Fundamentals of Nursing

Concepts, Process, and Practice

Kozier & Erb’s │9th Edition
Nursing Process
 A theory of how nurses organize the care of individuals, families and communities proposed by
Yura and Walsh in 1967.
 It originally started with the four-part process of Assessment, Planning, Implementation and
Evaluation.
 Currently, nursing process provides the framework in which nurses use their knowledge and
skills to express human caring and to help clients meet their health needs.
Characteristics of the Nursing Process:
1. It is systematic. 5. It is goal-oriented.
2. It is cyclic and dynamic rather than 6. It is universally applicable- can be used
static. with clients of any age at any point of
3. It is client-centered- nurse organizes the wellness-illness continuum; useful
plan of care according to client problems in a variety of settings.
rather than nursing goals. 7. It is an adaptation of problem-solving
4. It is interpersonal and collaborative- techniques and systems theory- based
depends on open and meaningful on the scientific method.
communications between the client and 8. It can be viewed as parallel to but
the nurse. separate from the medical process.
Four Core Competencies Essential to Nursing Practice
1. Cognitive Competencies
-enable nurses to reason and offer a scientific rationale for each element in a client’s plan of care;
select interventions that are most likely to yield outcome and use critical- thinking to solve
problems
2. Technical Competencies
-involve everything from manual dexterity and good hand-eye coordination to an ability to
troubleshoot when equipment malfunctions; enables nurses to manipulate equipment skillfully;
psychomotor skills.
3. Interpersonal Competencies
-enable nurses to establish and maintain caring relationships that facilitate the achievement or
valued goals while simultaneously affirming the worth of the participants in the relationship:
includes communication skills.
4. Ethical/legal Competencies
-enable nurses to conduct themselves in a manner that is consistent with their personal moral
code and professional role responsibilities; includes accountability and patient advocacy.
 ASSESSMENT
 Assessing is collecting, organizing,
validating and recording data about a
client’s health status.
Methods
1. Observing- gather data using the five
senses.
2. Interviewing- planned communication or
a conversation with a purpose.
 Directive interview- highly
structured and elicits specific
information.
 Nondirective interview – or
rapport building interview where
the nurse allows the client to
control the purpose, subject matter
and pacing of the conversation.
3. Examining- or physical examination that
uses observational skills to detect health
problems.
Types of Data
I. Subjective data- referred to as
symptoms or covert data
II. Objective data, also referred to as
signs or overt data.
Sources of Data
I. Primary source- client itself
II. Secondary source- family members
or other support persons and patient’s
record
III. Tertiary source- health professionals,
records and reports, laboratory and
diagnostic analyses
Organizing Data
 The nurse uses a written (or electronic)
format that organizes the assessment data
systematically.
 This is often referred to as a nursing health
history, nursing assessment, or nursing
database form.
Validating Data
 Validation is the act of ―double-checking‖ or
verifying data to confirm that it is accurate
and factual.
 The information gathered during the
assessment phase must be complete,
factual, and accurate because the nursing
diagnoses and interventions are based on
this information.
Collecting Data
 the nurse records client data. Accurate
documentation is essential and should
include all data collected about the client’s
health status.
 Data are recorded in a factual manner and
not interpreted by the nurse.
Goal
 Establish a database about the client’s
response to health concerns or illness.
Types of Assessment
Initial assessment
 performed within specified time period
 establishes complete database
Problem focused
 Ongoing process integrated with care
 Determines states of a specific problems
Emergency assessment
 Performed during physiologic or
psychological crises
 Identifies life-threatening problems
 Identifies new or overlooked problems
Time lapsed
 Occurs several month after th initial
assessment
 Compares current status to baseline
 DIAGNOSIS
 The term diagnosing refers to the reasoning process, whereas the term diagnosis is a
statement or conclusion regarding the nature of a phenomenon.
 The standardized NANDA names for the diagnoses are called diagnostic labels; and the
client’s problem statement, consisting of the diagnostic label plus etiology (causal relationship
between a problem and its related or risk factors), is called a nursing diagnosis.
Types of Nursing Diagnosis
1. Actual diagnosis-is a client problem that is present at the time of the nursing assessment.
2. Health promotion diagnosis- relates to clients’ preparedness to implement behaviors to
improve their health condition.
3. Risk nursing diagnosis is a clinical judgment that a problem does not exist, but the
presence of risk factors indicates that a problem is likely to develop unless nurses intervene.
