The Nursing
Process
Resources




Andrea Ackermann, Mount St. Mary
College, Critical-thinking-the-nursingprocess 2001.
http://www.umanitoba.ca/nursing/courses/1
28,(2005)
Sara-jo Wiscombe, Nursing Process
,Wallace Community College ,May 22,2001.
Tucker C, MODULE A INTRODUCTION TO
NURSING Process, August 21, 2002 .
The Nursing Process
An
organizational framework for the
practice of nursing
Orderly, systematic
Central to all nursing care
Encompasses all steps taken by the
nurse in caring for a patient
Definition of the Nursing
Process
 An
organized sequence of problemsolving steps used to identify and to
manage the health problems of clients
 It is accepted for clinical practice
established by the American Nurses
Association
Benefits of Nursing Process







Provides an orderly & systematic method for
planning & providing care
Enhances nursing efficiency by standardizing
nursing practice
Facilitates documentation of care
Provides a unity of language for the nursing
profession
Is economical
Stresses the independent function of nurses
Increases care quality through the use of
deliberate actions
The Nursing Process
Utilizes The Following
Assessment
Nursing
Diagnosis
Planning
Implementation
Evaluation
Characteristics of the
Nursing Process
 Within
the legal scope of nursing
 Based on knowledge-requiring critical
thinking
 Planned-organized and systematic
 Client-centered
 Goal-directed
 Prioritized
 Dynamic
Benefits of using the nursing
process




Continuity of care
Prevention of
duplication
Individualized
care
Standards of care

Increased client
participation

Collaboration of
care
Being Accountable
Using critical thinking before taking
actions
 Being responsible for your actions
 Entering the professional role
 Working at the level of your peers
 Using the nursing process

Something to think about:

Nurses are responsible for a unique
dimension of healthcare – “ the
diagnosis and treatment of human
responses to actual or potential health
problems”
MARTHA ROGERS,
NURSE THEORIST
“When
an apple is cut,
others see seeds in the
apple. We, as nurses,
see apples in the
seeds.”
What Are Your
Responsibilities?



Recognize health problems.
Anticipate complications.
Initiate actions to ensure appropriate
and timely treatment.
Begin to think CRITICALLY !!!!!!
Critical Thinking

MENTAL OPERATIONS –decision making
& reasoning

KNOWLEDGE-having the facts &
understanding the reason behind the
knowledge

ATTITUDES- curious/open-minded/nonjudgmental….
Critical Thinking
Critical thinking in nursing is an
essential component of professional
accountability and quality nursing
care.


Critical thinking is careful, deliberate,
and goal directed.
Assessment of Well-Being
 According
to the World Health
Organization is well-being in
these domains:
 Emotional
 Physical
 Social
 Spiritual
Lets Get Started :








Nurse collects background info from
previous charts
Ensure environment is conducive
Arrange seating
Allow adequate time
Nurse introduces self
Identifies purpose of interview
Ensure confidentiality of information
Provide for patient needs before starting
TYPES OF INTERVIEWS


DIRECTED
NON-DIRECTED
THINGS THAT IMPAIR COMMUNICATION:
 PRESENTING QUICK SOLUTIONS
 UNWARRANTED CHEERFULNESS
 FALSE REASSURANCE
 GIVING ADVICE
 CHANGING THE SUBJECT
ASSESSMENT
 Observation
 Interview
 Types
of questions
 Environment (physical and
emotional) Spiritual
conciderations
 Examination
Types of Data To Collect:
 Objective
data-observable and
measurable facts (Signs)
 Subjective data-information that only
the client feels and can describe
(Symptoms)
CULTURAL DIVERSITY
MUST PROVIDE CARE CONGRUENT
WITH A CLIENT’S EXPECTATIONS
 “This is not about you” ?
 Respect INDIVIDUAL’S DIFFERENCES,
What is the significance of the problem
or illness to the client?
 What does it mean in the
family/community?

COMMON Challenges:
Defense Mechanisms
COMPENSATION
 DENIAL
 DISPLACEMENT
RATIONALIZATION





PROJECTION
REPRESSION
SUPPRESSION
REGRESSION
Continued
THE NURSING PROCESS HELPS
NURSES UNDERSTAND THE
STRATEGIES CLIENTS USE IN
their attempt at coping:
This knowledge will help you
FURTHER INDIVIDUALIZE THEIR
CARE

Resources






Client
Other individuals
Previous records
Consultations
Diagnostics studies
Relevant literature
Assessment


Data base assessment –
comprehensive information you
gather on initial contact with the
person to assess all aspects of health
status.
Focus assessment – the data you
gather to determine the status of a
specific condition.
Sources of Data
 Primary
source: Client
 Secondary source: Client’s family,
reports, test results, information in
current and past medical records, and
discussions with other health care
workers
Disease Prevention



Primary prevention – protection from
a disease while still in a healthy state.
Secondary prevention – early
detection and treatment of disease.
Tertiary prevention – prevent
complications and to maintain health
once the disease process has
occurred.
Verifying Data








Essential in critical thinking!!!!!
Measurable data
Double check personal observations
Double check equipment
Check with experts and team members
Recheck out-liers
Compare objective and subjective data
Clarify statements
Planning
 Establish
the goals, interventions
and outcomes
General Guidelines for
Setting Priorities
1.
2.
3.
4.
Take care of immediate
life-threatening issues.
Safety issues.
Patient-identified issues.
Nurse-identified priorities based on
the overall picture, the patient as a
whole person, and availability of time
and resources.
Nurse Identified Priorities





