing interventionsEvaluation


Types of Nursing InterventionsDependent

Requires a health-care provider’s orderIndependent

Can be performed without consulting anyone else

Collaborative Involves working with other health-care

professionals in the hospital setting


Critical Thinking Skills Using skillful reasoning and logical thought

to determine the merits of a belief or actionThinking purposelyAvoiding jumping to conclusionsDo not just follow ordersValidating information obtained


Five Steps of the Nursing ProcessAssessmentDiagnosisPlanningImplementationEvaluation


AssessmentGathering of information

Interviewing the patient Ask questions Listen Verbal and nonverbal communication skills

Head-to-Toe body assessment or focused body system assessment

Review results of laboratory and diagnostic tests

To determine problems and/or needs of the patient


Objective Data vs. Subjective DataObjective data

Can be OBSERVED through senses of hearing, sight, smell, and touch

Describe what you see, hear, smell or feelSubjective data

Information known only to the patient or family members


Techniques Used to Gather DataInspection

Visual examination of the patient’s body for skin conditions and normal appearance of body parts

PalpationTouching or feeling the torso and limbs for

pulses, abnormal lumps, temperature, moisture, and vibrations


Techniques Used to Gather Data (cont.)Auscultation

Listening to body organs for abnormal sounds in the lungs, heart, or bowel

PercussionUsing tapping movements to detect

abnormalities of the internal organs


Primary Data vs. Secondary DataPrimary data

Information provided by the patientSecondary data

Information obtained from family members, friends, and the patient’s chart


DiagnosisFormulated through analysis of the

assessment informationNursing diagnosis related to the needs or

problems the patient is experiencingCompletely different than a medical diagnosis


Medical Diagnoses vs. Nursing Diagnoses

Medical diagnosesBased on signs, symptoms, lab findings, and

test resultsNursing diagnoses

Focused on the needs of the patients


PlanningProcess of determining priorities and what

nursing actions should be performed to help resolve or manage each patient problem

Expected outcomesRealistic time frame


ImplementationProcess of taking actions to resolve the

patient’s problems—the nursing diagnosesThe actions are referred to as interventionsPerformance of the interventions—

implementation


Evaluation When the nurse reflects on the interventions

he or she has performed Did they bring the patient to achieving the

goals or outcomes set in the planning stepIf not—then revise and change the

interventions to better fit the needs of the patient


QuestionWhat is the difference between the role of the

RN and the role of the LPN in the nursing process?

What does ADPIE stand for?


Initial Steps of Nursing InterventionsNursing students—before you begin any

intervention—you must be sure that you know how to perform it!

NEVER PERFORM ANY SKILL OR INTERVENTION THAT YOU HAVE NOT BEEN TAUGHT HOW TO DO

Your instructor must be present


Initial Steps of Nursing Interventions (cont.)Standard Protocol

Initial steps for most nursing interventionsRead: Initial Intervention Steps--Page 63Refer to handout

chapter 4

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