c h a p t e r
2
Nursing Process
Words to Know
actual diagnosis
assessment
collaborative problems
critical thinking
data base assessment
diagnosis
evaluation
focus assessment
goal
implementation
long-term goals
nursing diagnosis
nursing orders
Learning Objectives
nursing process
objective data
planning
possible diagnosis
potential diagnosis
short-term goals
signs
standards for care
subjective data
symptoms
syndrome diagnosis
wellness diagnosis
On completion of this chapter, the reader will:
●
●
●
●
●
●
●
●
●
●
●
●
Define nursing process.
Describe six characteristics of the nursing process.
List five steps in the nursing process.
Identify four sources for assessment data.
Differentiate between a data base assessment and a focus assessment.
Distinguish between a nursing diagnosis and a collaborative problem.
List three parts of a nursing diagnostic statement.
Describe the rationale for setting priorities.
Discuss appropriate circumstances for short-term and long-term goals.
Identify four ways to document a plan of care.
Describe the information that is documented in reference to the plan
of care.
Discuss three outcomes that result from evaluation.
I
n the distant past, nursing practice consisted of actions
based mostly on common sense and the examples set by
older, more experienced nurses. The actual care of clients
tended to be limited to the physician’s medical orders.
Although nurses today continue to work interdependently with physicians and other health care practitioners,
they now plan and implement client care more independently. In even stronger terms, nurses are held responsible and accountable for providing client care that is
appropriate and reflects currently accepted standards for
nursing practice.
DEFINITION OF THE
NURSING PROCESS
CHARACTERISTICS OF THE
NURSING PROCESS
●
The nursing process has seven distinct characteristics:
●
A process is a set of actions leading to a particular goal. The
nursing process is an organized sequence of problemsolving steps used to identify and to manage the health
16
problems of clients (Fig. 2-1). It is the accepted standard
for clinical practice established by the American Nurses
Association (ANA) (Box 2-1).
The nursing process is the framework for nursing
care in all health care settings. When nursing practice
follows the nursing process, clients receive quality care
in minimal time with maximal efficiency.
• Within the legal scope of nursing. Most state nurse
practice acts define nursing as an independent
problem-solving role that involves the diagnosis and
treatment of human responses to actual or potential
health problems.
CHAPTER 2
Assessment
1. Collect data
2. Organize data
Evaluation
1. Monitor client
outcomes
2. Resolve, continue,
revise the current
plan for care
Diagnosis
1. Analyze data
2. Identify nursing
diagnoses and
collaborative problems
Implementation
1. Carry out the
nursing orders
2. Document the
nursing care and
client responses
Planning
1. Prioritize problems
2. Identify measurable
outcomes (goals)
3. Select nursing
interventions
4. Document the plan of
care
FIGURE 2.1 The steps in the nursing process.
• Based on knowledge. The ability to identify and to
resolve client problems requires critical thinking,
which is a process of objective reasoning or analyzing
facts to reach a valid conclusion. Critical thinking
enables nurses to determine which problems necessitate collaboration with the physician and which fall
within the independent domain of nursing. Critical thinking helps nurses select appropriate nursing interventions for achieving predictable outcomes.
• Planned. The steps of the nursing process are organized and systematic. One step leads to the next in
an orderly fashion.
BOX 2-1
●
Standards of Clinical Nursing Practice
STANDARD I. ASSESSMENT
The nurse collects patient health data.
STANDARD II. DIAGNOSIS
The nurse analyzes the assessment data in determining diagnoses.
● Nursing Process
• Client-centered. The nursing process makes it easier
to formulate a comprehensive and unique plan of
care for each client. Clients are expected, whenever
possible, to actively participate in their care.
• Goal-directed. The nursing process involves a united
effort between the client and the nursing team to
achieve desired outcomes.
• Prioritized. The nursing process provides a focused
way to resolve the problems that represent the greatest threat to health.
• Dynamic. Because the health status of any client is
constantly changing, the nursing process acts like a
continuous loop. Evaluation, the last step in the
nursing process, involves data collection, beginning
the process again.
STEPS OF THE NURSING PROCESS
STANDARD V. IMPLEMENTATION
The nurse implements the interventions identified in the plan of care.
