THE NURSING PROCESS

RNSG 1209 Fall 2010

The Nursing Profession:

Has defined what makes nursing unique
Has identified a body of professional

knowledge

The Nursing Profession

The American Nurses Association (1995)

identified four essential features of todays contemporary nursing practice...

1.

2.
3. 4.

Attention to the full range of human experiences Integration of objective data Application of scientific knowledge Provision of a caring relationship

The Nursing Profession

ANA (2003) also recognized the nurses role

as client advocate supporting the right of clients to:

Define their own health-related goals Engage in care reflecting client values

THE NURSING PROCESS

The nursing process is a systematic method of

planning and providing care to clients.

Orderly, logical; focus on problem-solving Incorporates an interactive/ interpersonal approach to decision-making

It is the basis for accurate, complete

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

THE NURSING PROCESS

Process - A series of steps or acts that lead to accomplishment of some goal or purpose. 3 Characteristics of the nursing process: Inherent Purpose Internal Organization Infinite Creativity

Diagram of the Nursing Process

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

THE NURSING PROCESS

What is the purpose? Provide Client Care
Individualized Holistic Effective Efficient

The Nursing Process Is An Applied Logical, Problem-Solving Approach To Providing Client Care.

THE NURSING PROCESS

5 Components of the Nursing Process
Assessment
Diagnosis / Analysis Planning & Outcome Identification Implementation Evaluation

The Nursing Process

STEP 1 Assessment the systematic collection of data relating to clients

The Nursing Process

STEP 2 Diagnosis the analysis of collected data to identify the clients needs or problems

The Nursing Process

STEP 3 Planning a two-part process of:

identifying goals and desired outcomes selecting appropriate nursing interventions

The Nursing Process

STEP 4 Implementation putting the plan of care into action

The Nursing Process

STEP 5 Evaluation determining the clients progress
monitoring the clients response

How the Nursing Process Works

A process you routinely use to solve

problems
Applies readily to client-care situations

The Assessment Step

ANA Standard 1 Assessment: The nurse collects comprehensive data pertinent to clients health or situation.

THE NURSING PROCESS: ASSESSMENT

What is the purpose of nursing assessment? To establish a foundation of information regarding the clients physical, psychosocial, and emotional health in order to identify health promoting behaviors and actual/potential health problems.

Collect & organize information about the client.

THE NURSING PROCESS: ASSESSMENT Data Collection

Sources
Primary - client Secondary - family, lab, test, other health care providers, medical records. Subjective (symptoms) - clients point of view or perspective, their feelings & concerns.

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

THE NURSING PROCESS: ASSESSMENT

Assessments are: Comprehensive Focused Ongoing

Data must be: Validated Organized Interpreted Documented

The Diagnosis Step

ANA Standard 2 Diagnosis: The nurse analyzes the assessment data to determine the diagnoses or issues.

THE NURSING PROCESS: DIAGNOSIS

Diagnosis:
The 2nd step in the nursing process involves further analysis & synthesis of the data that has been collected. 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.

Defining Nursing Diagnosis

NANDAs Definition
Nursing diagnosis is a clinical judgment about

individual, family, or community responses to actual and potential health problems/life processes.
Nursing diagnoses provide the basis for

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

The Use of Nursing Diagnoses

Benefits of the nursing diagnosis
1. 2. 3. 4. 5.

Gives nurses a common language Promotes identification of appropriate goals Provides acuity information Can create a standard for nursing practice Provides a quality improvement base

Medical vs. Nursing Diagnoses

Medical diagnoses

illnesses/conditions; reflect alteration of the structure or function of organs or systems; verified by medical diagnostic studies
Nursing diagnoses

address human responses to actual and potential health problems/life processes

THE NURSING PROCESS DIAGNOSES

Examples of Approved NANDA DX
Decreased Cardiac Output Ineffective Airway Clearance Constipation Fluid Volume Deficient

Impaired Mobility

THE NURSING PROCESS DIAGNOSIS

3 Types of Nursing Diagnosis

Actual Risk

Wellness

Writing an Actual Diagnostic Statement

PES format The Problem (need), Etiology, and Signs and symptoms (or risk factors) are combined into a neutral statement that avoids value-laden or judgmental language.

