The Nursing Process Benefits of using the nursing process

 Continuity of care
 Prevention of duplication
 Individualized care
 Standards of care
 Increased client participation
 Collaboration of care
Being Accountable
 Using critical thinking before taking
actions
 Being responsible for your actions
 An organizational framework for the
practice of nursing  Entering the professional role
 Orderly, systematic  Working at the level of your peers
 Central to all nursing care  Using the nursing process
 Encompasses all steps taken by the Something to think about:
nurse in caring for a patient
 Nurses are responsible for a unique
Definition of the Nursing Process dimension of healthcare – “ the
diagnosis and treatment of human
 Assessment
responses to actual or potential health
 Nursing Diagnosis problems”
 Planning MARTHA ROGERS, NURSE THEORIST
 Implementation  “When an apple is cut, others see seeds
in the apple. We, as nurses, see apples
 Evaluation
in the seeds.”
Characteristics of the Nursing Process
ASSESSMENT
 Within the legal scope of nursing
 Observation
 Based on knowledge-requiring critical
 Interview
thinking
 Types of questions
 Planned-organized and systematic
 Environment (physical and
 Client-centered
emotional) Spiritual
 Goal-directed considerations

 Prioritized  Examination

 Dynamic
Types of Data To Collect:  Double check equipment
 Objective data-observable and  Check with experts and team members
measurable facts (Signs)
 Recheck out-liers
 Subjective data-information that only the
 Compare objective and subjective data
client feels and can describe
(Symptoms)  Clarify statements
ASSESSMENT Nursing Diagnosis
1. Health History 1. General Diagnoses
a. Elicit a description of symptoms Pain
including onset, duration, and location
and precipitating factors if known. Anxiety
Cardinal signs and symptoms. Knowledge Deficit
- Antepartum- nausea & vomiting 2. Complication-specific diagnoses
- Intrapartum- decreased fetal movement Fluid volume deficit
- Postpartum Activity intolerance
b. Explore personal and family history of Altered tissue perfusion
Risk factors- age, nutrition, ob hx, DM, Planning
2. Physical Examination  Establish the goals, interventions and
a. Vital Signs-BP, Temp, PR, RR, wt. outcomes

b. Inspection- vaginal bleeding. Example:

BOW, edema, size/shape of uterus etc. The client and family will understand the
complication and treatment regimen.
c. Palpation- uterus, cervix to detect
General Guidelines for Setting Priorities
Preterm cervical dilation
1. Take care of immediate life-threatening
3. Laboratory Studies and Diagnostic tests issues.
 CBC 2. Safety issues.
 Pregnancy test
3. Patient-identified issues.
 Serum alpha-fetoprotein measurement
 Ultrasound 4. Nurse-identified priorities based on the
 Blood Glucose overall picture, the patient as a whole
 Amniocentesis person, and availability of time and
 Cultures resources.

Verifying Data Nurse Identified Priorities

 Essential in critical thinking!!!!!  Composite of all patient’s strengths and

health concerns.
 Measurable data
 Moral and ethical issues.
 Double check personal observations
 Time, resources, and setting.
  Hierarchy of needs.
 Interdisciplinary planning.
DIAGNOSIS
 Sort, cluster, analyze information
 Identify potential problems and strengths
 Write statement of problem or strength
 Risk of infection related to compromised
nutrition
 Potential for effective breastfeeding
related to knowledge level and support
system
 Prioritize the problems
 Not a medical diagnosis
Interventions
 Direct interventions: actions
performed through interaction
with clients.
 Indirect interventions: actions
performed away from the client,
on behalf of a client or group of
clients.
1. Ensure that appropriate physical
needs are addressed and monitor
2. Address emotional and
psychological needs
3. Provide client and family teaching
4. Promote compliance
Documenting the Plan of Care
 To ensure continuity of care, the plan
must be written and shared with all
health care personnel caring for the
client.
 Consists of:
1. Prioritized nursing diagnostic
statements.
2. Outcomes.
3. Interventions.
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
 Use patient’s own words in subjective
data – enclose in “ ___” (quotation
marks)
 Avoid generalizations – be specific
 Don’t make summative statements –
describe - e.g. patient is being cranky
should be patient resists instruction or
patient states “Don’t talk to me, I don’t
care about that”
Evaluation
1. Determining outcome achievement
2. Identifying the variables affecting
outcome achievement
3. Deciding whether to continue, modify, or
terminate the plan
1. The client and family understand the
complication and treatment regimen.
Evaluation
 The way nurses determine whether a
client has reached a goal.
 It is the analysis of the client’s response,
evaluation helps to determine the
effectiveness of nursing care.