Nursing Process
Nursing Fundamentals
Introduction: Nursing Process
• Communication tool
• Organization tool
Overview of the Nursing Process
• Purpose is to provide
client care that is:
– Individualized
– Holistic
Holistic Health
• Treat the Whole person
–
–
–
–
Mental
Spiritual
Social
Physical
Overview of the Nursing Process
• Process:
• Purpose:
– Individualized
– Holistic
– Effective
– Efficient
• Nursing CARE
Overview of the Nursing Process
• Consists of 5 steps
–AD-PIE
Nursing Process
• Used throughout the life span
• Used in every care setting
Small group questions:
1. What are the names of each of the steps?
2. What is the purpose of the nursing process?
Assessment
• Step #1
• Involves
– Collecting data
– Validating the data
– Organizing the data
– Interpreting the data
– Documenting the data
Assessment
• Types of assessment:
1. Comprehensive
2. Focused
3. Ongoing
Assessment
• Comprehensive
assessment
– Baseline
– Physical &
psychosocial
Assessment
• Focused Assessment
–Limited in scope
–Screening for a
specific problem
–Short stay
Assessment
• Ongoing
–Follow-up
–Monitoring
changes
Assessment
• Types of data
– Subjective
• Data from the client’s
viewpoint
– Interview
– Objective
• Observable & measurable
– Physical assessment
– Labs
– Tests
iClicker
John is being admitted to the psychiatric facility, after
being transferred from the acute hospital with a
diagnosis of schizophrenia and multiple sclerosis. What
type of assessment should be performed on John?
A. Comprehensive
B. Focused
C. Ongoing
Small group questions:
1. Baby Jane a 2 month infant goes into the
doctor for her initial immunization and well
baby check-up. What type of assessment
should the nurse perform?
A. Comprehensive
B. Focused
C. Ongoing
Which one of the following is objective
data?
A. Nausea
B. Pain
C. Dizziness
D. Unsteady gait
E. Anxiety
Which one of the following is subjective data?
A. Vomiting
B. Warm, moist skin
C. Head ache
D. Bruise on the right arm
E. Temperature 99.3 o F
Diagnosis
• Step 2 in the
nursing process
Nursing diagnosis:
• “A clinical judgment…
• about an individual, family or
community…
• responses to actual or potential health
problems”
• Forms the basis for nursing
interventions
Medical vs. Nursing diagnosis
Medical diagnosis
Nursing diagnosis
Identifies conditions the
MD is licensed &
qualified to treat
Identifies situations the
nurse is licensed &
qualified to treat
Medical vs. Nursing diagnosis
Medical diagnosis
Nursing diagnosis
Identifies conditions the
MD is licensed &
qualified to treat
Identifies situations the
nurse is licensed &
qualified to treat
Focuses on illness,
injury or disease
processes
Focuses on the clients
responses to actual or
potential health / life
problems
Medical vs. Nursing diagnosis
Medical diagnosis
Nursing diagnosis
Remains constant
until a cure is
effected
Changes as the clients
response and/or the health
problem changes
Medical vs. Nursing diagnosis
Medical diagnosis
Nursing diagnosis
Remains constant
until a cure is
effected
Changes as the clients
response and/or the health
problem changes
i.e. Breast cancer
i.e. Knowledge deficit
Powerlessness
Grieving, anticipatory
Body image disturbance
Individual coping, ineffective
Diangosis
Nursing diagnosis
Medical diagnosis
Breathing patterns,
ineffective
Activity intolerance
Chronic obstructive
pulmonary disease
Cerebrovascular accident
Pain
Appendectomy
Body image disturbance
Amputation
Body temperature, risk for
altered
Strep throat
Planning & Outcome identification
• Step 3
Planning & Outcome identification
–Types of
planning
• Initial
• Ongoing
• Discharge
Planning & Outcome identification
• Outcome identification
= Goals
– Short term
• Hrs - days (< week)
– Long term
• Wks. – mons.
Planning & Outcome identification
• Interventions
– Independent interventions
• No MD order needed
– Interdependent interventions
• With interdisciplinary team member
– Dependent interventions
• MD order required
The nursing care plan includes
“administer digoxin per MD order”.
What type of intervention is this?
A. Dependent
B. Interdependent
C. Independent
Prioritizing Nrs Dx
• Maslow’s hierarchy of needs
Maslow’s Hierarchy of Needs
Maslow’s Hierarchy of Needs
• Physiological:
– Breathing, food, water, sleep, homeostasis,
excretion
– ABC’s
Maslow’s Hierarchy of Needs
• Safety
– Security of body, employment, resources,
morality, family, health or property
• Physiological
Maslow’s Hierarchy of Needs
• Love/Belonging
– Friendship, family, sexual intimacy
• Safety
• Physiological:
Maslow’s Hierarchy of Needs
• Esteem
– Self esteem, confidence, achievement, respect of
others, respect by others
• Love/Belonging
• Safety
• Physiological
Maslow’s Hierarchy of Needs
• Self-Actualization
– Creativity, spontaneity, problem solving, lack of
prejudice, acceptance of facts
•
•
•
•
Esteem
Love/Belonging
Safety
Physiological:
Which of the following client issues
should receive the highest priority?
A. John’s best friend just stormed out of the room
mad.
B. Todd feels like not one respects his work
C. Mary feels scared she is going to die
D. Anna feels like she is lacking in creativity
Which of the following client issues should
receive the highest priority?
A. George is climbing out of bed and he can’t walk
B. Paul is having a difficulty breathing
C. Susan is crying hysterically because she just found
out the person who was driving in the car with
her, died in the car accident.
D. Jane has severe hip pain due to post-op hip
surgery
Implementation
• 4th step:
– Execution of the care
plan
–DO IT
–DO IT RIGHT
–DO IT RIGHT
NOW!
•
•
•
•
•
•
Direct
Assist
Supervise
Delegate
Teach
Monitor
Implementation
• 5 Rights of Implementation
1)
2)
3)
4)
5)
Right patient
Right medication
Right route
Right dose / amount
Right time
Evaluation
• 5th step
– Have the clients goals
have been met,
partially met or not
met.
Small group questions:
1. What is the purpose of the nursing process
and where is it used?
2. Name & describe the steps of the nursing
process
3. Explain the difference between objective
and subjective data.
4. Define holistic and explain how it relates to
nursing.
Role of the LVN & Psych Tech
• Use the nrs process
• Contribute to Dx & nrs
care plan
• Provide info
• Implement
• The RN has ultimate
responsibility
Critical Thinking & the Nursing Process
• Critical thinking
• Thinking like a nurse
Critical Thinking
•
•
•
•
Inquisitive
Open-minded
Flexible
Fairminded