The Nursing Process
Craven Unit 2 – Ch. 10-14
Cathi Collings MSN
& Peggy Korman CNM
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Chapter 11:
Nursing Assessment
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Nursing Process
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Nursing Assessment Activities
–Collection of data
–Validation of data
–Organization of data
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Preparing for Assessment
• Types of assessment
–Admission assessment
–Focused assessment
–Time-lapse assessment
–Emergency assessment
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NCLEX Question ?????
Which of the following is done to evaluate
any changes in the patient’s functional
health from baseline?
a. Focus assessment
b. Time-lapse assessment
c. Emergency assessment
d. Initial assessment
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Preparing for Assessment
• Setting and environment
– Quiet, private setting
– Restricted or secluded
– Minimal distractions
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Assessment Skills
• Observation
– Vision
– Smell
– Hearing
– Touch
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• Interviewing
– Preparatory
phase
– Introductory
phase
– Maintenance
phase
– Concluding
phase
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Assessment During an Interview
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Assessment Skills
• Physical examination techniques
– Inspection
– Palpation
– Percussion
– Auscultation
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Data Collection
• Types of data
– Subjective
– Objective
• Sources of data
– Primary
– Secondary
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Question
Tell whether the following statement is true
or false:
Bowel sound is an example of objective
data.
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Validate Data
• Comparing cues to normal function
• Referring to textbooks, journals, and
research reports
• Checking consistency for cues
• Clarifying the patient’s statements
• Seeking consensus with colleagues about
inferences
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Organize Data
• Functional health approach
• Head-to-toe model
• Body systems model
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Case Study
• P.J. is an 81 year old widowed male.
• c/o sore right foot, trouble walking for “few years”, worse in the last
month.
• Hx: Type 2 DM, HTN, diabetic neuropathy, former smoker
• 3 children, all live out of state.
• c/o recent poor appetite.
• 2 dime sized ulcers on right foot, yellow, black toes.
+ sensation to bilateral feet.
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Assessment
• Denies severe pain, 2/10 at toes.
• BP 180/92, HR 88 and regular, RR 20 and
unlabored, T 36.7
• S1, S2.
• DP/PT pulse 1+ left, not able to doppler or
palpate on right.
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Assessment
• Bilateral feet cool, R>L
• Cap refill R > 3 sec., L = 3 sec.
• Scattered expiratory wheezes RUL, RA,
SpO2 = 95%.
• AAOX3, pleasant, conversant.
• c/o hunger, “haven’t eaten yet today” (time
is now 6:10pm)
• Denies bowel/bladder problems.
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NURSING PROCESS
• DEFINITION
– THE ACT OF REVIEWING THE PATIENT’S
SITUATION IN ORDER TO OBTAIN
INFORMATION OF PAST HISTORY, PRESENT
STATUS AND TO IDENTIFY PATIENT
CURRENT PROBLEMS AND NEEDS
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NURSING PROCESS
(ADPIE)
• ASSESSMENT
• NURSING DIAGNOSIS
• PLANNING
• IMPLEMENTATION OF NURSING ACTIONS
• EVALUATION
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ASSESSMENT
• ASSESSMENT IS THE DELIBERATE AND
SYSTEMATIC COLLECTION OF DATA TO
DETERMINE A CLIENT’S CURRENT AND PAST
HEALTH STATUS AND FUNCTIONAL STATUS
AND TO DETERMINE THE CLIENTS PRESENT
AND PAST COPING PATTERNS
•
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DATA COLLECTION
• SUBJECTIVE DATA
– “THE PATIENT STATES”
– “I feel …”
• OBJECTIVE DATA
– MEASURABLE DATA
• TEMPERATURE
• PULSE
• RESPIRATIONS
– What you see
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ASSESSMENT DATA
• WHERE DOES THE NURSE OBTAIN ALL OF
THE INFORMATION NEEDED TO DEVELOP
A CARE PLAN FOR THE PATIENT?
– PATIENT
– FAMILY
– INFORMATION SYSTEMS (PT. CHART)
– REPORT (NURSE TO NURSE)
– Physical Assessment
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What next?
• Organize data - by system, problem, etc.
• Identify Subjective & Objective data
• Identify abnormal findings, links between
information
– E.g. c/o pain, hx of injury, current condition of
wound, treatments used, pain scale rating
– Nursing student, mother of 2 toddlers, PT
work all fit in “roles” or ‘stressors’ w/ coping
strategies, statements [“I am too busy to be
sick”]
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ASSESSMENT DATA
• SUBJECTIVE
• OBJECTIVE
– Nurses report (second
hand assessment
information)
– Patient statements
• “In quotes”
– Family statements
• “In quotes”
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–
–
–
X-Ray shows …….