STANDARD VI. EVALUATION
The nurse evaluates the patient’s progress toward attainment of outcomes.
Reprinted with permission from American Nurses Association. (1998). Standards of
clinical nursing practice, (2nd ed.). Washington, DC: American Nurses Association.
●
The steps of the nursing process, each of which is discussed in detail throughout this chapter, are as follows:
1.
2.
3.
4.
5.
Assessment
Diagnosis
Planning
Implementation
Evaluation
Assessment
Assessment, the first step in the nursing process, is the
systematic collection of facts, or data. Assessment begins
with the nurse’s first contact with a client and continues
as long as a need for healthcare exists. During assessment,
the nurse collects information to determine areas of abnormal function, risk factors that contribute to health
problems, and client strengths (Alfaro-LeFevre, 2002).
Types of Data
Data are either objective or subjective (Box 2-2). Objective data are observable and measurable facts and are
referred to as signs of a disorder. An example is a client’s
STANDARD III. OUTCOME IDENTIFICATION
The nurse identifies expected outcomes individualized to the patient.
STANDARD IV. PLANNING
The nurse develops a plan of care that prescribes interventions to attain
expected outcomes.
17
BOX 2-2
●
Examples of Objective and
Subjective Data
OBJECTIVE DATA
Weight
Temperature
Skin color
Blood cell count
Vomiting
Bleeding
SUBJECTIVE DATA
Pain
Nausea
Depression
Fatigue
Anxiety
Loneliness
18
UNIT 1 ● Exploring Contemporary Nursing
blood pressure measurement. Subjective data consist of
information that only the client feels and can describe,
and are called symptoms. An example is pain.
the client’s initial problems. Comparisons of ongoing
assessments with baseline data help determine if the
client’s health is improving, deteriorating, or remaining
unchanged.
Stop, Think, and Respond ● BOX 2-1
Which of the following represent objective data?
A. A client rates his pain as 8 on a scale of 0 to10,
with 10 being the most pain he has ever
experienced.
B. A client has an incisional scar in the right lower
quadrant of the abdomen.
C. A client says she slept very well and feels rested.
D. A client’s blood pressure is 165/86 mm Hg.
E. A client’s heart rate is irregular.
Sources for Data
The primary source for information is the client. Secondary sources include the client’s family, reports, test
results, information in current and past medical records,
and discussions with other health care workers.
FOCUS ASSESSMENT. A focus assessment is information
that provides more details about specific problems and
expands the original data base. For instance, if during the
initial interview the client tells the nurse that constipation
is more often the rule than the exception, more questions
follow. The nurse obtains data about the client’s dietary
habits, level of activity, fluid intake, current medications,
frequency of bowel elimination, and stool characteristics.
The nurse may ask the client to save a stool specimen for
inspection.
Focus assessments generally are repeated frequently
or on a scheduled basis to determine trends in a client’s
condition and responses to therapeutic interventions.
Examples include conducting postoperative surgical
assessments (see Chap. 27), monitoring the client’s level
of pain before and after administering medications, and
checking the neurologic status of a client with a head
injury.
Types of Assessments
There are two types of assessments: a data base assessment and a focus assessment (Table 2-1).
DATA BASE ASSESSMENT. A data base assessment (initial information about the client’s physical, emotional,
social, and spiritual health) is lengthy and comprehensive.
The nurse obtains data base information during the admission interview and physical examination (see Chap. 12).
Health care facilities generally provide a printed form to
use as a guide (Fig. 2-2). Information obtained during a
data base assessment serves as a reference for comparing
all future data and provides the evidence used to identify
TABLE 2.1
Organization of Data
Interpreting data is easier if information is organized.
Organization involves grouping related information. For
example, consider the following list of words: apple,
wheels, orchard, pedals, tree, and handlebars. At first
glance, they appear to be a jumble of terms. If asked to
cluster the related terms, however, most people would correctly group apple, tree, and orchard together, and wheels,
pedals, and handlebars together.
