Nursing Process
Jane R Bordner, RN, BSN
Nursing Instructor
HACC
N100
Spring 2014
Nursing
The Changing Face of Nursing
What Do Nurses Do?
Nursing process gives us a direct and
precise way to answer
 Nursing process = a problem solving
approach used to meet client needs

Nursing Process

Is an organized, systematic method of
giving individualized nursing care that
focuses on identifying and treating unique
responses of individuals or groups to an
actual or potential alteration in health.
Nursing Process continued…

Based on the fundamental belief that
every person is endowed with personal
worth and dignity, and has a right to high
quality care regardless of socioeconomic
status, cultural background, or religious
belief.
Purpose of Nursing Process
ID nursing-related client health care needs
 Establish a plan of care to meet needs
 Implement nursing interventions/actions
 Provide basis for ongoing evaluation

Nursing Process and Critical
Thinking
Critical thinking is very important in
nursing decision making
 Critical thinking is necessary to make
complex decisions involved in patient care
 Critical thinking answers the question:
who benefits and whose outcomes are
being met by my nursing actions?

Nursing Process and Critical
Thinking

Critical thinking : analyze assumptions,
challenge status quo, recognize
limitations, and take actions to improve it.
Steps in the Nursing Process
Step 1
Step 2
Step 3
Step 4
Step 5
Assessment
Nursing Diagnosis
Planning Care
Implementation
Evaluation
Use of Nursing Process

Family member illness
Assessment
 Diagnosis
 Planning
 Implementation
 Evaluation

Role of the LPN

Assessment
Assist in data collection

Nursing Diagnosis
Assist in choosing ND

Planning
Assist in formulating and
choosing interventions

Implementation

Evaluation
Carry out plan within scope of
practice
Assist in evaluation and
revision of plan of care
Step 1: Assessment


Thorough and holistic
Based on:




clinical and laboratory data
medical history
patient’s account of symptoms.
Requires:




data collection
data validation
data sorting
data documentation
Types of Data

Subjective Data/Signs


Client’s perceptions
What the client tells you.

Example: “I am in pain.” “I feel
nauseous.”

Objective
Data/Symptoms


Observations or
measurements
Things the nurse sees,
hears, and feels.

Example: Vital signs,
bowel sounds,
temperature of skin
Subjective vs. Objective Data
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
___ My leg pain is a throbbing pain
___ 2 seconds capillary refill
___ Lung sounds clear bilaterally
___ I have no allergies
___ I fell last night
___ Apical pulse 68 and regular
___ Patient moaning
___ Moderate yellow sputum
___ I am extremely tired
___ Skin warm and dry to touch
Shift Assessment
Organized
 Systematic
 Brief
 Accurate
 Order depends upon presenting S&S

Types of Assessments

Shift Assessment

Focused Assessment

Comprehensive Health Assessment
Focused Assessment
Detailed assessment of particular system
 Brief (2 to 5 minutes)
 “Quick check”
 ID changes in areas most likely to change
 Based on problems ID’d in shift assessment
or new problems that arise
 Find changes early and avoid complications

Example

Patient admitted with pneumonia. Though
the nurse asks questions and assesses all
systems, he/she will focus much more
attention on the respiratory system listening to breath sounds, asking about
shortness of air, cough, etc…
Example
Next shift, same patient,
 New nurse enters his room and he reports
abdominal pain. The nurse will briefly
assess all systems, but in addition to
focusing on the respiratory system, he/she
will also do a detailed assessment of the
GI system.

WHATSUP guide to Symptom
Assessment







W
H
A
T
S
U
P
Where is it?
How does it feel? Describe it?
Aggravating and alleviating factors?
Timing: When did it start? How long
does it last?
Severity on scale of 1 to 10
Useful other data. Other symptoms?
Patient’s perception of problem
Using WHATSUP
Mrs. Cooper, age 47, had a hysterectomy 2 weeks
ago. She is admitted with a right calf deep vein
thrombosis that she thinks resulted from having
surgery. She rated her pain, which began 2 days
ago and is constant, at 8. She has increased calf
tenderness with leg movement. Leg elevation and
Tylenol #3 increases her comfort. Her calf is hot
to touch and red. Her legs measure: R calf 9
inches; L calf 8 inches; R thigh 14 inches; L thigh
14 inches.
Comprehensive Health
Assessment
Assessment of all body systems and
detailed health history
 Provides baseline of client’s health status
and functional abilities at that time
 Helps nurse determine plan of action to
address client’s nursing needs
 Abnormal assessment findings signal
nurse to gather additional data in that area

Parts of Comprehensive Health
Assessment

Interview

Physical Exam


Complete shift assessment
Auxiliary Data
Components of Nursing Interview
Biographical Data
 Chief Complaint
 History of Present Illness
 Past Medical History
 Environmental History
 Psychosocial and Cultural History
 Review of Systems (ROS)

