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THE NURSING PROCESS

RNSG 1209

Fall 2010

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The Nursing Profession:

Has defined what makes nursing unique

Has identified a body of professionalknowledge

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The Nursing Profession

The American Nurses Association (1995)identified four essential features of today’s

contemporary nursing practice...

1. Attention to the full range of human experiences

2. Integration of objective data

3. Application of scientific knowledge

4. Provision of a caring relationship

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The Nursing Profession

ANA (2003) also recognized the nurse’s role

as client advocate supporting the right of

clients to: Define their own health-related goals

Engage in care reflecting client values

http://nursingworld.org/books/pdescr.cfm?cnum=24

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THE NURSING PROCESS

The nursing process is a systematic method ofplanning and providing care to clients.

Orderly, logical; focus on problem-solving

Incorporates an interactive/ interpersonalapproach to decision-making

It is the basis for accurate, complete

documentation required to meet legal standardas well as the standards of care identified in theTexas Nurse Practice Act and TJC.

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THE NURSING PROCESS

Process - A series of steps or acts that lead toaccomplishment of some goal or purpose.

3 Characteristics of the nursing process:Inherent Purpose

Internal Organization

Infinite Creativity

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Diagram of the Nursing Process

The steps of the nursing process are interrelated,forming a continuous circle of thought and action.

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THE NURSING PROCESS

What is the purpose?

Provide Client Care Individualized

Holistic

EffectiveEfficient

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The Nursing Process Is An Applied

Logical, Problem-Solving Approach

To Providing Client Care.

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THE NURSING PROCESS

5 Components of the Nursing Process

Assessment

Diagnosis / Analysis

Planning & Outcome Identification

Implementation

Evaluation

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The Nursing Process

STEP 1

Assessment—

the systematic collection of data relatingto clients

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The Nursing Process

STEP 2Diagnosis—

the analysis of collected data to identifythe client’s needs or problems

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The Nursing Process

STEP 3

Planning—

a two-part process of:

identifying goals and desired outcomes

selecting appropriate nursing interventions

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The Nursing Process

STEP 4

Implementation—

putting the plan of care into action

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The Nursing Process

STEP 5

Evaluation—

determining the client’s progress

monitoring the client’s response

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How the Nursing Process Works

A process you routinely use to solveproblems

Applies readily to client-care situations

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The Assessment Step

ANA Standard 1

Assessment: The nurse collects comprehensive data pertinent to client’s

health or situation.

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THE NURSING PROCESS:

ASSESSMENT

What is the purpose of nursing assessment?

To establish a foundation of informationregarding the client’s physical, psychosocial, and

emotional health in order to identify healthpromoting behaviors and actual/potential healthproblems.

Collect & organize information about the client.

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ASSESSMENT

Data Collection Sources

Primary - clientSecondary - family, lab, test, other health care

providers, medical records.

Subjective (symptoms) - client’s point of view or

perspective, their feelings & concerns.

Objective (signs) - observable, measurable info fromassessment, labs, diagnostic testing.

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ASSESSMENT

Assessments are:ComprehensiveFocusedOngoing

Data must be:ValidatedOrganized

InterpretedDocumented

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The Diagnosis Step

ANA Standard 2

Diagnosis: The nurse analyzes the assessment data to determine the diagnoses or issues.

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DIAGNOSIS

Diagnosis: The 2nd step in the nursing process involves furtheranalysis & synthesis of the data that has beencollected.

NANDA - North American Nursing Diagnosis

Association

First list of nursing dx in 1973

Latest updates/revisions for 2009-2011

Critically analyze data gathered from the assessment.

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Defining Nursing Diagnosis

NANDA’s Definition

Nursing diagnosis is a clinical judgment aboutindividual, family, or community responses to

actual and potential health problems/lifeprocesses.

Nursing diagnoses provide the basis for

selection of nursing interventions to achieveoutcomes for which the nurse is accountable.

