The Nursing Process

Geralyn Michelfelder, DNP, MSN, RN

Barbara Mottola, MSN, RN
N 110 Fall 01!
1
Outcomes

Discuss each of the five steps of the nursing

process (QSEN/KSA/Teamwork & o!!a"oration# Safet$%

ompare an& contrast su"'ective an& o"'ective

assessment &ata (QSEN/KSA Qua!it$ (mprovement#
(nformatics%

Descri"e how &ata is c!ustere&) va!i&ate&) an&

&ocumente& to form a nursing &iagnosis
(QSEN/KSA/*atient+centere& are#Evi&ence+"ase& *ractice%
2
Outcomes

Differentiate a me&ica! &iagnosis from a nursing

&iagnosis, (QSEN/KSA/*atient+centere& are# Teamwork &
o!!a"oration%

Differentiate nurse+initiate&) ph$sician+initiate&)

an& co!!a"orative interventions, (QSEN/KSA/ *atient+
centere& are# Teamwork & o!!a"oration# Qua!it$ (mprovement%
3
Description

A &$namic critica! thinking too!

-ramework that provi&es interpersona!)

in&ivi&ua!i.e&) approach to nursing care

/o&e! that inc!u&es a co!!a"orative

effort
4
Description

!assification too! to &escri"e hea!th status of an

in&ivi&ua!) fami!$) or communit$ an& risk of
comp!ications

/etho& of pro"!em+so!ving

/eans to i&entif$ patient strengths an&

responses to hea!th an& i!!ness situations
5
Description
Design wa$s to

Assist c!ients in &ea!ing with i!!nesses

(mp!ement care

Eva!uate care
6
Nee& for Nursing *rocess

Organizes care in a s$stematic manner

*rovi&es involvement for patient an&

fami!$/significant other

Necessar$ to communicate p!an of care

7
Nee& for Nursing *rocess

A means of individualization of care whi!e

provi&ing continuit$ with the pu"!ishe&
stan&ar&s of care

*romotes nursing autonomy

8
(ncorporates

The art of nursing

The science of nursing

The care of an$ group of peop!e

The care of an$ t$pe of human response to

i!!ness
9
Steps

Assessment

Nursing Diagnosis

*!anning

(mp!ementation

Eva!uation
10
Assessment

Data co!!ection

0erification of &ata

!ustering of &ata

Documentation of &ata
11
Assessment + Data o!!ection
1ea!th assessment
Data"ase formation2hea!th histor$

*h$sio!ogic assessment2ph$sica! e3am
12
Assessment 4 Data o!!ection

Sources

*rimar$ vs, secon&ar$

Su"'ective vs, o"'ective

Ac5uisition
13
Assessment

*rimar$ source + patient

v,s,
Secon&ar$ source 4 fami!$) chart)
others
14
Assessment

Su"'ective &ata + s$mptoms

omes from patient &irect!$

*atient6s fee!ings & perceptions

v,s,

O"'ective &ata + signs

omes from outsi&e the patient

O"serve& "$ using the five senses &uring

o"servation & e3amination

7sua!!$ measura"!e
15
Ac5uisition
Sources of Data

1ea!th histor$ 4 "ase!ine information a"out past

& present hea!th o"taine& "$ interviewing patient

*h$sica! assessment

(nterviews with frien&s & fami!$

/e&ica! recor&s

Other hea!th care mem"ers

16
Assessment
0erification of &ata) communication of
fin&ings

ompare su"'ective/o"'ective &ata for

congruenc$

8ook for factors that can a!ter accurac$

Dou"!e check e5uipment# recheck own

&ata
17
/r, 9!enn
:;+$ear o!& A A O 3< white ma!e
presents to c!inic in no apparent &istress, Dresse&
appropriate!$ in f!anne! shirt an& 'eans an& we!!+worn
work "oots, !othing sme!!s s!ight!$ of smoke, Smokes
cigarettes
= packs /&a$, 9ait stea&$, /O a"& &iscomfort, Skin
warm an& &r$,
0S >* ?@A/BA B@,= - + @C (regu!ar% + =A (regu!ar) TA)
un!a"ore&# occasiona! cough2non+pro&uctive per pt%
O= Sat B<D >* ?@A/BA
1eight :6=E Feight @; kg,