Important Interview Techniques
Introduce yourself
 Unhurried manner
 Good eye contact (if culturally appropriate)
 Silence/Listening skills/Clarifying
 Observation skills (Get objective data
during interview)
 Age and developmental considerations
 Continually work on developing therapeutic
relationship

What is Caring?
Responding
 Sensing emotions
 Acceptance
 Making a connection
 “Caring for the Whole Person”

Critical Thinking: Data Collection
Your neighbor, Mr. Lewis, age 76, knocks on
your door. He says “Look at my left foot. It
is very swollen. I wore new shoes
yesterday that felt tight. Now I can hardly
get any shoes on this foot. There is a
tender area on the top of my foot. I think
something is wrong. Can you help me?”
Sources of Data
 Client
 Family
members or significant others
 Other members of health care team
 Current and previous hospital records
 Diagnostic studies/Laboratory reports
Documentation of Data
ALL objective and subjective data must be
documented
 Only what was observed by or stated to
you
 Subjective data using direct quotes
 NOT DOCUMENTED, NOT DONE

Common Diagnostic Tests

Blood
CBC
Electrolytes
ABG’s
Blood Glucose

Urine
Urinalysis (UA)
Urine Culture and
sensitivity
Common Diagnostic Tests

Radiological
Exams
Chest X-ray
Upper GI
Lower GI
CT & MRI scans

Stool
Ova and Parasites
Clostridium difficile (C. diff)
Occult blood
Common Diagnostic Tests
 Sputum
Culture and
Sensitivity
Acid Fast Bacilli
Cytology
 Other
EKG or ECG
Stress Test
TB Test
Medications
Patient History
Laboratory Studies
Assessment Data
Step 2: Nursing Diagnosis
Standardized label that identifies client’s
problem
 Makes it understandable to all nurses
 Language of nurses
 Address actual or potential health
problems

Step 2: Nursing Diagnosis
ID’d by nurse after analyzing assessment
data and comparing it with what is
considered to be normal
 Abnormal findings are organized into data
clusters
 Nursing diagnoses are developed from
data cluster

Nursing, Medical, Collaborative
Diagnoses
Nursing diagnoses: problems which
can be treated independently by nurses
 Medical diagnoses: those that require
care that only a physician or nurse
practitioner can render
 Collaborative diagnoses: problems that
can be helped by both medical and
nursing interventions

Medical VS. Nursing Diagnoses

Medical
ID’s pathological
basis for illness
 Focuses on
physical condition
only
 Addresses actual
problems


Nursing
ID’s response to
illness
 Focuses on
physical,
psychosocial, and
spiritual needs
 Addresses actual
and potential
problems

Medical VS. Nursing Diagnoses

Medical
Not validated with
client
 Uses standardized
treatments and
goals
 May not be
resolvable


Nursing
Validated with
client
 Uses individualized
goals and
interventions
 Usually resolvable

Medical VS. Nursing Diagnosis
Client admitted with medical diagnosis of
congestive heart failure (CHF)
 Look up medical diagnosis in front of your
Nursing Diagnosis Handbook.
 Many potential nursing diagnosis based on
one medical problem
 Assessment data will reveal which may
best FIT YOUR client

Writing Nursing Diagnoses

Part 1
Nursing Diagnosis Label
related to (R/T)

Part 2
Etiology (cause)
as evidenced by (AEB)

Part 3
Signs and Symptoms
Example
Client has abdominal surgery this am.
Assessment data reveals that the client is
experiencing pain. It is rated by the patient
as 4 on a scale of 0 to 5. The patient is
also exhibiting facial grimacing and is
moaning.
 The nursing diagnosis related to this
assessment data is ACUTE PAIN.

Writing Nursing Diagnosis

Part 1
Acute pain
related to…

Part 2
actual tissue damage
from abdominal surgery
as evidences by…

Part 3
Patient stating “My
pain is 4 of 5.” Moaning/
facial grimacing
Part 1 of Statement
NANDA list of approved nursing diagnosis
labels
 Problems that nurses routinely address in
practice
 List in back of your Nursing Diagnosis
Handbook
 “I am so nauseated from my chemo
treatments that I cannot eat anything.”

Part 2 of Statement
Etiology or cause
 Statement follows nursing problem and
words “related to” = R/T
 Comes from your nursing knowledge and
assessment data
 Etiology is individualized for each client
 NO MEDICAL DIAGNOSIS
 “I am so nauseated from my chemo
treatments that I cannot eat anything.”