Nurses organize assessment data in much the same
way. Using knowledge and past experiences, they cluster
related data (Box 2-3). Data organized into small groups
COMPARISON OF DATA BASE AND FOCUS ASSESSMENTS
DATA BASE ASSESSMENT
FOCUS ASSESSMENT
Obtained on admission
Consists of predetermined questions and systematic head-totoe examination
Performed once
Suggests possible problems
Findings documented on an admission assessment form
Time-consuming; may take 1 hour or more
Supplies a broad, comprehensive volume of data
Provides breadth for future comparisons
Reflects the client’s condition on entering the health
care system
Compiled throughout subsequent care
Consists of unstructured questions and collection of physical
assessments
Repeated each shift or more often
Rules out or confirms problems
Findings documented on a checklist or in progress notes
Completed in a brief amount of time (about 15 minutes)
Collects limited data
Adds depth to the initial data base
Provides comparative trends for evaluating the client’s
response to treatment
CHAPTER 2
● Nursing Process
FIGURE 2.2 One page of a multipage admission assessment form is shown. (Courtesy of the Community
Health Center of Branch County, Coldwater, MI.)
19
20
UNIT 1 ● Exploring Contemporary Nursing
BOX 2-3
●
Organization of Data
ASSESSMENT FINDINGS
Lassitude; distended abdomen; dry, hard stool passed with difficulty; fever;
weak cough; thick sputum
RELATED CLUSTERS
Lassitude, fever
Weak cough, thick sputum
Distended abdomen; dry, hard stool passed with difficulty
is more easy to analyze and takes on more significance
than when the nurse considers each fact separately or
examines the entire group at once.
Stop, Think, and Respond ● BOX 2-2
TABLE 2.2
CATEGORIES OF
NURSING DIAGNOSES
TYPE
EXPLANATION AND EXAMPLE
Actual diagnosis
A problem that currently exists
Impaired Physical Mobility related to
pain as evidenced by limited range
of motion, reluctance to move
A problem the client is uniquely
at risk for developing
Risk for Deficient Fluid Volume
related to persistent vomiting
A problem may be present, but
requires more data collection
to rule out or confirm its
existence
Possible Parental Role Conflict
related to impending divorce
Cluster of problems predicted to
be present because of an event
or situation (Carpenito, 2004)
Rape Trauma Syndrome and Disuse
Syndrome
A health-related problem with
which a healthy person obtains
nursing assistance to maintain
or perform at a higher level
Potential for Enhanced Breastfeeding
Risk diagnosis
Possible diagnosis
Syndrome diagnosis
Organize the following data into two related
clusters: cough, dry skin, infrequent urination,
fever, nasal congestion, thirst.
Wellness diagnosis
Diagnosis
Diagnosis, the second step in the nursing process, is
the identification of health-related problems. Diagnosis
results from analyzing the collected data and determining whether they suggest normal or abnormal findings.
categories, the nurse can use his or her own terminology
when stating the nursing diagnosis.
Nursing Diagnoses
Nurses analyze data to identify one or more nursing diagnoses. A nursing diagnosis is a health issue that can be
prevented, reduced, resolved, or enhanced through independent nursing measures. It is an exclusive nursing
responsibility. Nursing diagnoses are categorized into five
groups: actual, risk, possible, syndrome, and wellness
(Table 2-2).
THE NANDA LIST. The ANA has designated the North
American Nursing Diagnosis Association (NANDA) as
the authoritative organization for developing and approving nursing diagnoses. NANDA is the clearinghouse for
proposals suggesting diagnoses that fall within the independent domain of nursing practice. NANDA reviews the
proposals for appropriateness. While research is ongoing,
NANDA incorporates its findings into a list published for
clinical use. The most recent index, which is revised every
2 years, is provided on the inside cover.
Although entries in the NANDA list change, most
authorities believe that nurses should use the language of
approved diagnoses whenever possible. When a client’s
problem does not fit into any of the NANDA-approved
DIAGNOSTIC STATEMENTS. A nursing diagnostic statement
contains one to three parts:
1. Name of the health-related issue or problem as
identified in the NANDA list
2. Etiology (its cause)
3. 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” (Box 2-4).
Different types of diagnoses have different stems.
