NURSING

NURSING PROCESS
PROCESS
 nursing process – a systematic problem solving approach toward providing individualized nursing care.
 NANDA-I – North American Nursing Diagnosis Association International
 CHARACTERISTICS OF THE NURSING PROCESS
1. Framework for care to individuals, families, & communities
2. Orderly & systematic
3. Interdependent
4. Provides specific care for the individuals, family, & community
5. Client centered
6. Appropriate for use throughout lifespan
7. Used in ALL settings
 steps of the nursing process?
 ADPIE
 Assessment – Collect data; Organize data; Validate data; Document data
 Diagnosis – Analyze data; Identify health problems, risks, and strengths; Formulate
diagnostic statements
 Planning – Prioritize problems/diagnoses; Formulate goals/desired outcomes; Select Nursing
Interventions; Write nursing interventions
 Implementation – Reassess the client; Determine the nurse's need for assistance; Implement
the nursing interventions; Supervise delegated care; Document nursing activities
 Evaluation – Collect data related to outcomes; Compare data with outcomes; Relate nursing
actions to client goals/outcomes; Draw conclusions about problem status; Continue, modify,
or terminate the client's care plan
 How does the nurse obtain assessment info?
 Initial (or admission assessment)
 Focused assessment – Collects data about a problem that has already been identified. This type of
assessment determines whether the problem still exists, or any changes.
 Emergency assessment – Performed to identify a life‐threatening problem (choking, stab wound, heart
attack).
 How does the nurse obtain assessment info?
 past medical hx

BYMR
  family hx
 reason for admission
 current meds
 previous hospitalizations & surgeries
 psychosocial assessment
 nutrition - complete physical assessment
 DATA COLLECTION
 subjective data – Information verbalized or stated by the client. (symptoms)
 objective data – Observable and measurable information. Remember to include your senses: smell,
hearing, touch and sight. (signs)
 sign – An objective finding perceived by the examiner ex. (fever, rash, etc.)
 symptom – Subjective findings verbalized or stated by the client ex. ("I have a headache" " I feel sick
in my stomach.")
 2 SOURCES OF DATA
o PRIMARY – Information obtained from the patient (only)
o SECONDARY – Family members; Significant others; Past & current health records, laboratory tests,
diagnostic procedures, consultations from other healthcare professionals.
 COLLECT THE DATA THEN BLANK THE DATA
 VALIDATE – Confirm and verify the information. Keep it free from errors, bias, or misinterpretation.
 CLUSTERING – clustering of data often contains defining characteristics which are specific assessment
findings that support nursing diagnosis.
 During the clustering of data what is used critical thinking is used to analyze and synthesize the
information that is collected. The data is then put into specific clusters that describe a specific client
problem.
 IDENTIFY HOW YOU DEVELOP A NURSING DIAGNOSIS (WHAT IS FIRST / NEXT ETC)
1. Complete thorough assessment of the patient.
2. Highlight or underline relevant symptoms (defining characteristics).
3. Make a list of symptoms.
4. Cluster and interpret the symptoms.
5. Analyze and interpret the symptoms.
6. Select a nursing diagnosis based on the definition found in the nursing diagnosis manual by Doenges,
Moorhouse and Murr.

BYMR
 7. Remember to prioritize the identified problems.
 A medical diagnosis describes a disease process. A nursing diagnosis describes an individual, family or

group response to an actual or potential problem.