Part 3 of Statement
Defining characteristics
 Follows words “as evidenced by” = AEB
 List signs and symptoms obtained from
assessment
 S&S that supports your statement
 Use all relevant information

Objective
 Subjective


“I am so nauseated from my chemo
treatments that I cannot eat anything.”
Nursing Diagnosis
Nausea R/T
treatment/medications AEB
pt stating “I am so nauseated
from my chemo treatment that I
cannot eat anything”.
Nursing Diagnosis: Actual vs.
High Risk Problems
 Actual
 Existing
problem
 Client has S&S of
problem
 Requires 3 part
nursing diagnosis
statement
 High
Risk
 High
probability of
occurring in future
 There are no S&S
 Requires 2 part
nursing diagnosis
statement
High Risk Diagnosis

Assessment Data
Patient has been on bedrest for 1 week
 Patient is incontinent of urine
 Patient unable to move or turn self in bed
 Skin is clean and intact

High Risk Diagnosis
Risk of impaired skin integrity: Risk factors:
incontinence and physical immobility.
*Note: This is a risk problem because no skin
breakdown has occurred yet. You are going to
use your nursing skill to prevent skin
breakdown.
Nursing Diagnosis
Nursing Diagnosis Practice

Assessment Data
Patient states she is feeling “nervous and
anxious”.
 Her hand are shaking.
 Staff observes her crying.
 Progress notes state that her physician told
her earlier that her lung biopsy was positive
for cancer.

Nursing Diagnosis
Anxiety R/T
change in health status AEB
pt stating that she feels “anxious and fearful”
and episodes of crying and shakiness.
Nursing Diagnosis Practice

Assessment Data
92 year old female.
 Patient has weakness in all extremities.
 Fatigues rapidly with activity.
 Unable to perform ADL’s without becoming
fatigued.
 Frequently makes statements such as “I feel
so tired and weak”.

Nursing Diagnosis
Activity intolerance R/T
generalized weakness AEB
inability to perform ADL’s without fatigue and
stating “I feel so tired and weak”.
Nursing Diagnosis Practice

Assessment Data
82 year old male
 Past medical history of a stroke with left-sided
weakness and bilateral cataracts
 Walks with a walker
 Shuffling gait

Nursing Diagnosis
Risk for falls R/T
impaired vision/impaired mobility
Impaired physical mobility R/T
neuromuscular impairment AEB
left-sided weakness and using walker to
ambulate
Nursing Process Worksheet
READ and HIGHLITE abnormal data
 IDENTIFY objective vs. subjective data
 What does abnormal data tell us?
 What are some nursing diagnoses?

Nursing Diagnoses
What problems do you see here?
 Are they actual problems or high risk
problems?
 How would you write them?
 Look at NANDA list. What works for this
patient?

Nursing Diagnosis Worksheet

ACTIVITY PROBLEMS
1. Activity intolerance related to
____________ AEB
______________________________.
2. Sleep deprivation related to
____________ AEB
______________________________.
Nursing Diagnosis Worksheet
3. Fatigue related to
____________________ AEB
______________________________.
Nursing Diagnosis Worksheet
•
PAIN
1.
•
Chronic pain related to
_________________ AEB
______________________________.
NUTRITION
1.
Imbalanced nutrition: less than body
requirements related to
________________ AEB
_______________________________.
Nursing Diagnosis Worksheet
•
SAFETY
1.
•
Impaired skin integrity related to
_________________ ABE
_______________________________
____.
RISK PROBLEMS
1.
Risk for injury related to
______________________________.
Nursing Diagnosis Worksheet
•
OTHERS?
1.
Impaired physical mobility related to
_________________________ AEB
______________________________.
Nursing Process Summary
The nursing process is a problem solving
approach. Experienced nurses engage in
this type of thinking as a matter of routine.
 You need to learn how to think this way in
order to be a successful nurse.

Nursing Process Summary
Types of Assessments

Shift Assessment

Focused Assessment

Comprehensive Health Assessment
Shift Assessment
Involves a brief systemic review of client’s
condition at beginning of a shift
 Nurse compares assessment findings with
those from previous shift
 Takes 10 to 15 minutes

Preparation
ID client
 Privacy
 Keep client comfortable
 Body mechanics
 Lighting
 Quiet
 Equipment

Shift Assessment

Equipment Needed
Stethoscope
 BP cuff
 Thermometer
 Watch with a second hand
 Pen light
 Measuring Tape (maybe)

Cultural Sensitivity
Cultural differences influence a patient’s
behavior
 Recognition of cultural diversity helps to
respect the patient
 Consider a patient’s

Health beliefs
 Use of alternative therapies
 Nutritional habits
 Family relationships
 Use of personal space

Physical Assessment Includes
Inspection
 Palpation
 Percussion
 Auscultation

Inspection

The use of vision and hearing to
distinguish normal from abnormal findings
Use adequate lighting
 Position and expose body parts
 Inspect for size, shape, color, symmetry,
position, and abnormalities
 Side to side comparison
 Pay attention to detail

