Transition to
Registered Nursing
Nursing Process: Overview, Assessment and
Nursing Diagnosis
West Coast University
Week 3
3-1
Objectives
• History of the Nursing Process and Nursing
Diagnosis
• Discuss characteristics of Nursing Process and
Nursing Diagnosis
• Describe Assessment
• Formulate a Nursing Diagnosis
3-2
This is Nursing
3-3
This is Brian on Nursing
3-4
History of Nursing Diagnosis
•
1950’s
– Introduction only – mainly used in relationship to the care plan
– only sporadically in the literature
•
1970’s
– 1st National Conference for classification of Nursing Diagnosis and
formed the North American Nursing Diagnosis Association (NANDA)
– ANA published standards of practice & a social policy statements
3-5
History of Nursing Diagnosis
• 1970’s – continued
– ANA published standards of practice & a social policy
statements
• Defined nursing as diagnosis and treatment of human response
to actual or potential health problems
• 1990’s
– 9th Conference of NANDA was held and Taxonomy II was
published
3-6
Globalization of Nursing
• Nursing Diagnosis is recognized globally
– Provides common language for nursing to talk to each other,
identifies problems, gives nursing greater accountability, and
professional autonomy
– Captures nursing’s contributions to health, enables crosscountry comparisons of nursing and promotes the
development of nursing
3-7
Timeline
• Pre-1955: No clearly identifiable boundaries
defined for nursing practice
• 1955: Term nursing process coined by Lydia Hall
• 1973: ANA published Standards of Clinical
Nursing Practice
continues
3-8
Timeline
• 1973: Classification of nursing
diagnoses began: North American Nursing
Diagnosis Association (NANDA)
• 1980: ANA published A Social Policy Statement
• 1982: NCLEX exams were revised
to include concepts
• 1994: JCAHO initiated requirements for
accredited hospitals to use the nursing process
• Current: Ongoing use of the five-step process
• In 2006 NANDA had their 13 Conference
3-9
Basic Characteristics of the Nursing
Process
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•
•
•
Method of providing care
Purposeful, systematic, and orderly
Method of problem solving and decision making
Scientifically based—understanding of the
human body
• Philosophically based—understanding of
philosophical views
3-10
Nursing Process Characteristics
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•
•
•
Method for organization
Promotes wellness
Restores wellness
Maintains present state of health
continues
3-11
Nursing Process Characteristics
• Promotes quality care
• Promotes coordinated, ongoing care
• Serves as a guide to avoid omissions or
inaccuracies
• Provides a framework for nursing
continues
3-12
Nursing Process Characteristics
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•
•
•
•
Client centered
Assists to plan according to client needs
Client participates
Promotes collaboration with other disciplines
Universally applicable
3-13
Nursing Skills
• Interpersonal
• Technical
• Intellectual
3-14
Critical Thinking
• Purposeful thought process
• Strategy used in search for meaning
• Deliberate questions are asked
3-15
Problem Solving
•
•
•
•
•
•
Gather data
Identify problem
Interpret data
Plan to resolve
Implement plan
Evaluate results
3-16
Decision Making
• Based on scientific theories
• Results from nurse’s ability to think critically
• Perceptual and intellectual skills used
3-17
Maslow’s Hierarchy of Needs
3-18
Benefits of the Nursing Process
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•
•
•
Improved quality of care
Continuity of care
Promotes client participation in care
Delivery of care is organized, continuous,
and systematic
• Efficient use of time and resources
• Expectations of client and standards of
care are met
• Holds nurses accountable and responsible
3-19
Five Steps of the Nursing Process
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•
•
•
•
Assessment
Diagnosis
Planning and outcome identification
Implementation
Evaluation
3-20
Scope and Standards of Practice
I.
II.