Writing an Actual Diagnostic Statement

The problem (need) and etiology sections of

the diagnostic statement are joined by the phrase related to.

Acute Pain r/t abdominal surgical incision

AEB pain scale rating 7/10; guarding abdomen with movement; moaning with movement

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.

Writing a Client Diagnostic Statement

Common Errors:
Using the medical diagnosis:

Self Care deficit r/t stroke

Relating the problem to an unchangeable

situation: Risk for injury r/t blindness

Writing a Client Diagnostic Statement

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

Writing a Client Diagnostic Statement

Common Errors:
Lack of specificity:

Constipation r/t nutritional intake

Combining two nursing diagnoses:

Anxiety and Fear r/t separation from parents

Writing a Client Diagnostic Statement

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

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

Client with surgical incision, Risk for Infection

invasive procedure
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 body temperature, parent does not keep the child covered, Risk for Hypothermia
Risk Factors (R/T): extremes of age, inadequate clothing
2001 Delmar Thomson Learning

Wellness Nursing Diagnosis

Indication of desire to attain higher level

of wellness
Examples:

Nutrition, Readiness for Enhanced

Parenting, Readiness for Enhanced Therapeutic Regimen Management, Effective

2001 Delmar Thomson Learning

The Planning Step

ANA Standard 3 Outcome identification: The nurse identifies expected outcomes for a plan individualized to the patient or situation.

THE NURSING PROCESS PLANNING/OUTCOME DENTIFICATION Planning:

Establish proposed course of nursing action in the

resolution of nursing dx & development of the clients plan of care.

This step occurs after the nursing dx has been

developed and the clients strengths have been identified.

Maslows Hierarchy of Needs

Setting Priorities for Client Care

Kalish expanded Maslows hierarchy, resulting

in a more comprehensive description of the specific need categories.

Failure to meet human needs at any level can

dramatically interfere with a clients overall progress.

Kalishs Expanded Hierarchy

Setting Priorities for Client Care

Need to determine the priorities of care

Can rank client care needs based on a system that helps identify basic to higher level actions/interventions.

By ranking clients needs, you can proceed in

a logical way to facilitate their recovery.

Establishing Client Goals

Once you have prioritized client needs,

establish the goals for treatment/discharge.

Goals:

Broad guidelines indicating the overall direction for movement as a result of the interventions of the healthcare team

Establishing Client Goals

Short-Term Goals:

Those goals that usually must be met before discharge or movement to a less acute level of care

Long-Term Goals:

Those goals that may not be achieved before discharge from care but may require continued attention by the client and/or others

Identifying Desired Outcomes

The next step is to determine specific outcomes Outcomes: Measurable steps to achieve

the goals of treatment and to meet discharge criteria; the results of actions undertaken to achieve a broader goal

S.M.A.R.T. GOALS
S - Specific behavior M - Measurement criteria

A - Attainable
R - Realistic T - Time oriented/target dates

Subject
The client
Identifies the person who will perform 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
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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Examples:

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 3rd postoperative day Within forty-five minutes In twenty-four hours Within 3 weeks of medication therapy
2001 Delmar Thomson Learning

Goal Application
Client (subject) will ambulate (behavior) assisted by physical therapy (PT) to nurses station and return to room twice (criteria of performance) daily (time frame).

2001 Delmar Thomson Learning

Goal Application
Mr. Johnson (subject) will verbalize (behavior) understanding of medication regime (criteria of performance) prior to discharge (time frame).

