Nursing Process

Part Three, 211 NUR

Learning Outcomes

1. Describe the phases of the nursing process.2. Identify major characteristics of the nursing

process.3. Identify the purpose of assessing.4. Identify the four major activities associated

with the assessing phase.

Learning Outcomes (cont'd)

5. Differentiate objective and subjective data and primary and secondary data.

6. Identify three methods of data collection, and give examples of how each is useful.

7. Compare closed and open-ended questions, providing examples and listing advantages and disadvantages of each

Nursing Process

Defined as: is a Systematic, rational method of planning to

providing nursing care.

Is “A series of steps or acts that lead to accomplishment of some goal or purpose”

Goals of Nursing process

1. To identify Patient healthcare status, actual or potential health problems

2. To establish plans to meet the identified needs.

3. To deliver specific nursing interventions to address those needs.

Benefits of Nursing process

1. Improves quality of care Pts. Receive.2. Promotes efficient use of time & resources.3. Serves as framework for nurses’ accountability.4. Enhances collaboration.5. Continuity of care and Prevention of duplication.

Characteristics of the Nursing Process

1. Cyclic and dynamic rather than static.2. Client centered.3. Problem-solving and systems theory.4. Decision making.5. Interpersonal and collaborative. 6. Universal applicability.7. Critical thinking skills.

MARTHA ROGERS, NURSE THEORIST

“When an apple is cut, others see seeds in the apple. We, as nurses, see apples in the seeds.”

5 Steps in the Nursing Process

1. Assessment2. Nursing Diagnosis3. Planning4. Implementing5. Evaluating

Figure 11-1 The nursing process in action.

Figure 11-1 (continued) The nursing process in action.

Figure 11-3 Assessing.

1. Assessment

• Collecting data• Organizing data• Validating data• Documenting data

Four types of assessment1. Initial nursing assessment2. Problem-focused assessment3. Emergency assessment4. Time-lapsed reassessment

1. Assessment

Types of Assessments

• Initial or Comprehensive – Performed within a specified time period– Establishes complete database

• Problem-Focused– Ongoing process integrated with care– Determines status of a specific problem

Types of Assessments (cont'd)

• Emergency– Performed during physiologic or psychologic crises– Identifies life-threatening problems

• Time-lapsed (on going)– Occurs several months after initial assessment – Compares current status to baseline

Small group questions

1. Baby Jane a 2 month infant goes into the doctor for her initial immunization and well baby check-up. What type of assessment should the nurse perform?A. ComprehensiveB. Focused

C. Time-lapsed (on going)

A. Collecting Data

• Gathering information about a client’s health status.

• It must be both systematic and continuous.• Should include past history and current

problem.• Can be subjective or objective.• From primary or secondary source.

Subjective Data

• Symptoms or covert data• Can be described only by person affected• Includes sensations, feelings, values, beliefs,

attitudes, and perception of personal health status and life situations

• Obtained through Nursing health history.

Objective Data

• Signs or overt data • Detectable by an observer• Can be measured or tested against an

accepted standard• Can be seen, heard, felt, or smelled• Obtained through observation or physical

examination

Small Group Questions

4. Which of the following are objective data and which are subjective data.A. NauseaB. VomitingC. Unsteady gaitD. AnxietyE. Bruises on the right arms and faceF. Temperature 101 F

Sources of Data

• Primary Source– The client

• Secondary Sources– All other sources of data

• Family members• Other health care providers• Medical records

Methods of Data Collection

• Observing– Gathering data using the senses– Used to obtain following types of data:

• Skin color (vision)• Body or breath odors (smell)• Lung or heart sounds (hearing)• Skin temperature (touch)

Methods of Data Collection

• Interviewing– Planned communication or a conversation with a

purpose – Used to:

• Get or give information• Identify problems of mutual concern• Evaluate change• Teach • Provide support• Provide counseling or therapy

Closed and Open-ended Questions

• Closed Question• Restrictive

– Yes/no– Factual

• Less effort and information from client• “What medications did you take?”• “Are you having pain now?”

