Nursing Process
 The nursing process is based on a nursing theory
developed by Ida Jean Orlando. She developed this theory
in the late 1950's as she observed nurses in action. She
saw "good" nursing and "bad" nursing.
 From her observations she learned that the patient must be
the central character.
 Nursing care needs to be directed at improving outcomes for the
patient, and not about nursing goals.
 The nursing process is an essential part of the nursing care plan.
Nursing Process
 A systematic, rational method of planning and providing
individualized nursing care
Historical Development of the
Nursing Process
 1955—nursing process term used by Hall
 1960s—specific steps delineated
 1967—Yura and Walsh published first comprehensive
book on nursing process
 1973—ANA Congress for Nursing Practice developed
Standard of Practice
 1982—state board examinations for professional
nursing uses nursing process as organizing concept
Five Steps of the Nursing Process
 Assessing—collecting, validating, and communicating of
patient data
 Diagnosing—analyzing patient data to identify patient
strengths and problems
 Planning—specifying patient outcomes and related nursing
interventions
 Implementing—carrying out the plan of care
 Evaluating—measuring extent to which patient achieved
outcomes
Question
Which step of the nursing process is a nurse using when she analyzes
patient data to determine her patient’s strengths following a CVA?
A. Assessing
B. Diagnosing
C. Planning
D. Implementing
E. Evaluating
Answer
Answer: B. Diagnosing
Rationale:
The diagnosing step involves analyzing patient data to determine
strengths and weaknesses.
The assessing step refers to the collection, validation, and
communication of patient data.
In the planning step, the nurse determines patient outcomes and
related nursing interventions, and in the Implementing step, the
nurse carries out the plan.
When evaluating, the nurse measures the extent to which the
patient achieved outcomes.
The Steps of the Nursing Process
Question
Which of the following characteristics of the
nursing process describes the interaction and
overlapping of steps within the process itself?
A. Systematic
B. Dynamic
C. Interpersonal
D. Universally Applicable
Answer
Answer: B. Dynamic
Rationale:
The nursing process is dynamic in that there is much interaction
and overlapping of the steps.
It is systematic since it is an ordered sequence of activities.
Interpersonal refers to the human being at the heart of nursing.
The nursing process is universally applicable in that it is a
framework for all nursing activities.
Characteristics of the Nursing
Process
 Systematic—part of an ordered sequence of activities
 Dynamic—great interaction and overlapping among the
five steps
 Interpersonal—human being is always at the heart of
nursing
 Outcome oriented—nurses and patients work together to
identify outcomes
 Universally applicable—a framework for all nursing
activities
Problem Solving and the Nursing
Process
 Trial-and-error problem solving
 Scientific problem solving
 Intuitive thinking
 Critical thinking
Question
Tell whether the following statement is true or
false.
Critical thinking occurs when a nurse directly
apprehends a situation based on its similarity or
dissimilarity to other situations.
A. True
B. False
Answer
Answer: B. False
Intuitive thinking occurs when a nurse directly
apprehends a situation based on its similarity or
dissimilarity to other situations.
Assessing: The Primary Source
of Information Is the Patient
Objective Data vs. Subjective
Data
 Objective data
 Observable and measurable data that can be seen, heard,
or felt by someone other than the person experiencing them
 For example, elevated temperature, skin moisture, vomiting
 Subjective data
 Information perceived only by the affected person
 For example, pain experience, feeling dizzy, feeling anxious
Nursing Diagnosis
Types:
 Actual
 Risk
 Possible
 Wellness
 Syndrome
Diagnosing
Formulation of Nursing Diagnoses
 Defining characteristics—identifies the subjective and
objective data that signal the existence of a problem
 Problem—identifies what is unhealthy about patient
 Etiology—identifies factors maintaining the unhealthy
state
Question
A patient who admits to smoking two packs of cigarettes
a day is diagnosed with lung cancer based on his
symptoms and a series of test results. Which of the
following is the etiology in this scenario?
A. Lung cancer
B. Test results
C. Smoking cigarettes
D. The subjective and objective data
Answer
Answer: C. Smoking cigarettes
Rationale:
The etiology is the factor that maintains the
unhealthy condition (smoking cigarettes). Lung
cancer is the problem, and the remaining factors
are the distinguishing characteristics.
Question
Which of the following nursing diagnoses is
written correctly?
A. Child Abuse related to maternal hostility
B. Breast Cancer related to family history
C. Deficient Knowledge related to alteration in diet
D. Imbalanced Nutrition related to insufficient
funds in meal budget
Answer
Answer: D. Imbalanced Nutrition related to
insufficient funds in meal budget
Rationale:
Answer A makes legally inadvisable statements,
answer B is a medical diagnosis, and answer C
reverses the clauses in the statement.
Common Sources of Error in
Nursing Diagnoses
 Premature diagnoses based on incomplete
database
 Erroneous diagnoses resulting from inaccurate or
faulty database
 Routine diagnoses resulting from failure to tailor
data to patient
 Errors of omission
Limitations of Nursing
Diagnosis
 If used incorrectly, patient might be
“misdiagnosed.”
 Nursing practice might be restricted.
Question
Which of the following nursing diagnoses would
most likely be considered a high priority?
A. Disturbed personal identity
B. Impaired gas exchange
C. Risk for powerlessness
D. Activity intolerance
Answer
Answer: B. Impaired gas exchange
Rationale:
Impaired gas exchange poses a threat to the patient’s wellbeing.
Disturbed personal identity and risk for powerlessness are non–
life-threatening and are ranked as medium priorities.
Activity intolerance, if not specifically related to the current
health problem, is a low priority.
Maslow’s Hierarchy of
Human Needs
 Physiologic needs
 Safety needs
 Love and belonging needs
 Self-esteem needs
 Self-actualization needs
Planning
 Establish priorities.
 Identify and write expected patient outcomes.
 Select evidence-based nursing interventions.
 Communicate the plan of care.
Outcome Identification &
Planning
Three Elements of
Comprehensive Planning
 Initial
 Ongoing
 Discharge
Initial Planning
 Developed by the nurse who performs the nursing
history and physical assessment
 Addresses each problem listed in the prioritized
nursing diagnoses
 Identifies appropriate patient goals and related
nursing care
Ongoing Planning
 Carried out by any nurse who interacts with patient
 Keeps the plan up to date
 States nursing diagnoses more clearly
 Develops new diagnoses
 Makes outcomes more realistic and develops new
outcomes as needed
 Identifies nursing interventions to accomplish patient
goals
Discharge Planning
 Carried out by the nurse who worked most closely
with the patient
 Begins when the patient is admitted for treatment
 Uses teaching and counseling skills effectively to
ensure home care behaviors are performed
competently
Long-Term vs. Short-Term
Outcomes
 Long-term—requires a longer period to be
achieved and may be used as discharge goals
 Short-term—may be accomplished in a specified
period of time
Common Errors in Writing
Patient Outcomes
 Expressing patient outcome as nursing
intervention
 Using verbs that are not observable or
measurable
 Including more than one patient behavior or
manifestation in short-term outcomes
 Writing vague outcomes
Problems Related to Outcome
Identification and Planning