4. Wellness diagnosis ―describes human responses to levels of wellness in an individual, family
or community.‖
Components of Nursing Diagnosis
A nursing diagnosis has three components: (1) the problem and its definition, (2) the etiology,
and (3) the defining characteristics. Each component serves a specific purpose.
 Problem (Diagnostic Label) and Definition
- describes the client’s health problem or response for which nursing therapy is given.
- It describes the client’s health status clearly and concisely in a few words.
- The purpose of the diagnostic label is to direct the formation of client goals and desired
outcomes.
- It may also suggest some nursing interventions.
 Etiology (Related Factors and Risk Factors)
- identifies one or more probable causes of the health problem, gives direction to the
required nursing therapy, and enables the nurse to individualize the client’s care.
 Defining Characteristics
- cluster of signs and symptoms that indicate the presence of a particular diagnostic label.
- For actual nursing diagnoses, the defining characteristics are the client’s signs and
symptoms. For risk nursing diagnoses, no subjective and objective signs are present.
- Thus, the factors that cause the client to be more vulnerable to the problem form the
etiology of a risk nursing diagnosis.
Formulating Diagnostic Statements
 Basic Two-Part Statements includes the following:
1. Problem (P): statement of the client’s response (NANDA label)
2. Etiology (E): factors contributing to or probable causes of the responses.
 Basic Three-Part Statements
- nursing diagnosis statement is called the PES format and includes the following:
1. Problem (P): statement of the client’s response (NANDA label)
2. Etiology (E): factors contributing to or probable causes of the response
3. Signs and symptoms (S): defining characteristics manifested by the client.
 PLANNING
 Planning is a deliberative, systematic phase of the nursing process that involves decision
making and problem solving.
 In planning, the nurse refers to the client’s assessment data and diagnostic statements for
direction in formulating client goals and designing the nursing interventions required to
prevent, reduce, or eliminate the client’s health problems.
Types of Planning
1. Initial Planning-nurse who performs the admission assessment usually develops the initial
comprehensive plan of care.
2. Ongoing Planning- done by all nurses who work with the client.
3. Discharge Planning- process of anticipating and planning for needs after discharge, is a
crucial part of a comprehensive health care and should be addressed in each client’s care plan.
Developing Nursing Care Plans
The end product of the planning phase of the nursing process is a formal or informal plan of care.
 Informal nursing care plan is a strategy for action that exists in the nurse’s mind.
 Formal nursing care plan is a written or computerized guide that organizes information
about the client’s care. The most obvious benefit of a formal written care plan is that it provides
for continuity of care.
 Standardized care plan is a formal plan that specifies the nursing care for groups of clients
with common needs.
 Individualized care plan is tailored to meet the unique needs of a specific client—needs that
are not addressed by the standardized plan. It is important for all caregivers to work toward
the same outcomes and, if available, use approaches shown to be effective with a particular
client.
Guidelines for Writing Nursing Care Plans
1. Date and sign the plan.
2. Use category headings.
3. Use standardized/approved medical or English symbols and key words rather than complete
sentences to communicate your ideas unless the agency policy dictates otherwise.
4. Be specific.
5. Refer to procedure books or other sources of information rather than including all the steps on a
written plan.
6. Tailor the plan to the unique characteristics of the client by ensuring that the client’s choices, such
as preferences about the times of care and the methods used, are included.
7. Ensure that the nursing plan incorporates preventive and health maintenance aspects as well as
restorative ones.
8. Ensure that the plan contains ongoing assessment of the client.
9. Include plans for the client’s discharge and home care needs.
Activities in the Planning Process
1. Setting priorities
2. Establishing client goals/desired outcomes
3. Selecting nursing interventions and activities
4. Writing individualized nursing interventions on care plans.
Setting Priorities
Priority setting is the process of establishing a preferential sequence for addressing nursing diagnoses
and interventions.
Priorities change as the client’s responses, problems, and therapies change. The nurse must consider a
variety of factors when assigning priorities, including the following:
1. Client’s health values and beliefs.
2. Client’s priorities
3. Resources available to the nurse and client
4. Urgency of the health problem
5. Medical treatment plan
Purpose of Desired Goals
1. Provide direction for planning nursing interventions.
2. Serve as criteria for evaluating client progress.
3. Enable the client and nurse to determine when the problem has been resolved.
4. Help motivate the client and nurse by providing a sense of achievement.
Types of Nursing Interventions
 Independent interventions
-are those activities that nurses are licensed to initiate on the basis of their knowledge and
skills. They include physical care, ongoing assessment, emotional support and comfort,
teaching, counseling, environmental management, and making referrals to other health care
professionals.