Closed and Open-ended Questions (cont'd)

• Open-ended Question• Specify broad topic to discuss• Invite longer answers• Get more information from client• Useful to change topics and elicit attitudes

The Interview Setting

• Time– Client free of pain– Limited interruptions

• Place– Private– Comfortable environment– Limited distractions

The Interview Setting (cont’d)

• Seating Arrangement – Hospital– Office or clinic– Group

• Distance– Comfortable

• Language – Use easily-understood terminology

Methods of Data Collection

• Examining (physical examination)– Systematic data-collection method– Uses observation and inspection, auscultation,

palpation, and percussion– Vital signs, height and weight

b. Organizing data

• Nursing Models Framework– Gordon’s functional health pattern framework– Orem’s self-care model– Roy’s adaptation model

• Wellness Models• Nonnursing Models

– Body systems model– Maslow’s Hierarchy of Needs– Developmental theories

b. Organizing data

Validating Data

• Assessment complete• Objective and related subjective data agree• Additional data overlooked• Avoiding jumping to conclusions• Cues: subjective & objective• Inferences = nurse’s interpretation of the cues

Documenting

• Record client data• Record factual manner not interpreting by

nurse• Record subjective data with quotes in client’s

own words

Question

Which of the following behaviors would indicate that the nurse was utilizing the assessment phase of the nursing process, to provide nursing care?A. Propose hypothesesB. Generate desired outcomesC. Reviews results of laboratory testsD. Documents care

Question

Which of the following elements is best categorized as secondary subjective data?A. The nurse measures a weight loss of 10 pounds

since the last clinic visit.B. Spouse states the client has lost all appetite.C. The nurse palpates edema in lower extremities.D. Client states severe pain when walking up stairs.

2. Diagnoses

Figure 12-1 Diagnosing. The pivotal second phase of the nursing process.

• Nursing diagnosis:– “A clinical judgment about individual, family or

community responses to actual or potential heal problems / life processes.

– A nursing diagnosis provides the basis for selection of nursing interventions to achieve outcomes for which the nurse is accountable.”

Diagnoses

• Diagnosing refers to the reasoning process• Diagnosis is a statement or conclusion

regarding the nature of a phenomenon• Diagnostic labels are the standardized NANDA

names• Nursing diagnosis is the problem statement

consisting of the diagnostic label plus etiology

Types of Nursing Diagnoses

• Actual Diagnosis– Problem presents at the time of the assessment– Presence of associated signs and symptoms

• Risk Diagnosis– Problem does not exist– Presence of risk factors

Types of Nursing Diagnoses (cont'd)

• Health Promotion Diagnosis– Preparedness to implement behaviors to improve

their health condition– Example: Readiness for enhanced Nutrition

• Wellness Diagnosis– Describes human responses to levels of wellness

in an individual, family, or community– Example: Readiness for Enhanced Family Coping

Components of a Nursing Diagnosis

• Problem statement (diagnostic label)– Describes the client’s health problem or response – Qualifiers added to give additional meaning

• Etiology (related factors and risk factors)– Identifies one or more probable causes of the

health problem

Components of a Nursing Diagnosis

• Defining characteristics– Cluster of signs and symptoms indicate the – presence of a particular diagnostic label (actual

diagnoses)– Actual nursing diagnoses client’s have signs and

symptoms– For risk for nursing diagnoses no subjective or

objective data

Nursing Diagnoses

• A statement of nursing judgment based on education, experience, expertise and licensed to treat

• Describes human response, a client’s physical, sociocultural, psychological, and spiritual responses to an illness or a health problem

• Changes when client’s responses change

Medical Diagnoses

• Made by a physician• Refers to a disease process• Remains the same for as long as the disease

process is present

Ex: DiagnosisNursing diagnosis Medical diagnosis

Breathing patterns, ineffective

Chronic obstructive pulmonary disease

Activity intolerance Cerebrovascular accident

Pain Appendectomy

Body image disturbance Amputation

Body temperature, risk for altered

Strep throat

Steps in Diagnostic Process

• Analyzing Data– Compare data against standards– Cluster cues– Identify gaps – Identifying health problems, risks, and strengths

• Formulating diagnostic statements

Writing Nursing Diagnoses

• Basic Two-Part Statement – Problem (P)– Etiology (E)

• Basic Three-Part Statement– Problem (P)– Etiology (E)– Signs and symptoms (S) what’s the evidence of the

problem.