Failure to involve patient

Insufficient data collection

Nursing diagnoses developed from inaccurate or insufficient data

Outcomes stated too broadly

Outcomes derived from poorly developed nursing diagnoses

Failure to write nursing order clearly

Nursing orders that do not solve problems

Failure to update the plan of care
Parts of a Measurable Outcome
 Subject
 Verb
 Conditions
 Performance criteria
 Target time
Question
Which one of the following nursing actions would most likely occur during
the ongoing planning stage of the comprehensive care plan?
A. The nurse collects new data and uses them to update the plan and
resolve health problems.
B. The nurse uses teaching and counseling skills to help the patient carry
out self-care behaviors at home.
C. The nurse who performs the admission nursing history develops a
patient care plan.
D. The nurse consults standardized care plans to identify nursing
diagnoses, outcomes, and interventions.
Answer
Answer: A. The nurse collects new data and uses them to
update the plan and resolve health problems.
Rationale:
In the ongoing planning stage, any nurse who interacts
with the patient updates the plan to facilitate the
resolution of health problems, manage risk factors, and
promote function.
Teaching and counseling are the key to discharge
planning.
The nurse performing the admission nursing history
consults standardized care plans during initial planning to
formulate the initial care plan.
Nursing
Intervention/Implementation
Types of Nursing Interventions
 Independent nursing actions
 Nurse-initiated interventions

