The Nursing Process
 Module G
HOW OBERVANT ARE YOU????
 Looking,
Listening, Feeling,
Smelling --- Do the above in
order too --- Assess, Diagnosis,
Plan, Implement,
and Evaluate
THE NURSING PROCESS – 5 STEPS
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1. Assessment
2. Diagnosis
3. Planning
4. Implementation
5. Evaluation
Each step is
dependent on the
accuracy of the step
preceding it.
AssessmentData Collection is a Primary Tool
 Puzzle Pieces
 Gathering Info about pt
 Data collection requires us to
examine the data
 Does it fit the picture?
 Formal vs Informal
 Pt is our primary source for
this data
 What are secondary sources?
Focus vs Data Base Assessment
 Focus Ass’t – is
performed to gather
detailed information
about a specific
condition.
 Baseline Data - is
gathered on initial
contact with pt to gather
info about all aspects of
health status
Two Types of Data
 S – Subjective - What the
patient tells you
 Subjective = Statements
 “I’m itching”
 O – Objective – Detectable
by an observer or can be
tested
 O = Objective
 What are some examples?
Nursing Diagnosis Process
 Data Validation \
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> Interpretation of
 Data Clustering /
Data
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Identification of
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Client needs
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Formulation of
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Nursing Diagnosis
Organizing Data
 Your assessment tool
will assist you with
this
 Clustering into
categories helps you
get a better picture
 Maslow’s Heiarchary
of Needs helps you
too
Steps in Data Analysis
 1. Do you see a pattern or
trend
 2. Compare your data to
Standards (Norms) i.e., B/P
168/102 (Normal 110/70) –
Rales heard in lung fields (
Normal – clear lung sounds)
 3. Make a reasonable
conclusion
Four Methods Nurses use to:
Collect Data
 1. Interview
 2. Nursing Health
History
 3. Physical
Examination –
Head
 4. Diagnostic and
Laboratory
Results
What’s Next ????
 Once data collection & analysis is complete
we next DIAGNOSE using NANDA. You are
looking for the Diagnostic label (NANDA)
that addresses the problem.
 Problem – is an unmet need or anything
that interferes with a persons ability to
meet their needs.
 Related factors – Etiology : Follows the
Diagnostic label & directs interventions
 Ex: Impaired skin integrity R/T immobility
Three Types of Diagnoses
 Actual
 “Risk for”
 Wellness
Legalities in Stating Nursing
Diagnoses
 Don’t write the diagnostic statement in such a
way that it may be legally incriminating.
 High risk for injury R/T Lack of side rails or
High Risk for injury R/T Disorientation
 Don’t state the Nsg Dx using medical
terminology; focus on the person’s response to
the medical problems
 Mastectomy R/T Cancer vs.
Body Image disturbance R/T effects of surgical
procedure.
 Don’t use 2 problems @ the same time.
Planning
 Setting
 Establish:
 1. Realistic patient-centered goals
 2. Measurable goal criteria
 Address: 7 guidelines when writing goals
and outcomes
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1.
3.
5.
7.
Patient centered
Observable
Time Limited
Realistic
2. Singular
4. Measurable
6. Mutual
 Two Types of Goals: Short vs. Long Term
Planning – Determining Nursing
Interventions
 Types: Nurse Initiated,
Physician initiated,
Collaborative
 Elements:
 Requires decision making
 Scientific rationale based
 Psychomotor & IPR skills
 Clinical functioning
 Address: Who, What, When,
Where, How
Components of a Goal
Subject
Behavior
Condition (Time)
Criteria – List
 Each is a separate outcome
 Each is specific & concrete
 Each is measurable, seen,
heard, felt, observable
 Must R/T goal
 Realistic
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Implementation
 The actual process of
putting the PLAN into
action, a team effort
including:
 1. Reporting
 2. Performing the
care
 3. Setting Priorities
 4. Documentation
 5. Assessing &
reassessing
 6. Adhere to polices
Evaluation
 To judge or appraise
 Determine if expected
outcomnes were met
 A constant on-going
process for
determining if patient
goal(s) are being met
or if patient needs are
changing
 3 Goal Possibilities:
 Met, Partially Met, Not
Met
Nursing Process is Dependent On:
 Knowledge –
 What to
 Why
 Skills –
 How to
 Caring –
 Willing to
 Able to
Critical Thinking? Who needs it?
 Critical Thinkers look
beyond the obvious =
Sound Judgment
 Sound Judgments =
Safe Care
 Safe Care =
Accountability because
we critically think.
Questions often asked by critical
thinkers
 What if? Do I have
enough data (facts)?
 How can I? How could I
have missed that? What
did I assume & why?
 What did I learn
about?*Critical Thinkers
are always learning.
Critical Thinking
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Confidence
Contextual perspective
Creativity
Flexibility
Inquisitiveness
Intellectual integrity
Intuition
Open=Minded
Persistence
Reflection
= Habits of the Mind