The Nursing ProcessSt. Joseph’s College of QC

The Nursing Process

In 1980, The American Nurses’ Association (ANA) defined nursing as:

The diagnosis and treatment of HUMAN RESPONSES to actual or potential health problems

 

Introduction

A problem-solving method Systematic, goal-directed, flexible, rational approach Ensures consistent, continuous, quality nursing care Provides a basis for professional accountability Input of nurse and patient/family critical

The Steps of the Nursing Process are cyclic, overlapping and interrelated:

AssessDiagnoseEvaluatePlanImplement

Step One of the Nursing Process:

Assessment: the most critical step

Answers the questions: “What is happening?” (actual problem), or “What could happen?” (potential problem)

Involves collecting, organizing, and analyzing information/data about the patient

Results in Nursing Diagnoses

Two parts: Data collection & Data analysis

1. Data Collection: A Holistic Approach

Types of data

Subjective: “symptoms” that the patient describes; e.g. “I can’t do anything for myself”

Objective: signs that can be observed, measured, and verified; e.g. swollen joints

Sources of data

Primary: the patient; is always the best source Secondary: everything/everybody else

Methods of Data Collection

Observation

Requires practice and skillSystematic, head-to-toe (cephalocaudal)

Results in objective, factual informationDocument exactly what you observe

e.g. “Yawned frequently, had dark circles under eyes”

NOT “Patient seems tired”

Observation results in a General Survey

The General Survey: a brief description of patient’s appearance and behavior.

64 year old, well groomed African-American male in acute distress. Awake, alert, and oriented. Approximately 6’, 170lbs. Hair sparse and gray, eyes brown. Sitting on side of bed, holding siderail for support. Verbal responses coherent but halting.

 

 

Methods of data collection

Interview

Structured form of communicationPurpose: to provide care specific to this individual’s needs and problemsFocus: patient’s perceptionsNurse must: explain purpose of interview, provide comfort and privacy, ensure confidentialityResult: A comprehensive Health History

Components of the Health History

Demographic dataCC: chief complaintHPI: history of present illnessPMH: past medical historyFMH: family medical history (genogram)ROS: review of systemsPsychosocial history

Methods of Data Collection

Examination

Inspect Palpate Percuss Auscultate

Nurse must: explain what you are doing, provide privacy, and ask permission before you touch the patient

2. Data Analysis

Data review

Are data accurate and complete?

Data interpretation

What are the patient’s actual and/or potential problems? Develop a problem list based on the data Prioritize the patient’s problems

Step Two of the Nursing Process

Nursing Diagnosis: a statement that describes a specific human response to an actual or potential health problem that requires nursing intervention

Written in P E format

P = Problem: use North American Nursing Diagnosis Association (NANDA) category [due to or related to]

E = Etiology: cause of the problem

 

The Patient

A Holistic-Physical-Emotional-Psychosocial-Developmental-Spiritual Being

Data Base

Medical Diagnosis Nursing Diagnosis

Rheumatoid Arthritis Self-care deficit:bathing, related to joint stiffness

 Step Three of the Nursing Process

Plan: to provide consistent, contiuous care that will meet the patient’s unique needs.

Includes Patient Goals & Nursing Orders

Patient Goals: describe the desired result of nursing care

What will the patient (or part of the patient) do to resolve or lessen the problem identified in the         nursing diagnosis?

By when will this be accomplished?

Patient Goals are directly related to the patient’s problem as stated in the nursing diagnosis:

One goal should describe resolution of the problemAdditional goals should describe steps that contribute to problem resolution Patient Goals can be long term or short term

Patient Goals are:

Focused on the patientClear and ConciseObservable, Measurable, Realistic: how much? how far? how long? how well?Written with a specific time frame: by when should the goal be accomplished?Determined by the nurse and the patientMr. H. will perform entire bath unassisted by 4-4-01

 Nursing Orders

Describe what the nurse will do to help the patient achieve the goals.

Nursing Orders must:

Focus on nursing actions Describe when and how the nurse will perform nursing actions Include the date & be signed by the nurse 3/30/01        The nurse will assist Mr. H. with bathing qAM until he is able to bathe independently. E. Bruderle, RN

 Step Four of the Nursing Process

Implement: Carry out the care plan

Reassess the patient Validate that the care plan is accurateCarry out nurses’ orders Document on patient’s chart

Step Five of the Nursing Process

Evaluate: Compare the patient’s current status with the stated Patient Goals

Were the goals achieved? Why not? Review the nursing process

Problem: “I can’t do anything for myself”

Nursing Diagnosis: Self care deficit: bathing, related to joint stiffnessPatient Goal (resolution): Mr. H. will perform entire bath unassisted by 4-4-00.Patient Goal (contributory): Mr. H. will bathe his upper body unassisted by 4-1-00.Nursing order: 3/30/01 The nurse will assist Mr. H. with bathing q AM until he is able to bathe independently. E.Bruderle RN Evaluation: Was Mr.. H. able to bathe unassisted by 4-4-00?