Protocols

Standing orders
 Collaborative nursing actions
 Physician-initiated interventions
 Collaborative interventions
Question
Tell whether the following statement is true or false.
A nurse who follows the protocol for taking vital signs
following surgery is performing a physician-initiated
intervention.
A. True
B. False
Answer
Answer: B. False
A nurse who follows the protocol for taking vital
signs following surgery is performing a nurseinitiated intervention.
Common Reasons for
Noncompliance
 Lack of family support
 Lack of understanding about the benefits
 Low value attached to outcomes
 Adverse physical or emotional effects of treatment
 Inability to afford treatment
Question
Tell whether the following statement is true or
false.
When a patient fails to cooperate with the plan of
care despite the nurse’s best efforts, it is time to
reassign the patient to another caretaker.
A. True
B. False
Answer
Answer: B. False
When a patient fails to cooperate with the plan of
care despite the nurse’s best efforts, it is time to
reassess the strategy.
Evaluation
Evaluating Step
 Allows achievement of outcomes
 Directs nurse–patient interactions
 Measures patient outcome achievement
 Identifies factors to achieve outcomes
 Modifies the plan of care, if necessary
Question
Tell whether the following statement is true or
false.
The purpose of evaluation is to allow the
patient’s achievement of expected outcomes to
direct future nurse–patient interactions.
A. True
B. False
Answer
Answer: A. True
The purpose of evaluation is to allow the
patient’s achievement of expected outcomes to
direct future nurse–patient interactions.
Action Based on Outcome
Achievement
 Terminate plan of care when expected outcome is
achieved.
 Modify plan of care if there are difficulties
achieving outcomes.
 Continue plan of care if more time is needed to
achieve outcomes.
Question
Which of the following actions should the nurse
take when a patient has achieved each expected
outcome in the plan of care?
A. Terminate the plan of care
B. Modify the plan of care
C. Continue the plan of care
Answer
Answer: A. Terminate the plan of care
Rationale:
The plan of care is terminated when the patient has
achieved all of its goals.
The plan of care is modified when there are difficulties
achieving outcomes.
The plan of care is continued if more time is needed to
achieve the outcomes.
Four Types of Outcomes
 Cognitive—increase in patient knowledge
 Psychomotor—patient’s achievement of new
skills
 Affective—changes in patient values, beliefs, and
attitudes
 Physiologic—physical changes in the patient
Question
Which one of the following examples is a psychomotor outcome?
A. A patient learns how to control his weight using the
MyPyramid Food Guide.
B. A patient is able to test for glucose levels and inject insulin as
needed.
C. A patient values his health enough to decide to quit smoking.
D. A patient is able to ambulate the hallway following knee
surgery.
Answer
Answer: B. A patient is able to test for glucose levels and inject
insulin as needed.
Rationale:
Psychomotor outcomes involve the patient’s achievement of a
new skill, such as controlling diabetes.
Cognitive outcomes involve an increase in patient knowledge
(Answer A).
Affective outcomes pertain to changes in patient values (Answer
C).
Physiologic outcomes target physical changes in the patient
(Answer D).
Evaluating Outcomes
 Cognitive—asking patient to repeat information or
apply new knowledge
 Psychomotor—asking patient to demonstrate new skill
 Affective—observing patient behavior and conversation
 Physiologic—using physical assessment skill to collect
and compare data
Question
Tell whether the following statement is true or false.
Asking a patient to plan an exercise program to lower blood
pressure based on information provided to him in an A/V
presentation is an excellent method to evaluate a physiologic
outcome.
A. True
B. False
Answer
Answer: B. False
Asking a patient to plan an exercise program to
lower blood pressure based on information
provided to him in an A/V presentation is an
excellent method to evaluate a cognitive outcome.
Revisions in the Plan of Care
 Delete or modify the nursing diagnosis.
 Make the outcome statement more realistic.
 Increase the complexity of the outcome
statement.
 Adjust time criteria in outcome statement.
 Change nursing interventions.
Improving Professional
Performance

Peer review

Quality assurance programs

Structure evaluations

Process evaluations

Outcome evaluations

Quality improvement

Nursing audit

Concurrent and retrospective evaluations
Standards for Establishing and Sustaining Health
Work Environments
Four Domains of Critical
Thinking
 Elements of thought—basic building blocks of thinking
 Abilities—the skills essential to higher-order thinking
 Affective dimensions—attitudes, dispositions, passions,
traits of mind essential to higher-order thinking
 Intellectual standards—used to critique higher-order
thinking
Critical Thinking and Clinical
Reasoning

Is purposeful, informed, outcome-focused thinking

Is driven by patient, family, and community needs

Is based on principles of nursing process and scientific method

Uses both intuition and logic, based on knowledge, skills, and
experience

Requires strategies that make the most of human potential

Is constantly reevaluating, self-correcting, and striving to
improve