 MEDICAL DX – Identification of a disease condition based on specific findings such as diagnostic tests
and procedures. Remains the same as long as the disease is present.
 NURSING DX – Clinical judgment in response to actual or potential health problems. Provides a basis for
providing nursing care through various interventions to achieve outcomes. Changes possibly from day
to day as the patient's response changes

 4 types of NANDA-I dx
 ACTUAL DIAGNOSIS – Represents a problem that has been validated by the presence of defining
characteristics (signs and symptoms).
 RISK DIAGNOSIS – Is defined by NANDA‐I , "describes human responses to health conditions/life
processes that may develop in a vulnerable individual, family, or community. It is supported by risk
factors that contribute to increased vulnerability" (NANDA, 2007). Ex. infection after surgery
 HEALTH PROMOTION DIAGNOSIS – Clinical judgment of a person, family, or community desire to
enhance their well being and readiness to implement health behaviors of a higher level. Ex.
nutrition
 WELLNESS DIAGNOSIS – Describes the human responses to levels of wellness in an individual, family
or community that have readiness to enhance well being. Ex.Coping, readiness of enhanced related
to successful cancer treatment.
 A nursing diagnosis consists of 3 parts or what is referred to PES format:
 P= Problem
 E =Etiology
 S =Signs and Symptoms
 PROBLEM – to identify the health status or problem of the individual using the approved NANDA - I list.
Ex.Pain, acute
 ETIOLOGY – the cause ; Identifies the physiologic, psychological, sociologic, spiritual, or environmental
factors assumed to be the cause of the problem or a contributing factor.
o The etiology is linked to the problem with the phrase "related to" ; The etiology cannot be related
to a medical diagnosis.
 SIGNS & SYMPTOMS – Identified as subjective and/or objective data that supports the problem.
o Identified by the nurse from the clustering of significant data including assessment findings.

BYMR
 o Signs & symptoms are linked to the etiology by the phrase "as evidenced by"
 How do you formulate a risk dx? What does a risk dx consist of? Consist of a problem and
the etiology only – there are NO signs & sypmtoms because it hasn't happened yet.

 PLANNING PHASE OF THE NURSING PROCESS

 Develop a plan of care. This is accomplished by developing client centered goal and expected
outcomes.
 Use critical thinking to develop nursing interventions to resolve the client's problem and achieve the
goals.

 goal
 "A broad statement that describes the desired change in a client's condition or behavior."
 Components of a correctly written goal include expected outcomes or measurable criteria to evaluate
the achievement of the goal.
o SHORT TERM GOAL – An objective behavior or response you expect the client to achieve in a
short period of time usually less than one week.
o LONG TERM GOAL – An objective behavior or response you expect the client to achieve in a
longer period of time possibly over several days, weeks, or months.

 expected outcome
 An outcome is a measurable change in the client's status that you expect to occur related to the
implemented care.
 Guidelines to remember when writing goals
 CLIENT CENTERED
 SINGULAR
 OBSERVABLE
 MEASURABLE
 TIME LIMITED
 MUTUAL
 REALISTIC

 NURSING INTERVENTIONS
 Are actions or treatments based on knowledge or judgment that the nurse performs to meet the
patient outcomes.
 3 TYPES OF NURSING INTERVENTIONS
o INDEPENDENT (example: positioning)

BYMR
 o DEPENDENT (example: med admin)
o COLLABORATIVE OR INTERDEPENDENT ( example: Oxygen Therapy)
 Frequent errors when writing nursing interventions
1. Failure to be precise or fully indicate the nursing action.
2. Failure to indicate frequency
3. Failure to indicate quantity
4. Failure to indicate method

 scientific rationale
 Is the reason for choosing the particular intervention based on supportive evidence from textbooks,
journals, and/or online nursing references (so we know why we are doing the task we are doing)

 IMPLEMENTATION PHASE
 This step begins after the care plan has been developed by the nurse. This is the step of the nursing
process where the nurse performs the interventions as a means of achieving the goals

 evaluation phase
 Evaluation is the final stage of the nursing process. You as the nurse determine if the patient has
achieved the expected outcomes not if the nursing interventions were completed.
 The evaluation phase has 5 components
1. Identifying criteria and standards.
2. Collecting data to determine if the criteria or standards are met.
3. Interpreting and summarizing findings.
4. Documenting findings and any clinical judgment.
5. Terminating, continuing or revising the care plan.

BYMR