Potential diagnoses are prefaced with the term “risk for,” as
BOX 2-4
●
Parts of a Nursing Diagnostic Statement
1. Disturbed Sleep Pattern = problem
2. Related to excessive intake of coffee = etiology
3. As manifested by difficulty in falling asleep, feeling tired during the day,
and irritability with others = signs and symptoms
CHAPTER 2
in Risk for Impaired Skin Integrity related to inactivity.
The word “possible” is used in a diagnostic statement to
indicate uncertainty—for example, Possible Sexual Dysfunction related to anxiety. Wellness diagnoses are prefaced with the phrase “Potential for enhanced.”
Potential and possible nursing diagnoses do not
include the third part of the statement. In potential nursing diagnoses, the signs or symptoms have not yet been
manifested; in possible nursing diagnoses, the data are
incomplete. The factors that place the client at risk or
make the nurse suspect such a diagnosis, however, are
identified in the nursing assessment documentation. Syndrome diagnoses and wellness diagnoses are one-part
statements; they are not linked with an etiology or signs
and symptoms.
Nursing diagnoses
Collaborative
problems
Nursing
21
Medical diagnoses
Other health care professionals
(medicine, social services, etc.)
FIGURE 2.3 These two overlapping circles illustrate that the nurse
independently treats nursing diagnoses. Doctors, other health professionals, and nurses work together on collaborative problems.
Collaborative Problems
Collaborative problems are physiologic complications
whose treatment requires both nurse- and physicianprescribed interventions. They represent an interdependent domain of nursing practice (Fig. 2-3). The nurse is
specifically responsible and accountable for:
• 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
• Reporting trends that suggest development of complications
• Managing the emerging problem with nurse- and
physician-prescribed measures
• Evaluating the outcomes
Collaborative problems are identified on a client’s plan
for care with the abbreviation PC, which stands for Potential Complication (Table 2-3). Because a collaborative
problem requires the nurse to use diagnostic processes,
some nursing leaders are proposing use of the term “collaborative diagnosis” instead (Alfaro-LeFevre, 2002).
TABLE 2.3
● Nursing Process
Stop, Think, and Respond ● BOX 2-3
Which of the following nursing diagnostic statements is written correctly based on the data and
the information in this chapter?
Data: The client eats only bites of the food
served. She has lost 15 lbs in the last 3 weeks and
currently weighs 130 lbs, which is more than 10%
underweight for her height. She has been experiencing chronic vomiting after eating for the last
3 weeks and is physically weak.
1. Risk for Imbalanced Nutrition: Less than Body
Requirements related to vomiting
2. Imbalanced Nutrition: Less than Body Requirements related to inadequate intake of food
secondary to vomiting as manifested by caloric
intake below daily requirements, recent weight
loss of 15 lbs, and current weakness
3. Weight Loss related to vomiting as evidenced
by reduced intake of food
4. Possible Malnutrition due to inadequate
consumption of nutrients
CORRELATION OF COLLABORATIVE PROBLEMS
MEDICAL DIAGNOSIS OR MEDICAL TREATMENT
POSSIBLE CONSEQUENCE
COLLABORATIVE PROBLEM
Myocardial infarction (heart attack)
Heart failure
Severe burns
HIV positive (infected with AIDS virus)
Gastric decompression
(suctioning stomach fluid)
Cardiac catheterization (inserting a
catheter into the heart)
Abnormal heart rhythm
Fluid in the lungs
Serum moves into tissue, depleting blood volume
Decreased blood cells that fight infection
Removes acid and electrolytes
PC: Dysrhythmias
PC: Pulmonary edema
PC: Hypovolemic shock
PC: Immunodeficiency
PC: Alkalosis
PC: Electrolyte imbalance
PC: Hemorrhage
Arterial bleeding
22
UNIT 1 ● Exploring Contemporary Nursing
Planning
BOX 2-5
The third step in the nursing process is planning, or the
process of prioritizing nursing diagnoses and collaborative problems, identifying measurable goals or outcomes,
selecting appropriate interventions, and documenting the
plan of care. Whenever possible, the nurse consults the
client while developing and revising the plan.
●
Goals versus Outcomes
GOAL
The client will be well hydrated by 8/23.