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The Use of Nursing Diagnoses

Benefits of the nursing diagnosis

1. Gives nurses a common language

2. Promotes identification of appropriate goals

3. Provides acuity information

4. Can create a standard for nursing practice

5. Provides a quality improvement base

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Medical vs. Nursing Diagnoses

Medical diagnoses illnesses/conditions; reflectalteration of the structure or

function of organs orsystems; verified bymedical diagnostic studies

Nursing diagnoses

address human responsesto actual and potentialhealth problems/lifeprocesses

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THE NURSING PROCESS

DIAGNOSES

Examples of Approved NANDA DX

Decreased Cardiac Output

Ineffective Airway Clearance

Constipation

Fluid Volume Deficient Impaired Mobility

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THE NURSING PROCESS

DIAGNOSIS

3 Types of Nursing Diagnosis

Actual

Risk Wellness

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Writing an Actual Diagnostic Statement

PES format

The Problem (need), Etiology, and Signs

and symptoms (or risk factors) arecombined into a “neutral” statement that

avoids value-laden or judgmental

language.

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Writing an Actual Diagnostic Statement

The problem (need) and etiology sections ofthe diagnostic statement are joined by the

phrase“related to.”

Acute Pain r/t abdominal surgical incisionAEB pain scale rating 7/10; guarding

abdomen with movement; moaning withmovement

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THE NURSING PROCESS

DIAGNOSIS

Examples-Three Part Statement

Toileting, Self Care Deficit R/T neuromuscular impairment AEB paralysis of right side of body

Ineffective Airway Clearance R/T retained secretions AEB adventitious breath sounds and ineffective cough

Constipation R/T poor eating habits, insufficient fiber and fluid intake AEB hard/formed stool.

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Writing a Client Diagnostic Statement

Common Errors:

Using the medical diagnosis:

Self Care deficit r/t stroke

Relating the problem to an unchangeablesituation:

Risk for injury r/t blindness

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Common Errors:

Confusing the etiology or signs/symptoms for

the need:Postoperative lung congestion r/t bedrest

Use of a procedure instead of the “human

response”:

Catheterization r/t urinary retention

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Common Errors:

Lack of specificity:

Constipation r/t nutritional intake

Combining two nursing diagnoses:Anxiety and Fear r/t separation from parents

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Common Errors:

Relating one nursing diagnosis to another:

Ineffective coping r/t anxiety

Use of judgmental or value-laden language:

Chronic pain r/t secondary/monetary gain

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Writing a Risk Nursing Diagnosis

Potential problem No supporting evidence because the problem

does not currently exist

List all factors that place client at risk

Examples:

Cancer patient, Risk for Infection

Risk Factors (R/T): inadequate secondary defenses,

immunosuppression Client with surgical incision, Risk for Infection

Risk Factors (R/T): inadequate primary defenses,

invasive procedure © 2001 Delmar Thomson Learning

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© 2001 Delmar Thomson Learning

Risk Nursing Diagnoses

Examples: Client who is semi-conscious, vomiting, Risk for

Aspiration Risk Factors (R/T): reduced level of consciousness,

vomiting

Neonate unable to maintain his bodytemperature, parent does not keep the child

covered, Risk for Hypothermia Risk Factors (R/T): extremes of age, inadequate

clothing

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Wellness Nursing Diagnosis

Indication of desire to attain higher levelof wellness

Examples: Nutrition, Readiness for Enhanced

Parenting, Readiness for Enhanced

Therapeutic Regimen Management, Effective


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The Planning Step

ANA Standard 3

Outcome identification: The nurse identifies expected outcomes for a plan individualized

to the patient or situation.

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THE NURSING PROCESS

PLANNING/OUTCOME DENTIFICATION

Planning:

Establish proposed course of nursing action in theresolution of nursing dx & development of the client’s

plan of care.

This step occurs after the nursing dx has beendeveloped and the client’s strengths have been

identified.