18

Fhat &o $ou want to know a"out ne3tG

19
A"&omina! &iscomfort "egan a"out = &a$s ago)
aroun& C+; (sca!e of ?+?A%) a!! over a"&omen)
fee!ing Hfu!!)E was intermittent++ now constant)
ha& simi!ar e3perience in past (=3 in !ast $ear%
an& &iscomfort su"si&e& eventua!!$ "$ itse!f,
/isse& work to&a$ &ue to &iscomfort# especia!!$
concerne& "ecause it worsene&, A"&omen
!ooks gross!$ &isten&e&# s!ight!$ "igger
accor&ing to patient,
20
Data
Su"'ective vs, O"'ective
21

(s there an$thing a!arming a"out /r,

9!enn6s presentationG
/r, 9!enn6s hart+a"norma!
fin&ingsG
P"
Scal# intact) no infestation
"yes *EII8A) no 'aun&ice
"ars nose, throat mucosa pink) intact# no !esions# &entition poor repair) upper &entures#
missing man$ !ower teeth# !ower teeth crooke& with cavities# no fou! o&or# s!ight a!coho!
Face s$mmetrica!# tin$ pettechiae on cheeks "i!atera!!$# ru&&$ comp!e3ion# paroti&
g!an&s en!arge& "i!atera!!$
Nec$ caroti&s e5ua! "i!atera!!$) no "ruit# una"!e to pa!pate th$roi&# no J0D
%hest "arre!+shape&) e5ua! chest e3cursion) TA
&eart apica! regu!ar) strong) no murmurs# ra&ia! pu!ses strong) e5ua!# pe&a! pu!ses
"are!$ pa!pa"!e "i!atera!!$) skin coo! "oth !ower e3tremities
S$in &r$) intact# no &iaphoresis,
"'tre(ities strength e5ua! a!! e3tremities# No e&ema# &rumming fingers,
Genitalia no &ischarge# sma!! e3terna! hemorrhoi&s) no irritation,
)bdo(en firm) &isten&e&# no 0A ten&erness# !iver smooth) en!arge&# genera!
&iscomfort a!! C 5ua&rants# &ecrease& "owe! soun&s a!! C 5ua&rants
23
A"norma! -in&ings/
*ertinent Negatives

Scal# intact) no infestation

"yes *EII8A) no 'aun&ice

"ars nose, throat mucosa pink) intact#

no !esions# &entition poor repair) upper
&entures# missing man$ !ower teeth# !ower
teeth crooke& with cavities# no fou! o&or#
s!ight a!coho!
24

Face s$mmetrica!# tin$ pettechiae on

cheeks "i!atera!!$# ru&&$ comp!e3ion#
paroti& g!an&s en!arge& "i!atera!!$

Nec$ caroti&s e5ua! "i!atera!!$) no "ruit#

una"!e to pa!pate th$roi&# no J0D

%hest "arre!+shape&) e5ua! chest

e3cursion) TA
25

&eart apica! regu!ar) strong) no murmurs#

ra&ia! pu!ses strong) e5ua!# pe&a! pu!ses
"are!$ pa!pa"!e "i!atera!!$) skin coo! "oth
!ower e3tremities

S$in &r$) intact# no &iaphoresis,

"'tre(ities strength e5ua! a!!

e3tremities# no e&ema# &rumming fingers,
26

Genitalia no &ischarge# sma!! e3terna!

hemorrhoi&s) no irritation,

)bdo(en firm) &isten&e&# no 0A

ten&erness (no f!ank ten&erness%# !iver
smooth) en!arge&# genera! &iscomfort a!! C
5ua&rants# &ecrease& "owe! soun&s a!! C
5ua&rants