OUTCOME
The client will have adequate hydration as evidenced by an oral intake
between 2,000–3,000 mL/24 hours and a urine output ± 500 mL of the
intake amount by 8/23.
Setting Priorities
Not all clients’ problems can be resolved in a brief time.
Therefore, it is important to determine which problems
require the most immediate attention. This is done by setting priorities. Prioritization involves ranking from those
that are most serious or immediate to those of lesser
importance.
There is more than one way to determine priorities.
One method nurses frequently use is Maslow’s Hierarchy
of Human Needs (see Chap. 4). Problems interfering with
physiologic needs have priority over those affecting other
levels of needs (Table 2-4). The ranking can change as
problems are resolved or new problems develop.
Establishing Goals
are sometimes used interchangeably, outcomes are generally more specific (Box 2-5). What is important is that
the goal statement or outcome contains the criteria
or objective evidence for verifying that the client has
improved. Depending on the agency, nurses may identify
short-term goals, long-term goals, or both.
SHORT-TERM GOALS. Nurses use short-term goals (outcomes achievable in a few days to 1 week) most often in
acute care settings, because most hospital stays are no
longer than 1 week. Short-term goals have the following
characteristics (Box 2-6):
• Developed from the problem portion of the diagnostic
A goal (expected or desired outcome) helps the nursing
team know whether the nursing care has been appropriate for managing the client’s nursing diagnoses and
collaborative problems. Therefore, a written goal accompanies each one. Although the terms goal and outcome
statement
• Client-centered, reflecting what the client will accomplish, not the nurse
• Measurable, identifying specific criteria that provide evidence that the goal has been reached
• Realistic, to avoid setting unattainable goals, which
can be self-defeating and frustrating
TABLE 2.4
PRIORITIZING NURSING
DIAGNOSES
HUMAN NEED
EXAMPLES OF NURSING DIAGNOSES
Physiologic
Inbalanced Nutrition: Less than Body
Requirements
Ineffective Breathing Pattern
Pain
Impaired Swallowing
Urinary Retention
Risk for Injury
Impaired Verbal Communication
Disturbed thought Processes
Anxiety
Fear
Social Isolation
Impaired Social Interactions
Interrupted Family Processes
Parental Role Conflict
Disturbed Body Image
Powerlessness
Caregiver Role Strain
Ineffective Breastfeeding
Delayed Growth and Development
Spiritual Distress
Safety and security
Love and belonging
Esteem and
self-esteem
Self-actualization
• Accompanied by a target date for accomplishment,
the predicted time when the goal will be met. Identifying a target date builds a time line for evaluation
into the nursing process.
LONG-TERM GOALS. Nurses generally identify long-term
goals (desirable outcomes that take weeks or months to
accomplish) for clients who have chronic health problems
BOX 2-6
●
Components of Short-Term Goals
NURSING DIAGNOSTIC STATEMENT
Constipation related to decreased fluid intake, lack of dietary fiber, and lack
of exercise as manifested by no normal bowel movement for the past 3 days,
abdominal cramping, and straining to pass stool
SHORT-TERM GOAL
The client will
client–centered
have a bowel movement
identifies measurable criteria that
reflect the problem portion of the
diagnostic statement
in 2 days (specify date)
identifies a target date for achievement within a realistic time frame
CHAPTER 2
that require extended care in a nursing home or who receive community health services or home health care. An
example of a long-term goal for the client with a cerebrovascular accident (stroke) is the return of full or partial
function to a paralyzed limb. The client is unlikely to
have achieved this goal by the time of discharge. If a client
achieves short-term goals in the hospital, however, he or
she is more likely to achieve long-term goals during home
care or in other community settings.
GOALS FOR COLLABORATIVE PROBLEMS. Goals for collaborative problems are written from a nursing rather than
from a client perspective. They focus on what the nurse
will monitor, report, record, or do to promote early detection and treatment (Alfaro-LeFevre, 2002).