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Maslow’s Hierarchy of Needs

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Setting Priorities for Client Care

Kalish expanded Maslow’s hierarchy, resulting

in a more comprehensive description of thespecific need categories.

Failure to meet human needs at any level candramatically interfere with a client’s overall

progress.

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Kalish’s Expanded Hierarchy

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Setting Priorities for Client Care

Need to determine the priorities of care

Can rank client care needs based on a systemthat helps identify basic to higher level

actions/interventions.

By ranking client’s needs, you can proceed in

a logical way to facilitate their recovery.

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Establishing Client Goals

Once you have prioritized client needs,establish the goals for treatment/discharge.

Goals: Broad guidelines indicating the overalldirection for movement as a result of theinterventions of the healthcare team

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Establishing Client Goals

Long-Term Goals: Those goals that may notbe achieved before

discharge from care butmay require continuedattention by the clientand/or others

Short-Term Goals: Those goals that usuallymust be met beforedischarge or movementto a less acute level ofcare

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Identifying Desired Outcomes

The next step is to determine specificoutcomes -

Outcomes: Measurable steps to achievethe goals of treatment and to meetdischarge criteria; the results of actions

undertaken to achieve a broader goal

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S.M.A.R.T. GOALS

S - Specific behavior

M - Measurement criteria

A - Attainable

R - Realistic

T - Time oriented/target dates

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Subject

The client

Identifies the person who willperform the desired behavior.

Goals are client-centered!


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Behavior

What the client will do

Can be seen, felt, heard, or measured

Examples: Will verbalize

Will ambulate

Will report Will eat

Will demonstrate


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Criteria of Performance

Level of behavior May include a time limit or description

How far, how long, how much

Examples: Understanding of medication regime

Length of the hall

Decrease in pain level of four or less Seventy-five percent of meal

Decreased BP within 48 hrs


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Condition(s)

Aid which facilitates performance

May clarify

Examples: With the assistance of physical therapy

With the administration of analgesics

With assistance of family

With use of medication and diet therapy


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Time Frame

Important!

When accomplished

Examples:

Within forty-eight hours

By 3 rd postoperative day

Within forty-five minutes

In twenty-four hours

Within 3 weeks of medication therapy


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Goal Application

Client (subject )

will ambulate (behavior )

assisted by physical therapy (PT) tonurse’s station and return to room twice

(criteria of performance )

daily (time frame ).


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Goal Application

Mr. Johnson (subject )

will verbalize (behavior )

understanding of medication regime (criteria

of performance )

prior to discharge (time frame ).


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THE NURSING PROCESS

NURSING DX, GOALS, OUTCOMES

Nursing Dx - Impaired urinary elimination R/T urinarytract infection AEB frequency and dysuria

Goal - Client will have improved urinary eliminationwithin 3 days of beginning antibiotics.

Expected Outcomes1. Client will take antibiotic as ordered2. By next visit, client will identify 3 actions to prevent

a UTI.

3. In 2 days, client will have a plan to increase waterintake.

Now develop nursing interventions! Actions that assist the client to achieve

goals/outcomes.

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The Implementation Step

ANA Standard 5

Implementation: The nurse implements the identified plan

THE NURSING PROCESS

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THE NURSING PROCESS

IMPLEMENTATION

Implementation:

Execution of the nursing care plan developedduring the planning phase. The actualperformance of the nursing interventions thathave been planned to meet goal/outcomes.

Meeting needs of client

Use of various skills

Based on orders, standards, protocol,guidelines

Client education

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Selecting Appropriate Nursing Interventions

Nursing interventions:

Any direct care treatment that a nurse performson behalf of a client

Includes nurse- and physician-initiatedtreatments, and provision of essential dailyfunctions for the client who cannot do them

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Selecting Appropriate Nursing Interventions

Nursing interventions need to be based on:

The client’s nursing diagnosis

The established goals and desired outcomes The ability of the nurse to implement the

intervention successfully

The ability and willingness of the client toundergo the intervention

The appropriateness of the intervention

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Delivering Nursing Care

Interventions may be composed ofmany activities ranging from simple

tasks to complex procedures.