0A+"ack
27

Fhat other 5uestions wou!& $ou want

to askG
28
*ast 1istor$

IOS (past me&ica! histor$%

Surgica! 1istor$

Socia! 1istor$

Occupation
29
*ast 1istor$

IOS (past me&ica! histor$%

Surgica! 1istor$

Socia! 1istor$

Occupation
30
0a!i&ation of Data

Compare present report of complaint (HPI

History of Present Illness) with history (ROS,
etc) and PE

8ook for congruenc$

0a!i&ation of Data

7sua!!$ hea!th$# on!$ goes to &octor6s

when necessar$

!ient sa$s no trou"!e with teeth

Denies fevers
32
0a!i&ation of Data

Di&n6t notice Hswo!!en neckE

No me&s

No hemorrhoi&s
33
0a!i&ation of Data

(rregu!ar >/# no >/ in ; &a$s# increasing

a"&omina! &iscomfort
1istor$ of smoking
34
0a!i&ation of Data

1istor$ of a!coho! consumption) "ut not a

pro"!em# !arge amount of a!coho!
consume& &ai!$

Sa$s he6s concerne&

35
Assessment

!uster &ata

Diagnostic reasoning 4
recognition of significance of fin&ings
36
!ustering of Data

/a'or comp!aint is a"&omina! pain

37
Other *ro"!ems

&ea*y s(o$er

ough) "arre! chest (!ong+term pro"!em) not acute at

present%

"nlarged li*er (pro"a"!$ not acute at present%

1eav$ &rinker

*aroti& g!an&s en!arge&

38
Other *ro"!ems

BP ele*ated (wi!! have to "e a&&resse& "$

ph$sician%

*oor &iet# high in Na

&e(orrhoids (not acute%

(rregu!ar "owe! ha"its) poor &iet) occupation

39
Assessment

Documentation of fin&ings

7se of too!

Descriptive an& concise

No interpretive statements
40
Nursing Diagnosis

Deve!op nursing &iagnoses

7se the North American Nursing Diagnosis

Association6s !ist (NANDA%
41
Nursing Diagnosis

HA c!inica! 'u&gment a"out in&ivi&ua!) fami!$)

or communit$ responses to actua! & potentia!
hea!th pro"!ems/!ife processesE

*rovi&es the "asis for se!ection of nursing

interventions to achieve outcomes for which
the nurse is accountable
42

Nursing Diagnosis

/e&ica! Diagnosis
43
Nursing Diagnosis

Differs from a me&ica! &iagnosis

/e&ica! 4 "ase& on i!!ness

Nursing 4 "ase& on patient6s responses to

Hactua! or potentia! hea!th pro"!ems/!ife
processesE (NANDA%
44
Nursing Diagnosis
(nc!u&es these ; rea!ms

*athoph$sio!og$

Treatment+re!ate&

*ersona!

Environmenta!

/aturationa!
45
Nursing Diagnosis21ow to
-ormu!ate

Ana!$sis of c!ustere& &ata) pattern

recognition

/ake reasona"!e conc!usion which

i&entifies patient pro"!ems

Frite the &iagnostic statement using the

formu!a
46
Friting Nursing Diagnoses

9enera!!$ = or < part statements

= 4 !a"e! of &iagnostic statement an& re!ate&

factors

< 4 !a"e! of &iagnostic statement an& re!ate&

factors an& c!ustere& s/s
47
Friting Nursing Diagnoses

H*ESE metho&

*K pro"!em 4 pro"!em statement (NANDA%

EK etio!og$ 4 etio!og$/causative factor(s%#

Hre!ate& toE

SK signs & s$mptoms 4 &efining

characteristics# come from &ata "ase# Has
evi&ence& "$E
48
T$pes of Nursing Diagnoses

Actual 4 e3isting at present

Risk 4 potentia! pro"!ems which ma$ occur

if action not taken to prevent them

Possible 4when nurse &oes not have enough

&ata to &ocument an actua! pro"!em)
"ut suspects that one e3ists

Wellness 4 when patient e3hi"its a hea!th response

or strength

Syndrome
49
Actua!