2001 Delmar Thomson Learning

THE NURSING PROCESS NURSING DX, GOALS, OUTCOMES

Nursing Dx - Impaired urinary elimination R/T urinary tract infection AEB frequency and dysuria Goal - Client will have improved urinary elimination within 3 days of beginning antibiotics.

Expected Outcomes 1. Client will take antibiotic as ordered 2. By next visit, client will identify 3 actions to prevent a UTI. 3. In 2 days, client will have a plan to increase water intake.
Now develop nursing interventions! Actions that assist the client to achieve goals/outcomes.

The Implementation Step

ANA Standard 5 Implementation: The nurse implements the identified plan

THE NURSING PROCESS IMPLEMENTATION

Implementation: Execution of the nursing care plan developed during the planning phase. The actual performance of the nursing interventions that have been planned to meet goal/outcomes.
Meeting needs of client Use of various skills Based on orders, standards, protocol,

guidelines Client education

Selecting Appropriate Nursing Interventions

Nursing interventions:

Any direct care treatment that a nurse performs on behalf of a client Includes nurse- and physician-initiated treatments, and provision of essential daily functions for the client who cannot do them

Selecting Appropriate Nursing Interventions

Nursing interventions need to be based on:
The clients 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 to

undergo the intervention

The appropriateness of the intervention

Delivering Nursing Care

Interventions may be composed of

many activities ranging from simple tasks to complex procedures.

Delivering Nursing Care

Before implementing interventions: Understand the reason for doing the intervention, its expected effect, and potential hazards.
Provide an environment conducive to

implementing the planned interventions.

Consider which interventions can be

combined.

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 of

long-term laxative use

2001 Delmar Thomson Learning

Documentation
It is legally required that all healthcare

settings document nursing observations, the care provided, and the clients response.
Many agencies use flow sheets to document

routine activities, monitoring, and ongoing client care.

The Evaluation Step

ANA Standard 6 Evaluation: The nurse evaluates progress toward attainment of outcomes

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 involve revision of client goals.

Evaluation occurs with each step of the nursing process

THE NURSING PROCESS EVALUATION

Document client responses to nursing

interventions
Evaluate effectiveness of interventions

Review the nursing care plan

Review client outcomes

Review, revise as needed

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

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 the

outcomes?
Were new needs/adverse client responses detected early

enough to make appropriate changes?

Modification of the Plan of Care

When the clients condition has changed in an anticipated or unanticipated direction:
A change in treatment approach is indicated

The plan of care must be modified to reflect these

changes
When revising outcomes, remember that they may

simply need to be restated or have their time frames lengthened.

Diagram of the Nursing Process

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

Scenario One:
The nurse is caring for a client who was involved in a motor vehicle accident and sustained superficial skin trauma. The clients epidermal layer of skin on the right knee, forearm, and hand is excoriated, reddened, and bleeding as the result of sliding across a cement pavement.
2001 Delmar Thomson Learning

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

2001 Delmar Thomson Learning

Scenario Two:
A family member brings a young man into the ED. He has been working outside in the extreme heat and humidity. He is unresponsive. His skin is red, hot, and dry. Assessment of the clients vital signs reveals: HR 106, BP 156/96, RR 26, and temp 106F.

2001 Delmar Thomson Learning

Answer:
Hyperthermia R/T: heat exposure, decreased ability to

perspire
AEB: increased body temperature above

normal range, 106F, flushed hot skin, increased heart rate (tachycardia), increased respiratory rate (tachypnea)

2001 Delmar Thomson Learning

Scenario Three
The client you are caring for has been medically diagnosed with a right cerebral vascular accident (stroke). He experiences partial paralysis on the left side of his body. He is unable to turn over while in bed without assistance and has demonstrated decreased muscle strength and control in the left extremities.

2001 Delmar Thomson Learning

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

2001 Delmar Thomson Learning

Hands On Practice
Case study
Develop a care plan Write at least 2 nursing dx for your client.

Must be written in NANDA format