Palpation
Involves using the hands
 Examine accessible body parts
 Palpate skin



Temperature, moisture, texture, turgor,
tenderness, and thickness
Palpate abdomen

Tenderness, distention, or masses
Percussion
Tapping the body with fingertips to
produce a vibration
 Character of sound

Determines location, size, and density of
structures
 Depends on the density of tissues
 Abnormal sounds can be mass, air, or fluid

Auscultation
Listening to sounds produced by the body
 Assess sounds heard in the heart, lungs,
and gastrointestinal systems
 Requires the use of a stethoscope
 Characteristics include

Frequency
 Loudness
 Quality
 Duration

General Survey
Begins when you first meet a patient
 Begins with review of primary health
pattern
 The survey provides information regarding

Characteristic of illness
 Hygiene
 Skin condition
 Body image
 Emotional state
 Developmental status

General Appearance
and Behavior
Gender and Race
Age
Signs of Distress
Body Type
Posture
Gait
Body Movements
Hygiene and Grooming
Dress
Body Odor
Affect and Mood
Speech
Patient Abuse
Subculture Abuse
Shift Assessment Includes
Vital signs
 Integumentary
 Neurological
 Musculoskeletal
 Circulatory
 Respiratory
 Gastrointestinal
 Genitourinary
 Psychosocial

Skin
Assessment
 Nursing history

Color
 Moisture
 Temperature
 Texture
 Turgor
 Vascularity
 Edema
 Lesions

Nails
Inspection and palpation
 Condition of nails reflects

General health
 Nutritional status
 Occupations
 Level of self-care

Hair and Scalp
Use inspection
 Assess

Distribution
 Thickness
 Texture
 Lubrication

Neurological
 Mental
Status
 Orientation
 Speech
Neurological System
Conduct a nursing history
 Assess

Language
 Intellectual function
 Cranial nerve function
 Sensory nerve function
 Motor function

Head and Neck
Inspection and palpation
 Assess

Headache, dizziness, seizures, poor vision,
loss
of consciousness
 Head size, shape contour of head and skull
 Facial symmetry

Nose and Sinuses
Inspection and palpation
 Assess for exposure to

Dust
 Pollutants
 Allergies
 Nasal obstruction
 Trauma
 Discharge, postnasal drip
 Headaches

Mouth and Pharynx
Assesses overall health
 Determine oral hygiene needs
 Develop therapies for dehydration
 Assess oral trauma
 Assess for airway trauma

Oral Cavity
Neck
Neck muscles
 Lymph nodes
 Carotid arteries
 Jugular veins
 Thyroid gland
 Trachea

Eyes
Vision
Ears
Hearing
Circulatory
Core
Body Temperature
Skin
Color
Temperature
Turgor
Capillary Refill
Edema
Skin Integrity/Alterations
BP
APICAL PULSE
Peripheral Pulses
Radial
Pulses
80A/80R
IV’s
Peripheral
PICC
Mediport
Breasts
Examine both female and male breasts
 Take a health history
 Use inspection and palpation

Respiratory
 Respirations
 Cough
O2
nasal cannula
face mask
Lung
Sounds
RUL
RML
RLL
LUL
LLL
LUNG SOUNDS
Gastrointestinal
Nutrition
Diet
%
eaten
N&V
Ht.
& Wt.
Abdomen
LOOK, LISTEN, & FEEL
Right Upper Quadrant
RUQ
RLQ
Right Lower Quadrant
Left Upper Quadrant
LUQ
LLQ
Left Lower Quadrant
Bowels
 What
is “normal”?
 Ask about
 Frequency
 Color
 Consistency
 Amount
Genitourinary
 Urine
 Intake
and Output
 Perineal Area
Foley Catheter
Draining urine
Female Genitalia
Examination of the genitalia includes
external and internal sex organs
 Must provide privacy
 Need to understand cultural sensitivity
 Conduct a nursing history
 Use inspection and palpation

Male Genitalia
Assess the integrity of external genitalia,
inguinal ring, and canal
 Conduct a nursing history
 Use inspection and palpation

Musculoskeletal
 Gait
 Posture
 Extremities
Contractures/Amputations
Enlargement
Alignment/Symmetry
Heat,
tenderness, edema
ROM
Muscle Strength
Abnormal Sensations
Musculoskeletal
BUE
BLE
RUE
LLE
LUE
RLE
Psychosocial
 Emotional
 Support
System
 Cultural
 Spiritual/Religion
 Social
Interaction
Additional Data
 Pain
 Self-care
Deficits
Wounds/Incisions
1.
2.
3.
4.
5.
6.
7.
8.
9.
Kocher/Subcostal
Midline
McBurney
Battle
Lanz
Paramedian
Transverse
Rutherford Morrison
Pfannenstiel
Tubes/Drains