 Dependent interventions
-are activities carried out under the orders or supervision of a licensed physician or other
health care provider authorized to write orders to nurses
 Collaborative interventions
-are actions the nurse carries out in collaboration with other health team members, such as
physical therapists, social workers, dietitians, and primary care providers.

SMART GOAL
S-pecific
M-easurable
A-ttainable
R-ealistic
T-ime bound
 IMPLEMENTATION
 Implementing is the action phase in which the nurse performs the nursing interventions.
 Using Nursing Interventions Classification (NIC) terminology, implementing consists of doing
and documenting the activities that are the specific nursing actions needed to carry out the
interventions.
Relationship of Implementing to Other Nursing Process Phases
The first three nursing process phases—assessing, diagnosing, and planning—provide the basis
for the nursing actions performed during the implementing step. In turn, the implementing phase
provides the actual nursing activities and client responses that are examined in the final phase, the
evaluating phase.
Implementing Skills
To implement the care plan successfully, nurses need cognitive, interpersonal, and technical skills.
These skills are distinct from one another; in practice, however, nurses use them in various
combinations and with different emphasis, depending on the activity.
 Cognitive skills (intellectual skills) include problem solving, decision making, critical
thinking, and creativity.
 Interpersonal skills are all of the activities, verbal and nonverbal, people use when
interacting directly with one another.
 Technical skills are purposeful ―hands-on‖ skills such as manipulating equipment, giving
injections, bandaging, moving, lifting, and repositioning clients.
Process of Implementing
The process of implementing normally includes the following:
1. Reassessing the client
2. Determining the nurse’s need for assistance
3. Implementing the nursing interventions
4. Supervising the delegated care
5. Documenting nursing activities.
Guidelines for Implementing nursing strategies:
1. Base nursing interventions on scientific knowledge, nursing research, and professional
standards of care (evidence-based practice) when these exist.
2. Clearly understand the interventions to be implemented and question any that are not
understood.
3. Adapt activities to the individual client.Aclient’s beliefs, values, age, health status, and
environment are factors that can affect the success of a nursing action.
4. Implement safe care.
5. Provide teaching, support, and comfort.
6. Be holistic.
7. Respect the dignity of the client and enhance the client’s self-esteem.
8. Encourage clients to participate actively in implementing the nursing interventions.
 EVALUATION
 Evaluating is a planned, ongoing, purposeful activity in which clients and health care
professionals determine (a) the client’s progress toward achievement of goals/outcomes and
(b) the effectiveness of the nursing care plan.
 Evaluation is an important aspect of the nursing process because conclusions drawn from the
evaluation determine whether the nursing interventions should be terminated, continued, or
changed.
 Evaluation is continuous.
 Evaluation done while or immediately after implementing a nursing order enables the nurse to
make on-the-spot modifications in an intervention.
 Through evaluating, nurses demonstrate responsibility and accountability for their actions,
indicate interest in the results of the nursing activities, and demonstrate a desire not to
perpetuate ineffective actions but to adopt more effective ones.
Relationship of Evaluating to Other Nursing Process Phases
Successful evaluation depends on the effectiveness of the steps that precede it. Assessment data must
be accurate and complete so that the nurse can formulate appropriate nursing diagnoses and desired
outcomes. The desired outcomes must be stated concretely in behavioral terms if they are to be useful
for evaluating client responses. Finally, without the implementing phase in which the plan is put into
action, there would be nothing to evaluate.
The evaluation phase has five components
1. Collecting data related to the desired outcomes (NOC indicators)
2. Comparing the data with desired outcomes
3. Relating nursing activities to outcomes
4. Drawing conclusions about problem status
5. Continuing, modifying, or terminating the nursing care plan.
Collecting Data
Using the clearly stated, precise, and measurable desired outcomes as a guide, the nurse
collects data so that conclusions can be drawn about whether goals have been met. It is usually
necessary to collect both objective and subjective data.
Comparing Data with Desired Outcomes
If the first two parts of the evaluating process have been carried out effectively, it is relatively
simple to determine whether a desired outcome has been met.
Three Possible Conclusions
1. Goal met- client response is the same as expected outcome.
2. Goal partially met- either a short term goal was achieved but the long term goal was not or
the expected outcome was only partially attained.
3. Goal not met
 An evaluation statement consists of two parts: a conclusion and supporting data. The
conclusion is a statement that the goal/desired outcome was met, partially met, or not met.