Lab results are ……
What you see
History from chart
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NURSING DIAGNOSIS
• NURSING DIAGNOSIS CLASSIFIES
HEALTH PROBLEMS WITHIN THE DOMAIN
OF NURSING
– DOMAIN
• A REALM OR RANGE OF PERSONAL KNOWLEDGE
AND RESPONSIBILITY
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NURSING DIAGNOSIS
• A NURSING DIAGNOSIS IS A CLINICAL
JUDGMENT ABOUT INDIVIDUALS,
FAMILIES, OR COMMUNITIES AND THEIR
RESPONSE TO ACTUAL AND/OR
POTENTIAL HEALTH PROBLEMS OR LIFE
PROCESSES
• (NANDA International, 2007)
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Nursing Diagnosis
• Provides the basis for selecting nursing
interventions to achieve outcomes for
which the nurse is accountable
• Both a label for the description and the
action of describing the patient’s problems
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Purpose of the Nursing
Diagnosis
• Purpose: ID problems, synthesize info
from assessment by:
– Analyzing data
– ID patient strengths
– ID normal [baseline] functional level and
– Indicators of actual or potential dysfunction
Formulate a diagnostic statement
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Your judgment
• The Nursing Diagnosis is where you share
your decisions about what the patient’s
PRIORITY Problems are; what are the
causes [Etiology- R/T]; and what are the
Symptoms [AEB]
– When you begin, use plain English
– Then find the NANDA diagnosis and language
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How to Choose a Nsg. Dx
• Identify patterns [in data]
• Validate the diagnosis
• Formulate the statement using nursing
language, within domain of nursing
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Nursing Diagnosis
• Language provides means of
communication between nurses
• Taxonomy: classification system [NANDA]
• Problem, etiology
• Leads naturally to planning, goal setting
and evaluation
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The Rules
• N.D. is different than medical diagnosis
– Medical DX describes disease/pathology
– Nursing DX describes patient response
• Actual, risk, or wellness
• Areas that nurses treat independently
• Collaborative Problems: M.D. and RN
involved – not in independent nursing
– RN can ID problem, communicate, Treat w/ M.D
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Sample data collection
– HR 80 B/P 140/78, sPO2 95% on RA, temp
103F [oral]
– Pt c/o dizziness
– Skin is intact, flushed, warm/hot, dry to touch
– Pt reports he was working outside, mowing
lawn for 3 hours; “had a couple of beers”
– Outside temp 97, humidity 17%
– Pt is 22 year old male
– Caucasian, appears stated age, Ht/Wt//BMI
WNL
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Example Data Set Cont.
• Slept well last nt; ate usual food in a.m.; none since 8
a.m. Hx of Rt rotator cuff repair last year, immunizations
up to date; describes self as ‘healthy’. No previous
similar problems
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Example – Nsg. Dx
• Pt with temp 103 F, dry, flushed skin, c/o
dizziness, tachycardia
– Open to interpretation [judgment]
– Fever? Infection? Something else….
• “Fever” doesn’t tell us much
– Interventions? Antipyretic? Antibiotics?
• “Hyperthermia r/t environmental stressors and
overexertion AEB dry, flushed skin, temp 103F
and “dizziness” tells us what is going on and
what we think caused the problem…
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N.D.
• …. And leads us to goals and interventions
Hyperthermia r/t environmental stressors
and overexertion AEB dry, flushed skin,
temp 103F and “dizziness”
Environment and overexertion are things to
educate pt about, control if possible
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N.D. and goals
• R/T …overexertion AEB dry, flushed skin,
temp 103F and “dizziness”
• Clues toward goals and interventions
• Pt will.. have temp WNL, …report absence
of dizzy feeling, ..demonstrate
understanding of risks of overexertion in
heat.. increase fluid intake at work [by …]
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N.D. and Interventions
• Etiology [R/T] leads us to appropriate
interventions
• NO antipyretics, antibiotics – wrong
etiology for this ‘fever’
• Hydrate, change environment, cool pt,
educate re: risks and need for H2O
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Nsg. Dx
resources
• Care plan Book
• NANDA List [Craven p 209-210]
Start with plain English THEN find NANDA
DX
With use, language will come more easily
• PRACTICE!
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Sample ASSESSMENT DATA 2
• OBJECTIVE
• SUBJECTIVE
– VITAL SIGNS
– Family states that pt.
developed increasing
confusion prior to falling
• Bp 182/90, P-110 irreg.
• R-22, T-99.0, Pulse Ox. 93%
•
– Family states that pt.
complained of severe
headache
– HEAD TO TOE ASSESSMENT
– Family states that patient
continues to be in pain.