The format for writing a nursing goal is, “The nurse
will manage and minimize (identify complication) by
(insert evidence of assessment, communication, and treatment activities),” or “(identify complication) will be managed and minimized by (evidence).” For example, if the
nurse identifies gastrointestinal bleeding as a PC, he or she
could state the goal, “The nurse will examine emesis and
stools for blood and report positive test findings, changes
in vital signs, and decreased red blood cell counts to the
physician” or “Gastrointestinal bleeding will be managed
and minimized as evidenced by negative Hemoccult tests,
red blood cell count greater than 2.5 million/dL, and vital
signs within normal ranges.”
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. The nurse selects strategies based on the knowledge that certain nursing actions produce desired effects.
Whatever interventions are planned, they must be safe,
within the legal scope of nursing practice, and compatible with medical orders.
Initial interventions generally are limited to selected
measures with the potential for success. Nurses should
reserve some interventions in case the client does not
accomplish the goal.
Documenting the Plan of Care
Plans of care can be written by hand (Fig. 2-4), standardized, computer-generated, or based on an agency’s written
standards or clinical pathways. Whatever method is used,
the Joint Commission on Accreditation of Healthcare
Organizations (JCAHO) requires that every client’s medical record provide evidence of the planned nursing interventions for meeting the client’s needs (Carpenito, 2004).
Nursing orders (directions for a client’s care) identify the what, when, where, and how for performing
nursing interventions. They provide specific instructions
so that all health team members understand exactly what
● Nursing Process
23
to do for the client (Box 2-7). Nursing orders are also
signed to indicate accountability.
Standardized care plans are preprinted. Both computergenerated and standardized plans provide general suggestions for managing the nursing care of clients with a
particular problem. It is up to the nurse to transform the
generalized interventions into specific nursing orders and
to eliminate whatever is inappropriate or unnecessary.
Agency-specific standards for care (policies that indicate which activities will be provided to ensure quality
client care) and clinical pathways (see Chap. 1) relieve the
nurse from writing time-consuming plans. Both tools help
nurses use their time efficiently and ensure consistent
client care.
Communicating the Plan of Care
Clients need consistency and continuity of care to achieve
goals. Therefore, the nurse shares the plan of care with
nursing team members, the client, and the client’s family.
In some agencies, the client signs the plan of care.
The plan of care is a permanent part of the client’s medical record. It is placed in the client’s chart, kept separately
at the client’s bedside, or located in a temporary folder at
the nurses’ station for easy access. Wherever it is located,
each nurse assigned to the client refers to it daily, reviews
it for appropriateness, and revises it according to changes
in the client’s condition.
Implementation
Implementation, the fourth step in the nursing process,
means carrying out the plan of care. The nurse implements medical orders as well as nursing orders, which
should complement each other. Implementing the plan
involves the client and one or more members of the health
care team. A wide circle of care providers with assorted
roles may be called on to participate, either directly or indirectly, in carrying out one client’s plan of care (Fig. 2-5).
The medical record is legal evidence that the plan of
care has been more than just a paper trail. The information in the chart shows a correlation between the plan
and the care that has been provided. In other words, the
nurse’s charting (see Chap. 9) reflects the written plan.
Nurses are just as accountable for carrying out nursing
orders as they are for physician’s orders.
In addition to identifying the nursing interventions that
have been provided, the record also describes the quantity
and quality of the client’s response. Quoting the client
helps identify his or her point of view and safeguards
against incorrect assumptions. In short, appropriate documentation maintains open lines of communication among
members of the health care team, ensures the client’s continuing progress, complies with accreditation standards,
and helps ensure reimbursement from government or private insurance companies.
24
UNIT 1 ● Exploring Contemporary Nursing
Name: Mrs. Rita Williard
Age: 68
Date of Admission: 11/10
Diagnosis on admission: CVA c left-sided weakness
Nursing diagnosis: Impaired Physical Mobility, High Risk for Injury, Situational Low Self-esteem
Long-term goals: Independent mobility using walker or quad cane, record of personal safety, positive self-regard
DATE
11/10
11/10
12/2
PROBLEM
GOAL
TARGET DATE
#1
The client will stand
Impaired Physical
Mobility related to left and pivot from bed to
wheelchair or commode.
sided weakness as
manifested by decreased
muscle strength in left
leg and arm, slowed
gait, dragging foot.
