Nursing Process
Nursing Fundamentals
Introduction: Nursing Process
• Communication tool
• Organization tool
Overview of the Nursing Process
• Process:
• Purpose:
– Individualized
– Holistic
– Effective
– Efficient
• Nursing CARE
Holistic Health
• Treat the Whole person
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Mental
Spiritual
Social
Physical
Overview of the Nursing Process
• Consists of 5 steps
–AD-PIE
Nursing Process
• Used throughout the life span
• Used in every care setting
Assessment
• Step #1
• Involves
– Collecting data
– Validating the data
– Organizing the data
– Interpreting the data
– Documenting the data
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
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
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
i.e. Breast cancer
i.e. Knowledge deficit
Powerlessness
Grieving, anticipatory
Body image disturbance
Individual coping, ineffective
Diangosis
Medical diagnosis
Nursing diagnosis
Chronic obstructive
pulmonary disease
Cerebrovascular accident
Breathing patterns,
ineffective
Activity intolerance
Appendectomy
Pain
Amputation
Body image disturbance
Strep throat
Nutritional deficit
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
Evidence based practices
Evidence based practices
4 basic steps
• Step 1 - Question
• Step 2 - Data
• Step 3 - Check
• Step 4 - Apply
Prioritizing Nrs Dx
• 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
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Esteem
Love/Belonging
Safety
Physiological:
Implementation
• 4th step:
– Execution of the care
plan
–DO IT
–DO IT RIGHT
–DO IT RIGHT
NOW!
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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.
Critical Thinking & the Nursing Process
• Critical thinking
• Thinking like a nurse
Critical Thinking
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Inquisitive
Open-minded
Flexible
Fairminded