– Pt c/o pain; points to face =
>6/10 or ‘severe’ pain
– Pt is 88 y.o male
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Pain 8/10
Blood Sugar 113
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• Neuro A & O X1 [person]
• VS as noted
• Heart sounds clear -rhythm
•
•
•
•
•
irregular
BS clear
+ Bowel sounds x4
0 edema
Rt. Extremities flaccid
Rt. Leg externally rotated
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Significant ASSESSMENT DATA
• SUBJECTIVE
• OBJECTIVE
– Family states that pt.
developed increasing
confusion prior to falling
– VITAL SIGNS
• Bp 182/90, P-110 irreg.
• R-22, T-99.0, Pulse Ox. 93%
•
– Family states that pt.
complained of severe
headache
– HEAD TO TOE ASSESSMENT
– Family states that patient
continues to be in pain.
– Pt c/o pain; points to face =
>6/10 or ‘severe’ pain
– Pt is 88 yo male
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Pain 8/10
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• Neuro A & O X1 [person]
• VS as noted
• Heart sounds clear -rhythm
•
•
•
•
•
irregular
BS clear
+ Bowel sounds x4
0 edema
Rt. Extremities flaccid
Rt. Leg externally rotated
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Additional Findings from chart
• FRACTURED Rt. HIP [x-ray]
• CONFUSION
• HYPERTENSION X 15 years
• INSULIN DEPENDENT DIABETES [25 yrs]
• HISTORY OF FALLS [ 3 last year]
• IRREGULAR HEART BEAT [a fib]
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Priorities
• ABC’s
• Safety
• Pain
• Pretty universal priorities – apply to most
all situations
• Actual Diagnoses before Risk Dx
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POTENITIAL NURSING
DIAGNOSES
• SAFETY [Risk for injury] R/T
– confusion, history of falls, impaired mobility
• SKIN INTEGRITY [risk for or actual
impaired] R/T
– Pressure/ischemia 2* to immobility, delicate
skin /age, tissue trauma
• PAIN [acute] R/T
– Tissue damage, swelling 2* to FRACTURED
HIP
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Other Possible N.DX
• Risk for impaired tissue/cerebral perfusion
R/T irregular heartbeat [potential clots]
• Risk for powerlessness R/T dependent
status after injury
• Risk for delayed surgical recovery R/T
altered immune and healing response 2*
to IDDM, age
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BUILDING A NURSING DIAGNOSIS
1. PROBLEM
2. ETIOLOGY
3. SYMPTOMS
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PES Diagnosis
[for actual problems]
• Acute Pain R/T tissue trauma AEB c/o pain
>6/10, fractured Rt hip
• Tells us [etiology] Tissue Trauma [which
we see (symptom) as a fracture on X-ray]
is causing PAIN (Problem) We also know
because the pt says he is in pain
(Symptom)
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An ‘At Risk’ Diagnosis
• Problem
• Etiology
• No symptoms ….
– Because the problem is not actual [yet]
– We want to prevent the problem!
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PE
PROBLEM
P - AT RISK FOR IMPAIRED SKIN
INTEGRITY
RELATED TO
E – pressure/ ischemia 2* to
immobilization, delicate skin, tissue
damage
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Wellness Diagnosis
• P only
– Diagnostic label
– Describes human responses to levels of
wellness in individual/populations that have a
readiness for enhancement to a higher state
• Readiness for enhanced health
maintenance
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Choosing Priority
NURSING DIAGNOSES
• Risk for injury R/t history of falls, impaired
mobility, confusion
• Acute Pain r/t tissue injury 2* to Hip FX
AEB c/o pain “severe” 6/10
• Risk for impaired skin integrity R/T
ischemia/pressure 2* to Immobility AEB
bedrest and traction
Which is the priority? Why?
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Priorities
• Pain
• If pain is 8 on a scale from 1-10, will pt be
able to comply with interventions until
pain is relieved?
• Probably not
• This is a clinical judgment
• Standard priorities – ABC, Safety, Pain
• Actual before Risk
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Resources in Craven
• Box 12-1 on page 208
• Box 12-2 on page 209-210
• Help you find N DX by area [cluster] of
data, functional health patterns
• Practice! “Practicing for NCLEX” questions
pg. 211
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Chapter 13:
Outcome Identification and
Planning
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Outcome Identification
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Outcome Identification
• Purpose
– Providing individualized care
– Promoting patient participation
– Planning care that is realistic and
measurable
– Allowing for involvement of support
people
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Outcome Identification
• Activities
– Establish priorities
– Establish patient goals and outcome
criteria
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Nursing Sensitive
• Patient outcomes
• Nursing Outcomes Classification
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Outcome Identification Activities
• Establish priorities
– High priority
– Medium priority
– Low priority
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NCLEX Question
Which of the following is a high-priority
nursing diagnosis?