#2
Risk for Injury
related to motor
deficit
#3
Situational Low
Self-Esteem related
to dependence on
others as manifested
by statements, “I need
as much help as a
baby; I feel so useless;
How embarrassing to
be so dependent.”
NURSING ORDERS
11/24
1) Passive ROM t.i.d. to
left arm and leg
2) Physical therapy b.i.d.
for practice at parallel bars
3) Apply left leg brace and
sling to left arm when up
4) Assist to balance on
right leg at bedside before
and after physical therapy
daily
C. Meyer, RN
The client will
transfer from bed to
wheelchair without
injury
12/1
1) Keep side rails up and
trapeze over bed
2) Use shoe & nonskid sole
on right foot (leg brace
on left) before transfer
3) Dangle for 5 minutes
before attempting to stand
4) Lock wheels on wheelchair
before transfer
5) Obtain help of second
assistant
6) Block left foot to avoid
slipping during pivot
7) Place signal light on
right side within reach
at all times
C. Meyer, RN
The client will
identify one or more
examples of improved
mobility and
self-care
12/18
1.) Allow to express feelings
without disagreeing or
interrupting.
2.) Reinforce concept that
the right side of body is
unaffected.
3.) Help to set and
accomplish one realistic
goal daily.
S. Moore, RN
FIGURE 2.4 Sample nursing care plan.
Evaluation
Evaluation, the fifth and final step in the nursing process,
is the way by which nurses determine whether a client has
reached a goal. Although this is considered the last step,
the entire process is ongoing. By analyzing the client’s
response, evaluation helps to determine the effectiveness
of nursing care (Table 2-5).
Before revising a plan of care, it is important to discuss any lack of progress with the client. In this way,
both nurse and client can speculate on what activities
need to be discontinued, added, or changed. Other health
CHAPTER 2
BOX 2-7
●
25
● Nursing Process
Nursing Orders
NURSING ORDER
Encourage fluids.
Pharmacist
Laboratory
Technician
WEAKNESSES
Lacks specificity
Likely to be interpreted differently
May result in inconsistent or less than adequate care
IMPROVEMENT
Provide 100 mL of oral fluid every hour while awake.
Dietitian
LPN
team members who are familiar with a particular client
or problems similar to those of the client may offer their
expertise as well. The evaluation of a client’s progress
may be the subject of a nursing team conference. Some
units even invite the client and family to participate.
MD
RN
Physical
Therapist
CLIENT
Unlicensed
Assistive Personnel
Respiratory
Therapist
FIGURE 2.5 Members of the health care team.
USE OF THE NURSING PROCESS
●
Use of the nursing process is the standard for clinical
nursing practice. Nurse practice acts hold nurses accountable for demonstrating all the steps in the nursing process
when caring for clients. To do less implies negligence.
More detailed discussions of the nursing process can be
found in specialty texts and in some of the suggested readings at the end of this chapter. Nursing Guidelines 2-1
reiterate the sequence of the nursing process.
Critical Thinking Exercises
1. If an unconscious client is brought to the nursing unit, how can
a nurse gather data?
TABLE 2.5
2. Three nursing diagnoses are on a client’s plan of care: Ineffective Breathing Pattern, Social Isolation, and Anxiety. Which
has the highest priority, and why?
3. A nurse, while reviewing a client’s plan of care, notices that the
client has made no progress in accomplishing the goal by its
projected target date. What actions are appropriate at this time?
●
NCLEX-STYLE REVIEW QUESTIONS
1. When managing the care of a client, which of the following nursing actions is most appropriate to perform first?
1. Develop a plan of care.
2. Determine the client’s needs.
3. Assess the client physically.
4. Collaborate on goals for care.
OUTCOMES FROM EVALUATION
ANALYSIS
REASON
ACTION
The client has reached the
goals.
The client has made some
progress.
Plan was effective and implemented
consistently.
Care has been inconsistent.
Target date was too ambitious.
Client’s response has been less than expected.
Discontinue the nursing orders.
The client has made no
progress.
The initial diagnosis was inaccurate.
New problems have occurred.
The target date was unrealistic.