E3isting at present time

< partsK 8a"e!) Etio!og$) S/S (*ES%

E3amp!eK onstipation related to ina&e5uate

&iet an& !ack of know!e&ge (&iet an& regu!ar
ha"its% as evidenced by reports of no >/ for ;
&a$s) firm & &isten&e& a"&omen) an& c/o
a"&omina! &iscomfort an& fee!ing of fu!!ness,
50
1igh Iisk

*otentia! pro"!ems that ma$ occur if action not

taken

= *arts

E3amp!eK 1igh risk for ineffective airwa$

c!earance re!ate& to ineffective cough,
51
*ossi"!e

(f the nurse suspects a pro"!em "ut &oes not

have enough &ata to &ocument an actua!
pro"!em

= *arts

E3amp!eK *ossi"!e f!ui& vo!ume &eficit re!ate& to

ina&e5uate intake an& high a!coho!
consumption,
52
Fe!!ness

Transition from ? !eve! of we!!ness to

"etter !eve! of we!!ness

? *art

E3amp!eK-!ui& "a!ance) rea&iness

for enhance&,
53
S$n&rome

Defining characteristics e5ua! actua! or high risk

&iagnosis# the &iagnostic !a"e! contains the etio!og$# ma$
ref!ect a c!uster of actua! or possi"!e nursing &iagnoses

? *art

E3amp!eK ; Nan&a S$n&romes

*ost trauma s$n&rome
(mpaire& environmenta! s$n&rome
Iape trauma s$n&rome
Disuse s$n&rome
Ie!ocation stress s$n&rome
54
Friting Nursing Diagnoses

Actua! + < part statement

Iisk 4 = part

*ossi"!e 4 = part

Fe!!ness 4 ? part

S$n&rome 4 ? part
55
Nursing Diagnosis

Use critical thinin! sills to analy"e and interpret

data

Reco!ni"e pattern

Compare to #normal # standards

$ae reasona%le concl&sion

*ro"!em 8ist for /r, 9!enn

Smoking

*oor &iet (high in Na an& fat%)

sufficient f!ui&sG

A!coho! consumption

A"&omina! pain2constipation
57
Nursing DiagnosisK
(ncorrect -ormat

7sing a me&ica! &iagnosis as the causative

factor, HLre!ate& to hemico!ectom$E, /a$ "e
inserte& as secondary to in or&er to c!arif$
statement,

7sing a nursing &iagnosis as the causative

factor, HLre!ate& to impaire& ph$sica!
mo"i!it$E,
58
Nursing DiagnosisK
(ncorrect -ormat

7sing statements that are 'u&gmenta! or

!ega!!$ ina&visa"!e, HLre!ate& to poor
attitu&e L,E,

Friting in terms of patient nee&s or

nursing interventions, HLre!ate& to
nee& of pain me&ication,E
59
E3amp!e ?

An3iet$ re!ate& to A(DS,

60
E3amp!e =

Iisk for in'ur$ re!ate& to &i..iness

secon&ar$ to high "!oo& pressure,
61
E3amp!e <

(mpaire& parenting re!ate& to fre5uent

screaming at chi!&,
62
E3amp!e C

Iisk for constipation re!ate& to reports of

"owe! movements once per week,
63
E3amp!e ;

hronic sorrow re!ate& to cr$ing an&

episo&es of ina"i!it$ to s!eep
64
E3amp!e :

Acute pain re!ate& to "reast A

65
Nursing Diagnoses for /r, 9!enn

*oor &iet) &ecrease& f!ui&sG

66
Nursing Diagnoses for /r, 9!enn

A"&omina! painLonstipation
67
Nursing Diagnosis Tips

Once patient nee& is met or pro"!em is

reso!ve&) the nursing &iagnosis no !onger
e3ists

Some nursing &3 are ongoing,

Diagnoses nee& to "e !iste& in or&er of

priorit$ (part of ne3t step# *!anning%

-re5uent sources of error inc!u&e &ata

co!!ection) c!ustering) interpreting) or
!a"e!ing
68
Nursing Diagnosis Tips

Do not use me&ica! &iagnoses as part of

nursing &iagnosis

/ust "e written within &omain of nursing

practice

*ro"!ems are those that the nurse can

treat or manage
69
o!!a"orative *ro"!ems

ertain ph$sio!ogic response which nurse

monitors to &etermine onset or change in
ph$sio!ogic con&ition

A nursing priorit$ which fo!!ows c!ose!$

with the me&ica! &iagnosis) or re5uires
input from other &iscip!ines
70
o!!a"orative *ro"!ems