Nursing Diagnosis

• Problem( Diagnostic Label)-based on your assessment of client…(gathered information), pick a problem from the NANDA list...

• Etiology- determine what the problem is caused by or related to (R/T)...

• Defining characteristics- then state as evidenced by (AEB) the specific facts the problem is based on...

Example of Nursing Dx

• Ineffective therapeutic regimen management R/T difficulty maintaining lifestyle changes and lack of knowledge AEB B/P= 160/90, dietary sodium restrictions not being observed, and client statements of “ I don’t watch my salt” “It’s hard to do and I just don’t get it”.

Table 12-6 Guidelines for Writing a Nursing Diagnostic Statement

Question

In the diagnostic statement “Excess fluid volume related to decreased venous return as manifested by lower extremity edema (swelling),” the etiology of the problem is which of the following?A.Excess fluid volumeB.Decreased venous returnC. EdemaD.Unknown

Question

Which of the following nursing diagnoses contains the proper components?A. Risk for caregiver role strain related to

unpredictable illness courseB. Risk for falls related to tendency to collapse when

having difficulty breathingC. Impaired communication related to strokeD. Sleep deprivation secondary to fatigue and a noisy

environment

3. Planning

Figure 13-1 Planning. The third phase of the nursing process, in which the nurse and client develop client goals/desired outcomes and nursing interventions to prevent, reduce, or alleviate the client’s health problems.

Initial Planning

• Developed the initial comprehensive plan of care

• Planning should be initiated after the initial assessment

Ongoing Planning

• Done by all nurses who work with the client• Individualization of initial care plan • Also occurs at the beginning of a shift

Discharge Planning

• Process of anticipating and planning for needs after discharge

• Addressed in each client’s care plan• Begins at first client contact• Involves comprehensive and ongoing

assessment

The Planning Process

• Consists of following activities:– Setting priorities– Establishing client goals/desired outcomes– Selecting nursing interventions– Writing individualized nursing interventions on

care plans

Setting Priorities

• Establishing a preferential sequence for addressing nursing diagnoses and interventions– High priority (life-threatening)– Medium priority (health-threatening)– Low priority (developmental needs)

Maslow’s Hierarchy of Needs

Goals/Desired Outcomes

• Goals are broad statements about the client’s status

• Desired outcomes are more specific, observable criteria used to evaluate whether the goals have been met

Table 13-2 Deriving Desired Outcomes from Nursing Diagnoses

• Subject: who is the person expected to achieve the outcome?

• Verb: what actions must the person take to achieve the outcome?

• Condition: under what circumstances is the person to perform the actions?

• Performance criteria: how well is the person to perform the actions?

• Target time: by when is the person expected to be able to perform the actions?

Components of Goal/Desired Outcome Statements

SMART Specific Measurable Attainable Relevant Time BoundPt will walk 50 ft.Pt will maintain HR<100Pt will state pain level is acceptable 6 (0-10)

Guidelines for Writing Goals/Desired Outcomes

Guidelines for Writing Goals/Desired Outcomes

• Must be realistic• Ensure compatibility with the therapies of

other professionals • Derive from only one nursing diagnosis• Use observable, measurable terms • Make sure client considers them to be

important and values them.