Composite of all patient’s strengths
and health concerns.
Moral and ethical issues.
Time, resources, and setting.
Hierarchy of needs.
Interdisciplinary planning.
Identifying Client-centered
Outcomes




State what the patient will do
or experience at the completion
of care.
Give direction to the patient’s
overall care.
Patient behaviors not nurse
behaviors!!
“The patient will…”
DIAGNOSIS
Sort, cluster, analyze information
 Identify potential problems and
strengths
 Write statement of problem or
strength
 Risk of infection related to
compromised nutrition

Nursing Diagnosis (cont.)
Potential for effective breastfeeding
related to knowledge level and
support system
 Prioritize the problems
 Not a medical diagnosis

Steps for deriving outcomes
from Nursing Diagnosis



Look at the first clause of the nursing
dx and restate in a statement that
describes improvement, control or
absence of the problem.
Risk for infection r/t surgical
procedure.
The client will demonstrate no signs
or symptoms of infection.
Components of Outcomes





Subject: who is the person expected to
achieve the outcome?
Verb: what actions must the person take to
achieve the outcome?
Condition: under what circumstances is
the person to perform the actions?
Performance criteria: how well is the
person to perform the actions?
Target time: by when is the person
expected to be able to perform the actions?
Nursing Interventions


1.
2.
3.
4.
5.
Road maps directing the best ways to
provide nursing care.
Evidence based nursing.
Monitor health status.
Minimize risks.
Resolve or control a problem.
Assist with ADLs.
Promote optimum health and
independence.
Interventions

Direct interventions: actions
performed through interaction
with clients.

Indirect interventions: actions
performed away from the client,
on behalf of a client or group of
clients.
Nursing Diagnosis
 Health
issue that can be prevented,
reduced, resolved, or enhanced
through independent nursing
measures
Documenting the Plan of
Care


1.
2.
3.
To ensure continuity of care, the plan must
be written and shared with all health care
personnel caring for the client.
Consists of:
Prioritized nursing
diagnostic statements.
Outcomes.
Interventions.
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
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”

Evaluation
1.
2.
3.
Determining outcome achievement
Identifying the variables affecting
outcome achievement
Deciding whether to continue,
modify, or terminate the plan
Determining Outcome
Achievement






Must be aware of outcomes set for the
client.
Must be sure patient is ready for
evaluation.
Is patient able to meet outcome criteria?
Is it:
Completely met?
Partially met?
Not met at all?
Record in progress in notes.
Update care plan.
Identifying Variable Affecting
Outcome Achievement

Maintain individuality of care plan:
1. Is the plan realistic for the client?
2. Is the plan appropriate at the time for
this particular client?
3. Were changes made in the plan when
needed?
4. How does the client feel about the plan?
Predict, Prevent, and
Manage




Focus on early intervention
Based on research
Predict and anticipate problems
Look for risk factors
Diagnostic Statements
 Name
of the health-related issue or
problem as identified in the NANDA list
 Etiology (its cause)
 Signs and Symptoms
 The name of the nursing diagnosis is
linked to the etiology with the phrase
“related to,” and the signs and
symptoms are identified with the
phrase “as manifested (or evidenced)
by”
Collaborative ProblemsNurse’s Responsibility
 Correlating
medical diagnoses or
medical treatment measures with the
risk for unique complications
 Documenting the complications for
which clients are at risk
 Making pertinent assessments to
detect complications
Continued
Reporting trends that suggest
development of complications
 Managing the emerging problem with
nurse- and physician-prescribed
measures
 Evaluating the outcomes

The Nursing Process
Nursing Diagnosis
 Judgment
or conclusion about the risk for—
or actual—need/problem of the patient
 NANDA format
NANDA – North American
Nursing Diagnosis Association





Identifies nursing functions
Creates classification system
Establishes diagnostic labels
Risk of infection related to compromised
nutritional state
Potential complication of seizure disorder
related to medication compliance
Planning
 The
process of prioritizing nursing
diagnoses and collaborative problems,
identifying measurable goals or
outcomes, selecting appropriate
interventions, and documenting the
plan of care.
 The nurse consults with the client
while developing and revising the plan.
Setting Priorities
 Determine
problems that require
immediate action
 Maslow’s Hierarchy of Human Needs
Short-Term Goals
 Outcomes
achievable in a few days or
1 week
 Developed form the problem portion of
the diagnostic statement
 Client-centered
 Measurable
 Realistic
 Accompanied by a target date
Long-Term Goals
 Desirable
outcomes that take weeks
or months to accomplish for client’s
with chronic health problems
The Nursing Process
Planning
 Identification
 Prioritization
 Time
frame
of goals and outcome criteria
Selecting Nursing
Interventions
 Planning
the measures that the client
and nurse will use to accomplish
identified goals involves critical
thinking.
 Nursing interventions are directed at
eliminating the etiologies.
Selecting an intervention
The nurse selects strategies based on
the knowledge that certain nursing
actions produce desired effects.
 Nursing interventions must be safe,
within the legal scope of nursing
practice, and compatible with medical
orders.

Communicating The Plan
 The
nurse shares the plan of care with
nursing team members, the client, and
client’s family.
 The plan is a permanent part of the
record.
Evaluation
 The
way nurses determine whether a
client has reached a goal.
 It is the analysis of the client’s
response, evaluation helps to
determine the effectiveness of nursing
care.
The Nursing Process
Evaluation
Ongoing
part of the nursing process
Determining the status of the goals
and
outcomes of care
Monitoring the patient’s response to
drug therapy
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