a. Impaired Gas Exchange
b. Fatigue
c. Stress Incontinence
d. Dysfunctional Grieving
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Establish Patient Outcomes and
Outcome Criteria
• Patient outcomes
– Short- versus long term
• Outcome criteria
– Specific, measurable, realistic
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Planning
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Planning
• Purposes
– Direct patient care activities
– Promote continuity of care
– Focus charting requirements
– Allow for delegation of specific activities
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Nursing Interventions
Classification (NIC)
• Physiologic: Basic
• Physiologic: Complex
• Behavioral
• Safety
• Family
• Health system
• Community
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Planning Activities
• Planning nursing interventions
• Writing a patient plan of care
– Patient centered
– Step-by-step process
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Types of Patient Plans of Care
• Instructional patient plans of care
• Instructional concept maps
• Clinical plans of care
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Clinical Patient Plans of Care
• Individual Plan of Care
• Standardized Plan of Care
• Generic Plan of Care
• Computerized Plan of Care
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The Goal leads to Interventions
• Instructions to Nurses [and HCT]
• Not Patient instructions
• [RN will] preface… Include timing
…Administer analgesics q 4hrs per orders for pain >4/10
… Assess and document pain at least hourly throughout
shift
… teach pt/family about pain scale, pain meds [onset and
duration, side effects] as indicated by assessment
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TYPES OF INTERVENTIONS
• NURSE INITIATED
– INDEPENDENT [focus on these]
• PHYSICIAN INITIATED
– DEPENDENT
• COLLABORATIVE
– INTERDEPENDENT [referrals, teamwork]
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Types of Interventions
• Cognitive:
– Educational: teaching/ pt./family education
– Supervisory
• Delegation to UAP
• Delegation to pt/family [learning for home]
• Interpersonal:
– Coordination, advocacy, refferral
– Support, modeling, listening
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Types of Interventions [cont.]
• Technical Interventions
– Maintenance [hygiene, skin care, etc]
• Help prevent complications, maintain function
– Monitoring: assess and note changes
• Communicate to HCT [VS, pulses, bleeding…]
– Psychomotor : technical interventions
• Insert Foley, IV, Suction, Assess
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Implementation Activities
• Reassess
– During each encounter
• Set Priorities
– As condition changes, resources change
• Perform Interventions
• Record [document] Interventions
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Implementation of plan
• The action phase
– Providing nursing care
– Delegating appropriate care
– Maintaining accountability
– Documenting care provided
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Implementing Nursing Care
• DECIDING ON Interventions
– Who can do them?
• Cannot delegate essential nursing actions like
assessment
• Referral when out of nursing domain/personal
ability
– When?
• consider patient preference, time, resources
• New info, feedback, assessment data
• Schedule multiple patients realistically
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Writing INTERVENTIONS
• NURSING ORDERS [independent]
– RN/CNA will REPOSITION EVERY TWO HOURS
– RN/CNA will provide SKIN CARE TO ALL BONY
PROMINENCES WITH REPOSITIONING
– ASSESSMENTS [pain, skin.. How often? When?]
– Education [teach pt/ family..]
• Dependent Orders
– RN will Administer Percocet 650 mg PO q 4hrs and
– reassess pain Q 30 min [independent] until <4/10
• Interventions should direct team –
what/when/how often?
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RATIONALE FOR INTERVENTION
• Research Evidence in support of a nursing
intervention [for school]
• Citation
– Frequent turning and repositioning … can prevent
localized obstruction of blood flow caused by
increased pressure (Craven, p. 946)
• Reference
– Craven, Hirnle & Jensen (2013) Fundamentals of
Nursing Human Health and Function (7th Ed.)
Philadelphia: Lippincott Williams & Wilkins
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EVALUATION
• Was the expected Goal/ Outcome met?
– Goal met/partially met/not met
• How do you know? [AEB]
• Will you revise or continue the plan of
care?
Goal met: pt skin intact at shift change. Continue with plan
of care.
Goal partially met: pt pain at 6/10 after 30 min. Revision:
Reposition q 2 hrs, ice to hip. Pain 4/10 at shift change.
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EVALUATION IS ONGOING AS IS THE
NURSING PROCESS
• EACH CARE PLAN MUST EVOLVE AS THE
PATIENT PROGRESSES
• Based on evaluation (reassessment), the
nursing diagnoses, priorities, and
interventions will change
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Next/ New Nursing Diagnoses ?
• Assessment to support DX:
• Goal Statement
• Interventions/Implementation
• Rationale
• Evaluation
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Remember:
SMART goals help students ADPIE
to their diet of P’s , V’S and R’s
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Acronyms
• ADPIE: nursing process
• SMART + PC: goals
• 4 P’s: hourly rounding checks
– pain, position, potty, personal needs
• VS: vital signs
• R’s: rights
– 7 rights of medication administration
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