Types of Nursing Interventions

• Independent interventions– Those activities nurses are licensed to initiate (i.e.,

physical care, ongoing assessment)• Dependent interventions

– Activities carried out under physician’s orders or supervision, or according to specified routines

Types of Nursing Interventions (cont'd)

• Collaborative interventions– Actions nurse carries out in collaboration with

other health team members– Reflect overlapping responsibilities of health care

team

Criteria for Choosing Appropriate Interventions

• Safe and appropriate for the client’s age, health, and condition

• Achievable with the resources available• Congruent with the client’s values, beliefs, and

culture• Congruent with other therapies• Based on nursing knowledge and experience

or knowledge from relevant sciences

Writing individualized Nursing Interventions

• Date when they are written• Verb

– Action verb starts the interventions and must be precise

• Conditions• Modifiers• Time element

– How long or how often the nursing action is to occur

Question

The nurse selects the nursing diagnosis of Risk for Impaired Skin Integrity related to immobility, dry skin, and surgical incision. Which of the following represents a properly stated outcome/goal? The client will:A. Turn in bed q2h.B. Report the importance of applying lotion to skin daily.C. Have healthy intact skin during hospitalization.D. Use a pressure-reducing mattress.

4. Implementation

Figure 14-1 Implementing. The fourth phase of the nursing process, in which the nurse implements the nursing interventions and documents the care provided.

The Nursing Process - Implementing

• Based on first three phases• Assessing• Diagnosing• Planning• Provides the basis for the nursing actions

performed during the implementing step• Provides actual nursing activities and client

responses are examined during evaluating phase

Successful Implementation

• To implement care successfully, nurses need:– Cognitive skills– Interpersonal skills– Technical skills

Cognitive Skills (Intellectual)

• Problem solving• Decision making• Critical thinking• Creativity

Interpersonal Skills

• Verbal and nonverbal• Effectiveness depends largely with ability to

communicate • Therapeutic communication • Necessary for caring, comforting, advocating,

referring, counseling, and supporting

Interpersonal Skills (cont'd)

• Include conveying knowledge, attitudes, feelings, interest

• Appreciation of the client’s cultural values and lifestyle

Technical Skills

• Purposeful “hands-on” skills• Often called tasks, procedures, or

psychomotor skills• Psychomotor refers to physical actions that

are controlled by the mind, not reflexes• Require knowledge and frequently manual

dexterity

Five Activities of the Implementing Phase

• Reassessing the client• Determining the nurse’s need for assistance• Implementing nursing interventions• Supervising delegated care• Documenting nursing activities

Reassessing the Client

• Reassess to make sure the intervention is still needed

• Client’s condition may have changed

Determining the Nurse’s Need for Assistance

• Unable to implement the nursing activity safely

• Assistance will reduce stress on the client• Lacks the knowledge or skills to implement a

particular nursing activity

Implementing Nursing Interventions

• Base on scientific knowledge • Clearly understand interventions • Adapt activities to the individual client• Implement safe care• Provide teaching, support, and comfort

Implementing Nursing Interventions (cont'd)

• Be holistic• Respect the dignity of the client and enhance

self esteem• Encourage active client participation

Supervising Delegated Care

• Responsible for the client’s overall care • Validates and responds to any adverse findings

or client responses

5. Evaluation

Documenting Nursing Activities

• Record nursing interventions and client responses

• Must not be recorded in advance

Figure 14-3 Evaluating. The final phase of the nursing process, in which the nurse determines the client’s progress toward goal achievement and the effectiveness of the nursing care plan. The plan may be continued, modified, or terminated.

Components of the Evaluation Process

• Collecting data related to the desired outcomes (NOC indicators)

• Comparing the data with outcomes• Relating nursing activities to outcomes• Drawing conclusions about problem status• Continuing, modifying, or terminating the

nursing care plan

EVALUATION & REASSESSMENT

• 1. Goal met• 2. Goal partially met• 3. Goal not met• 4. Goal in progress• Reassessment= the entire plan of care (data,

ND, goal/O, Nsg orders) must be reassessed

Documentation

• Clear and concise• Appropriate terminology

– Usually on a designated form• Physical assessment

– Usually by Review of Systems• Overview of symptoms• Diet• Each body system

Reference

• Kozier & Erb's Fundamentals of Nursing by Audrey T Berman, Samuel Merritt CollegeShirlee Snyder, Nevada State CollegeGeralyn Frandsen, EdD, MSN, RN, Maryville University