THE NURSING PROCESS - Oklahoma City Community College
THE NURSING PROCESS
COMPREHENSIVE
GOAL ORIENTED
INTERPERSONAL
SYSTEMATIC
DYNAMIC
NURSING PROCESS (CONT.)
The nursing process is universally applicable. It is equally at home in the surgical or the psychiatric setting or anything in-between.
The nursing process is simply a way of thinking that systemitizes the way nurses give care.
The nursing process gives nurses a structure for helping patients meet their health goals.
The Nursing Process (cont.)
Purpose of the nursing process:
To help nurses manage care, scientifically, holisticaly, and creatively.
PROBLEM SOLVING METHODS:
Trial and Error
Scientific Method
Intuitive Problem Solving
The Nursing Process (cont.)
THE 5 STEPS OF THE NURSING PROCESS
1. ASSESSMENT
2. DIAGNOSING
3. PLANNING
4. IMPLEMENTATION
5. EVALUATION
THE NURSING PROCESS ALWAYS FOLLOWS
THIS CYCLE, ALTHOUGH IT TAKES
VARYING AMOUNTS OF TIME TO
COMPLETE.
The Nursing Process (cont)
ASSESSMENT is a continuous, systematic collection, validation and communication of client data.
ASSESSMENT IS CONTINUOUSLY UPDATED!!!
Steps in the assessment phase of the nursing process:
1. Establish a data base by a. Taking the client’s vital signs b. Performing a head to toe examination c. Taking a complete nursing history d. Reviewing the client’s chart & the literature e. Consult with the client, his significant others
The Nursing Process (cont)
2. Constantly update the data base to reflect client changes
3. Validate all data
4. Communicate the data
ASSESSMENT TAKES PLACE IN ALL
REALMS: PHYSICAL, MENTAL,
EMOTIONAL, CULTURAL, SPIRITUAL
AND SOCIO-ENVIRONMENTAL!!!
The Nursing Process(cont.)
DIAGNOSING: USE NANDA (The North American
Nursing Diagnosis Association) as listed in your
Taylor, Lillis & Lemone text pp 263-265 and as described in detail in your Sparks & Taylor Nsg.
Diagnosis Reference Manual.
The Nursing Diagnosis Describes Only Problems
That Can Be Handled By Nurses!!!!!
The nursing diagnosis describes a human response
The nursing diagnosis differs from the medical diagnosis, but should complement it
The Nursing Process (cont.)
STEPS IN MAKING THE NURSING DIAGNOSIS:
1. Interpret and validate client data; analyze all data
2. Identify the client’s problems (and strengths)
3. Formulate and validate the nursing diagnoses, both actual & potential
4. Prioritize a list of appropriate nursing diagnoses (No client has only one problem in only one realm.)
The Nursing Process (cont.)
WRITING THE NURSING DIAGNOSIS: IN 3 STEPS
1. THE PROBLEM STATEMENT(NANDA) ie:
Constipation
2. THE ETIOLOGY (CAUSE OF THE
PROBLEM)ie:Related to (R/T) low residue diet and lack of exercise
3. THE EVIDENCE FOR THE
PROBLEM:As evidenced by(AEB)no stool for five days
Putting it all together: Constipation, R/T low residue diet & lack of exercise AEB no stool for five days
The Nursing Process (cont.)
PLANNING (TO END, HEAL OR OVER-COME
THE PROBLEMS IN THE PROBLEM
STATEMENTS OF THE NURSING
DIAGNOSES)
1. Establish priorities (most life threatening or disturbing first)
2. Select and write down (in cooperation with the client) the goals which are also known as expected outcomes = goals.
EXPECTED OUTCOMES (GOALS) MUST
ALWAYS BE DATED OR TIMED!!!
The Nursing Process (cont.)
GOALS MUST BE REALISTIC (in terms of the client’s potential for achieving them & the nurse’s ability to help the client achieve them.)
GOALS SERVE AS GUIDES IN SELECTING
NURSING INTERVENTIONS.
GOALS ARE ALWAYS STATED BEGINNING
WITH “CLIENT WILL” ie: By Sept. 17, client will state what high fiber foods he prefers
By Sept. 18, client will eat one high fiber food with each meal
By Sept. 17, client will walk length of hall tid with assistance
The Nursing Process (cont)
NURSING INTERVENTIONS (ALSO CALLED
IMPLEMENTATIONS)
NURSING INTERVENTIONS MAKE THE
CLIENT GOALS COME TRUE!!
NURSING INTERVENTIONS ALWAYS ARE
STATED “NURSE WILL”!!
ie: Nurse will consult with the client, dietician, and physician regarding upgrading client’s diet to a high fiber diet.
Nurse will walk with client, assisting and supporting him, the length of the hall tid.
IMPLEMENTATION IS THE ACTION PHASE
OF THE NURSING PROCESS (when the nurse does something with, to, or for the client)
The Nursing Process (cont.)
.All actions (interventions) planned for the client must be based on scientific principles and rationale.
Interventions are based on the least amount of discomfort, invasion and risk for the client.
The nurse never does for the client what he can safely and capably do for himself.
(We’re not taking them to raise; we’re usually trying to return them to their life.)
THE LAST STEP IN INTERVENTION IS
TO ACCURATELY DOCUMENT IT!!!
The Nursing Process (cont.)
Nursing interventions require intellectual, interpersonal and technical skills.
Intellectual skills required of the nurse include: problem identification, and problem solving, critical thinking, and the ability to make sound judgments.
A strong theoretical background is necessary for these intellectual skills!
The Nursing Process (cont.)
Interpersonal skills used during nursing intervention include: communicating, listening, conveying interest, compassion, empathy, and
TLC. These skills are invaluable in establishing rapport and building a therapeutic relationship.
Technical skills refer to the performance of procedures and the use of equipment and materials competently and proficiently.
(Practice makes perfect!)
The Nursing Process (cont.)
Nursing interventions can be:
1. DEPENDENT ie: giving the patient a medication (the nurse is dependent on the physician to write the medication order.)
2. COLLABORATIVE ie: consulting with a colleague such as a dietician, physical therapist or another nurse before taking action.
3. INDEPENDENT ie: when the nurse takes action alone, such as starting oxygen on a client who has become cyanotic or beginning one man rescue CPR.
The Nursing Process (cont.)
The last phase of the nursing process is
EVALUATION. Our patient goals and nursing actions are useless if we are not constantly evaluating whether or not they are making any headway in returning the client to health and functioning.
EVALUATION MEASURES THE DEGREE
TO WHICH THE NURSING PROCESS
HAS BEEN SUCCESSFUL.
EVALUATION MEANS WE REASSESS
AT EACH STEP TO ASSURE
EFFECTIVENESS AND ACCURACY.
The Nursing Process (cont.)
Common evaluation outcomes:
1. Client responded as expected, problem is solved, goals effective
2. Client’s problem has not been resolved, even though expected outcomes were accomplished. Re-evaluate, make new problem solving goals.
3.Client’s problem has not been resolved and has,in fact, worsened. Replanning is urgently needed.
4. Client has manifested a new problem; nursing process begins all over again.