Assessment: Nurse collects data
Diagnosis: Nurse analyzes data in
determining diagnoses
III. Outcome identification: Nurse identifies
expected outcomes
IV. Planning: Nurse develops a plan of care
V. Implementation: Nurse implements
interventions identified in plan
VI. Evaluation: Nurse evaluates client’s progress
From American Nurses Association. (1991). Standards of
clinical nursing practice. Washington DC: Author.
3-21
Questions Critical Thinkers Ask...
• What actual problems were identified during
assessment?
• What are possible causes?
• Is client at risk for developing other problems?
• What are the factors involved?
• Did the client indicate a desire to function at a
higher level of wellness?
continues
3-22
Questions Critical Thinkers Ask...
• What are the client’s strengths?
• What additional data might be needed to answer
these questions?
• What are possible sources of data collection?
• Is collaboration needed at this time?
• What data are pertinent to collect before
contacting the physician?
3-23
Assessment
•
•
•
•
Gathering data
Organizing
Verifying accuracy
Documenting data
3-24
Characteristics of Assessment
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•
•
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Systematic, ongoing, and continuous
Process of collecting data
Identification of problems
Data yield information regarding health status
3-25
Types of Data
• Subjective
• Objective
• Complements, clarifies, supports
3-26
Baseline Data
• Initial data becomes foundation
• Accurate data collection is critical
• Used for comparison of future data
3-27
Data Collection
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•
•
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Interview, physical exam, diagnostic exams
Communicated and documented
Begins when client enters health care system
Continues as long as there is a need
3-28
Validating & Clarifying Data
• Subjective Data: “I feel like my heart is racing”
• Objective Data: Pulse 150 beats per minute,
regular, strong
3-29
Sources of Data
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Client
Family or significant other
Nursing records
Medical records
Consultations
Health care team members
Diagnostic results
Relevant literature
3-30
Data Collection Tools
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•
•
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Organization
Documentation
Nursing models
Holistic
3-31
Methods of Data Collection
• Observation
• Interview
• Physical assessment
3-32
Promoting Data Collection
• Use communication techniques
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–
–
–
–
paraphrasing
clarifying
focusing
summarizing
open-ended questions
3-33
Data Clustering
• Determines relation
• Finds patterns
3-34
Diagnosis
• Analysis
• Problem identification
• Nursing diagnosis
3-35
Nursing vs. Medical Diagnoses
Nursing Diagnosis
•
•
•
•
Determined by the nurse
Clinical judgment about the client
Human responses to disease or treatment
May change
Medical Diagnosis
• Determined by physician
• Indicates disease, illness
• Doesn’t change
3-36
Definition: Nursing Diagnosis
• A clinical judgment about individual, family, or
community responses to actual or potential
health problems/life processes. Nursing
diagnosis provides the basis for selecting
interventions to achieve outcomes for which the
nursing is accountable
3-37
Types Nursing Diagnosis
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•
•
•
•
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Actual
Risk
Possible
Syndrome
Wellness
Collaborative
3-38
Making a Nursing Diagnosis
•
Know diagnoses
– Collect valid & pertinent data, cluster data, differentiate nursing
diagnosis from collaborative problems, prioritize
•
Defining the characteristics
– Major & Minor
•
Related factors
–
–
–
–
Pathophysiological
Treatment
Situational
Maturational
3-39
Actual ND
• Represents a problem that has been validated by the
presence of major defining characteristics.
• Has four parts
–
–
–
–
Label
Definition
Defining characteristics
Related factors
3-40
Risk ND
• Clinical judgment that an individual, family or community is
vulnerable to develop the problem than others in the same
or similar situation
3-41
Possible ND
• Describes a suspected problem requiring additional data.