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Delivering Nursing Care

Before implementing interventions:

Understand the reason for doing theintervention, its expected effect, and potential

hazards.

Provide an environment conducive toimplementing the planned interventions.

Consider which interventions can becombined.

S i di i h diff

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Same nursing diagnoses with different etiologies may require different interventions.

Constipation

Related to: inactivity, insufficient fiber intake

Intervention: encourage daily activity to stimulate

bowel elimination

Constipation

• Related to: long-term laxative use

• Intervention: instruct client on adverse affects oflong-term laxative use


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Documentation

It is legally required that all healthcaresettings document nursing observations, thecare provided, and the client’s response.

Many agencies use flow sheets to documentroutine activities, monitoring, and ongoing

client care.

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The Evaluation Step

ANA Standard 6

Evaluation: The nurse evaluates progress toward attainment of outcomes

THE NURSING PROCESS

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THE NURSING PROCESS

EVALUATION

Evaluation:

The final step in the nursing process,determining whether established goals have

been met.This is an ongoing process which may involverevision of client goals.

Evaluation occurs with each step of the nursing

process

THE NURSING PROCESS

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THE NURSING PROCESS

EVALUATION

Document client responses to nursinginterventions

Evaluate effectiveness of interventions

Review the nursing care plan

Review client outcomes

Review, revise as needed

Goals met, not met, or ongoing (in progress)

R t

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Reassessment

When an outcome is not met completely, ask: Were the outcomes realistic and appropriate?

Was the client involved in setting the outcomes?

Does the client believe the outcomes were important?

Have all the identified interventions been carried out?

What variables may have affected achievement of theoutcomes?

Were new needs/adverse client responses detected earlyenough to make appropriate changes?

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Modification of the Plan of Care

When the client’s condition has changed in ananticipated or unanticipated direction:

A change in treatment approach is indicated

The plan of care must be modified to reflect thesechanges

When revising outcomes, remember that they may

simply need to be restated or have their time frameslengthened.

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Diagram of the Nursing Process

The steps of the nursing process are interrelated,forming a continuous circle of thought and action.

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Scenario One:

The nurse is caring for a client who was

involved in a motor vehicle accident and

sustained superficial skin trauma. The

client’s epidermal layer of skin on the right

knee, forearm, and hand is excoriated,

reddened, and bleeding as the result ofsliding across a cement pavement.


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Answer:

Impaired Skin Integrity

R/T: mechanical factors, shearing forces

AEB: disruption of skin surface,destruction of skin layers: traumatized skin which is excoriated, reddened, and bleeding


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Scenario Two:

A family member brings a young man into theED. He has been working outside in theextreme heat and humidity. He is unresponsive.His skin is red, hot, and dry. Assessment of theclient’s vital signs reveals: HR 106, BP 156/96,

RR 26, and temp 106°F.


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Answer:

Hyperthermia

R/T: heat exposure, decreased ability to perspire

AEB: increased body temperature above normal range, 106°F, flushed hot skin,increased heart rate (tachycardia), increased respiratory rate (tachypnea)


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Scenario Three

The client you are caring for has beenmedically diagnosed with a right cerebralvascular accident (stroke). He experiencespartial paralysis on the left side of his body.He is unable to turn over while in bed withoutassistance and has demonstrated decreasedmuscle strength and control in the left

extremities.


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Answer:

Impaired Physical Mobility

R/T: neuromuscular impairment

AEB: inability to purposefully move within the

environment; decreased muscle strength and control; left-sided partial paralysis


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Hands On Practice

Case study

Develop a care plan

Write at least 2 nursing dx for your client.

Must be written in NANDA format

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