Nursing Process
Ch 11
What Is It?
• Framework = method = formula
• Systematic approach
• Dynamic
• Interpersonal
• Patient-centered
• Goal-oriented
Steps (Parts)
• Assessing
• Diagnosing
• Planning
• Implementing
• Evaluating
Quote . . .
• Nurses are responsible for a unique
dimension of healthcare – “ the
diagnosis and treatment of human
responses to actual or potential health
problems”
Evolution
• In 1960s nursing recognized as distinct
entity
• 1973 the ANA Congress developed
Standards of Practice
• Ongoing reassessments and revisions
Trends
• Initially plans of care were long and
handwritten
• Today’s care plans are
• Standardized
• Computerized
• Focus on similarities between illnesses, etc
Problem Solving
• Combination of
• Trial-and-error
• Scientific process
• Intuition
Purpose
• Provide patient care that is
• Scientific
• Holistic
• Creative
Critical Thinking
• Ability to
•
•
•
•
identify a problem
analyze it
develop a response
follow through
• Based on
• experience
• Knowledge
• Intuition
Critical Thinking, cont’d.
• “…active, organized, cognitive process
used to carefully examine one’s
thinking and the thinking of others.”
• Involves use of MIND
• Form conclusions
• Make decisions
• Draw inferences
• reflect
C. T. Characteristics
•
•
•
•
•
•
•
•
•
Independent thinker
Fair-minded
Intellectually humble
Intellectually courageous
Good faith & integrity
Curious & persevering
Disciplined
Creative
Confident
Assessing
Ch 12
4 Types
• Initial
• Shortly after contact with patient
• Most facilities have specific time-frames
• Establishes database for development of
plan
• Focused
• Gathers data about specific problem
• May be part of initial assessment, but more
often is not
• Emergency
• Identifies life-threatening problems
• Time-Lapse
• Compares current to previous data
Data Collection
• Consider
• time
• needs of patient
• developmental stage
• physical surroundings
• past and present coping patterns
Data Characteristics
• Complete
• Factual
• Accurate
• Relevant
Data Sources
• Subjective
• Patient
• Primary source
• Usually BEST source
• Family & significant others
• When patient is a child or impaired adult
• Spouses
• Consider confidentiality when including
friends
Data Sources, cont’d
• Objective
•Observed data (What is not spoken)
•Findings from physical exam
•Results from diagnostic or lab tests
•Information from pertinent nursing
or medical literature
Objective Sources cont’d.
• Patient record
•H&P
• Laboratory
• Consultations
• X-ray, CT, PT/OT, other ancillary
departments
Data Collection
• Demographics
• Medical history
• Habits
• Meds, allergies
• Environmental/familial factors
• Potential for injury
• Ability to participate in plan of care
Data Collection
• Physical assessment
• Usually by Review of Systems
•Overview of symptoms
•Diet
•Each body system
Interview
• Planned
• Consider schedule of tests
• Patient preferences
• Family or visitor presence
Interview Phases
• Preparatory
• Introduction
• Working
• Termination
Interview Phases
• Preparatory
• Nurse collects background info from
previous charts
• Ensure environment is conducive
• Arrange seating
• 3 – 4 ft apart
• Interviewer at 45° angle to patient
• Allow adequate time
Phases cont’d.
• Introduction
• Nurse introduces self
• Identifies purpose of interview
• Ensure confidentiality of information
• Provide for patient needs before starting
Phases cont’d.
• Working
• Nurse gathers info for subjective data
• Excellent communication skills are needed
• Active listening
• Eye contact
• Open-ended questions
Phases cont’d.
• Termination
• Inform patient when nearing end of
interview
• Ensure patient knows what will happen
with info
• Offer patient chance to add anything
Data Validation
• Verifies understanding of information
• Comparison with another source
•
patient or family member
•
record
•
health team member
Data Documentation
• Clear and concise
• Appropriate terminology
• Usually on a designated form
• Physical assessment
• Usually by Review of Systems
•Overview of symptoms
•Diet
•Each body system
Documentation
• Record in permanent record ASAP
• Use patient’s own words in subjective data –
enclose in “ ___” (quotation marks)
• Avoid generalizations – be specific
• Don’t make summative statements – describe
- e.g. patient is being ornery should be patient
resists instruction or patient states “Don’t talk
to me, I don’t care about that”