This is where data is not complete or an evaluation has not
been completed
• Not a NANDA ND because it is not classified, yet viable for
the clinical nurse for further clarification of a problem
3-42
Syndrome ND
• Clustering of predictable actual or high-risk NDs related to
events or situations
• Complex clinical situation, use with care and stated as a
one-part statement
• There should be a clustering of other NDs
3-43
Wellness ND
• Clinical judgment about an individual, family or community
transition from a specific level of wellness to a higher level
• Stated as a one-part
3-44
Collaborative Problems
• Physiologic complications that nurses monitor to detect
onset or changes in status. Nurses manage collaborative
problems with PCP-prescribed (dependent nursing
functions) and Nursing-prescribed (independent nursing
functions) to minimize complications
3-45
Cultural, Ethical & Spiritual ND
•
Cultural Needs
– Where is the cultural component?
– Belief system, knowledge, food, environment, powerlessness
•
Ethical Issues
– What do you do with issues that are illegal, or different from your
belief system?
•
Spiritual Concerns
– Does, or how does the patient utilize spirituality in there health care?
3-46
Components of a
Nursing Diagnosis
• Stated as one, two or three parts
Type of Diagnosis
Parts needed
Actual
3 – Label, Factors, S/S
Risk
2 – Label, Factors
Possible
2 – Label, Factors
Syndrome
1 – Label
Wellness
1 – Label
Collaborative
Need the stem: Potential Complications (PC)
3-47
Formulating Nursing Diagnosis
Diagnostic Label
(Stem)
Related to
Contributing Factors
(Etiology – RT)
Signs & Symptoms
(AEB)
As evidenced by/secondary to
3-48
Example of Actual Nursing Diagnoses
• Hyperthermia
– Client’s temperature is 104.6°F.
• Impaired Gas Exchange
– Client’s oxygen saturation in arterial blood is 92%.
continues
3-49
Example of Actual Nursing Diagnoses
• Pain
– Client states pain level “8” on scale of one to ten.
• Anxiety
– Client states he is experiencing anxiety.
• Self-care deficit
– Client is unable to perform ADLs.
3-50
Components of Actual
Nursing Diagnoses
• Problem
• Etiology
• Defining characteristics
3-51
Problem
• Label
• Nursing diagnosis
3-52
Etiology
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•
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Related to (R/T) or related factor
Involved in development of problem
Becomes focus for interventions
Cause component
Gives direction to problem statement
3-53
Defining Characteristics
• As evidenced by (AEB)
• Clinical evidence
• How response is manifested
3-54
Examples
3-55
Scenario One:
The nurse is caring for a client who was involved in a motor
vehicle accident and sustained superficial skin trauma. The
client’s epidermal layer of skin on the right knee, forearm,
and hand is excoriated, reddened, and bleeding as the
result of sliding across a cement pavement.
3-56
Answer:
• Impaired Skin Integrity
• R/T: mechanical factors, shearing forces
• AEB: disruption of skin surface, destruction of
skin, layers, traumatized skin excoriated,
reddened, bleeding
3-57
Scenario Two
The client you are caring for has been medically
diagnosed with a right cerebral vascular accident
(stroke). He experiences partial paralysis on the
left side of his body. He is unable to turn over
while in bed without assistance and has
demonstrated decreased muscle strength and
control in the left extremities.
3-58
Answer:
• Impaired Physical Mobility
• R/T: neuromuscular impairment
• AEB: inability to purposefully move within the
environment, decreased muscle strength, control,
left-sided partial paralysis
3-59
Components of Risk
Nursing Diagnoses
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•
•
•
Potential problem
Risk factor
No evidence
Problem does not exist
3-60
Risk Nursing Diagnoses Examples
• Cancer patient, Risk for Infection
– Risk Factors (R/T): inadequate secondary defenses,
immunosuppression
• Client with surgical incision, Risk for Infection
– Risk Factors (R/T): inadequate primary defenses,
invasive procedure
continues
3-61
Risk Nursing Diagnoses Examples
• Client who is semi-conscious, vomiting,
Risk for Aspiration
– Risk Factors (R/T): reduced level of
consciousness, vomiting
• Neonate unable to maintain his body
temperature, parent does not keep the child
covered, Risk for Hypothermia
– Risk Factors (R/T): extremes of age,
inadequate clothing
3-62