Nursing Process Unit III
NURS 2210
Nancy Pares, RN, MSN
Metro Community College
RN Role in developing nursing dx
• First used in 1953, but not implemented until
1974
• Currently five steps
– Assessment, diagnosis, outcome identification,
implementation, evaluation
• Emphasis on professionalism, accountability,
multiculturalism and scientific method of
problem solving
Comparison of nursing vs medical
model
medical
• Focuses on illness, injury or
disease process
nursing
• Focus on responses to
actual or potential diseases
• Remains constant until
cured
• Changes as client condition
changes
• Identifies conditions that
can be treated by qualifying
healthcare practitioner
• Identifies situations in
which the nurse is qualified
to intervene
Assessment Step 1
• Collection of data, organizing data, validating
data, identifying patterns, recording data
• Primary source
• Secondary source
• Subjective vs objective
Types of nursing diagnosis
• Actual
– Problem exists
• Risk
– Factors are present to cause problem
• Possible
– Problem could arise unless preventative action
taken
• Wellness
– ‘potential for enhanced…’; expressed desire
Developing Nursing dx- Step 2
• What are the problems?
• What are causes? Risk factors?
• Could a problem occur if prevention not
taken?
• What data is needed to answer these
questions?
• If more than one problem…which is priority?
Planning- Step 3
• List priority of nursing dx
– Use critical thinking- what needs attention first?
• Long and short term goals are written
– SMART
• Specific interventions are developed
• Plan of care is recorded
Implementation- Step 4
• Communicate with team to solve complex
problems
• Accurately report data and clues
• RN needs to know what can be delegated
• Is there a need to alter the intervention?
Evaluation- Step 5
• Was the goal met? Why not?
– Assessment incomplete
– Goal not SMART
– Goal not appropriate for individual client
Maslow’s Priority of Care
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Physiologic
Safety and security
Love and belonging
Self esteem
Self actualization
Delegation decision tree
• Are there rules and laws in place supporting the rules of
delegation?
• Is the task within the scope of practice
• Has there been an assessment of the client needs
• Is the person being delegated tasks competent
• Does the ability of the caregiver match the needs of the client
• Can the task be completed without nursing judgment
• Is the result of the task predictable
• Can the task be safely performed according to directions
• Can the task be completed without repeat assessment
• Is the appropriate supervision available
NCLEX questions LPN –cannot:
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Do new admission assessments
Give IV push meds
Write nursing diagnosis
Do complex skills
Care for clinically unstable clients
Care for clients with acute conditions
NCLEX– UAP/CNA
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Lowest level of skill
Least complicated task
Most stable
Look for client with chronic illness
Client care needs
RN
Admission Assessment
IV meds/blood products
Care plan
Client teaching
Unstable clients/acute
LPN
UAP
Vital signs
Feeding
Uncomplicated skills
Basic skills
Stable clients/chronic
Stable clients/chronic
Oral and IM meds
ambulation
• The nursing dx, ‘alteration in skin integrity R/T
immobility as manifested by Stage 1 pressure
ulcer on coccyx ‘ is what type of nursing dx?
• 1. Risk
• 2. Possible
• 3. Wellness
• 4. Actual
• Which of the following is an accurate
summary of the difference between medical
and nursing dx.?
• 1. Nursing dx determined by med dx
• 2. Med dx can be treated by nurse
• 3. Nursing dx reflects a human response to
actual problem
• 4. Only physicians can treat a pathophysiology.
• Client will ambulate 20 ft with walker twice a
day. Which phase of nursing process is this?
• 1. assessment
• 2. planning
• 3. implementing
• 4. evaluation
• An example of an independent nursing
intervention is:
• 1. admin IV fluids for client with nutritional
impairment
• 2. turning and repositioning q 2 hr
• 3. ordering chest xray for client with
breathing problem
• 4. reviewing lab values and reordering tests
for abnormal values.
• Using aseptic techniques, a nurse
demonstrates insulin preparation to a client.
This is an example of which phase of nursing
process?
• When a task is delegated, the role of the nurse
is to
• 1. validate the skill level of the care provider
• 2. assume the task was completed as
expected
• 3. allow the care provider independence
• 4. review care provider notes
• You determine that the client has not met an
expected outcome..What action do you take?
• 1. call a meeting of team
• 2. ask the client why the goal was not
accomplished
• 3. call for a nursing consultation
• 4. review and revise the care plan
• A nursing audit is used to evaluate
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1. the nursing process
2. institutional standards
3. quality of nursing care
4. client outcomes and goal achievement
• The purpose of evaluation is
• 1. determine whether problems are resolved
• 2. determine if the nurse developed outcome
criteria for the client
• 3. select appropriate goals and objectives
• 4. develop a time frame for completing the
nurse client relationship.