Nursing interventions were ineffective.
Check that nursing orders are clear and specific.
Continue care as planned; readjust target date.
Revise the plan by adding nursing interventions
or more frequent implementation.
Revise problem list; write new goals and
nursing orders.
Add new problems, goals, and nursing orders.
Revise expected date for achievement.
Add new nursing orders; discontinue ineffective
measures; readjust target date.
26
UNIT 1 ● Exploring Contemporary Nursing
NURSING GUIDELINES 2-1
Using the Nursing Process
■
Collect information about the client. Data collection is the basis for
identifying problems.
■
Organize the data. Organizing related data simplifies the process of
analysis.
■
Discuss the plan with nursing team members, the client, and family.
Verbally sharing the plan ensures that everyone is informed and
goal-directed.
■
Put the plan into action. Work produces results.
■
Analyze the data for what is normal and abnormal. Abnormalities
provide clues to the client’s problems.
■
Observe the client’s responses. Evaluating outcomes is the basis for
determining the effectiveness of the plan of care.
■
Identify actual, risk, possible, syndrome, and wellness nursing
diagnoses and collaborative problems. Problem identification directs
the nurse to select methods for maintaining or restoring the client’s
health.
■
Chart all nursing activities and the client’s responses.
Documentation demonstrates that the planned care has been
implemented and provides information about the client’s progress.
■
■
Prioritize the problem list. Setting priorities targets problems that
require the most immediate attention.
Compare the client’s responses with the goal criteria. If the planned
care is appropriate, there should be some measure of progress
toward accomplishing goals.
■
Set goals with specific criteria for evaluating whether the problems
have been prevented, reduced, or resolved. Goals predict the
expected outcomes from nursing care.
■
Discuss the progress, or lack of it, with the client, family, and other
nursing team members. Pooling resources may provide better
alternatives when revising the plan of care.
■
Select a limited number of appropriate nursing interventions. The
nurse uses scientific knowledge to determine which measures will be
most effective in accomplishing the goals of care.
■
Change the plan in areas that are no longer appropriate. The
nursing care plan changes according to the needs of the client.
■
■
Give specific directions for nursing care. Specific directions promote
consistency and continuity among caregivers.
Continue to implement and evaluate the revised plan of care. The
nursing process is a continuous sequence of actions that is repeated
until the goals have been met.
■
Document the plan for care using whatever written format is
acceptable. A written plan provides a means of communication
and reference for the nursing team to follow.
2. According to most nurse practice acts, if a charge nurse
assigns a licensed practical nurse to admit a new client,
the licensed practical nurse’s primary role is to
1. Create an initial nursing care plan.
2. Gather basic information from the client.
3. Develop a list of the client’s nursing diagnoses.
4. Report assessment data to the client’s physician.
3. At a team conference, staff members discuss a client’s
nursing diagnoses. A nursing assistant questions which
nursing diagnosis is of highest priority. From the list that
follows, the licensed practical nurse is most accurate in
identifying:
1. Ineffective Airway Clearance
2. Ineffective Coping
3. Deficient Diversional Activity
4. Interrupted Family Processes
References and Suggested Readings
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literature. Quality in Aging, 2(4), 33–41.
Beyea, A. (1999). Viewpoint. Nursing diagnosis or patient
problem? Nursing Diagnosis, 10(1), 32–34.
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CHAPTER 2
Myrick, F., & Yonge, O. (2002). Preceptor questioning and student critical thinking. Journal of Professional Nursing, 18(3),
176–181.
North American Nursing Diagnosis Association. (2001). Nursing diagnoses: Definitions and classifications 2001–2002.
Philadelphia: Author.
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● Nursing Process
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Taylor, C. (2002). Assessing patients’ needs: Does the same
information guide expert and novice nurses? International
Nursing Review, 49(1), 11–19.
Thoroddsen, A., & Thorsteinsson, H. S. (2002). Nursing diagnosis taxonomy across the Atlantic Ocean: Congruence
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Webster, J. (2002). Client-centered goal planning. Nursing
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Visit the Connection site at http://connection.lww.com/go/
timbyFundamentals for links to chapter-related resources on
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