-ocus is re&uction in severit$ of certain

ph$sio!ogic con&itions

>egin with * (*otentia! omp!ication%

E3amp!esK

* Sepsis

* Asthma

* D$srh$thmia
71
o!!a"orative *ro"!ems

Nurses monitor for these pro"!ems or

comp!ications

annot "e prevente& "$ the nurse

72
o!!a"orative *ro"!ems
73
*!anning

Setting patient+centere& goa!s (outcomes% &

choosing nursing actions (interventions% to
achieve goa!s,

o!!a"orative effort "etween nurse) patient)

fami!$) hea!th team,

1an&written or computeri.e& care p!an a&apte&

to the in&ivi&ua! +addendum,.
74
*!anningK Steps
1- Prioriti.e se!ecte& nursing &iagnoses,
=, Deve!op outco(e criteria,
<, Deve!op specific nursing actions
(inter*entions%
75
*!anning++*rioriti.e
?, *rioriti.e se!ecte& nursing &iagnoses

/a$ use a framework) such as Maslows

Hierarchy o !eeds

Se!f+actua!i.ation
Esteem nee&s
>e!onging nee&s
Safety needs
Physiologic needs (ABCs)
76
*!anning++*rioriti.e

A>6s

Ask the c!ient

Ana!$.e re!ationships "etween pro"!ems

Actua! vs, Iisk

77
1ow wou!& $ou prioriti.e the fo!!owingG

7rinar$ incontinence) stress

Se3ua!it$ patterns) a!tere&

Airwa$ c!earance) ineffective

Skin integrit$) risk for impaire&

78
1ow wou!& $ou prioriti.e the fo!!owingG

9as e3change) impaire&

Know!e&ge &eficit

1$pothermia

(nfection) risk for

79
1ow wou!& $ou prioriti.e the fo!!owingG

*ain) acute

Se!f+esteem) chronic !ow

/o"i!it$) impaire& ph$sica!

Socia! iso!ation
80
1ow wou!& $ou prioriti.e /r, 9!enn6s
present pro"!em !istG
Smoking
*oor &iet
A!coho! consumption
onstipation
81
*!anning++Outcomes
=, Esta"!ishment of goa!s ++ Deve!op
outcome criteria,

statements a"out e3pecte& "ehavior or human

responses ater the im"lementation o nursing
actions, These "ehaviors are eitherK

ognitive (thinking% "ehaviors

Affective (fee!ing% H

*s$chomotor (&oing% H
82
*!anning++Outcomes

riteria for outcomesK

(nc!u&es HpatientE or Hc!ientE

/easura"!e) o"serva"!e

-avora"!e status

Attaina"!e) realistic

Specifie& time !imit2!ong or short term

#ollaborative eort between nurse$
"atient$ amily$ % healthcare team&
83
Outcomes

Specific

/easurea"!e

Action / Attaina"!e

Iea!istic

Target
84
*!anning++Outcomes

/a$ choose to useK Nursing Outcomes

!assification (NO% 8istK
Outcomes (=:A% &eve!ope& in ?BBM
>ase& on c!inica! nursing practice & research
/a$ "e share& "$ a!! &iscip!ines
8anguage is c!ear

A&&ress the entire scope of nursing practice

85
*!anning++Outcomes

E3amp!es of Action 'erbs (measura"!e%

8ist) Iecor&) Name) State)

Descri"e) E3p!ain) (&entif$

Demonstrate) 7se) Sche&u!e

Differentiate) ompare) Ie!ate

Design) *repare) -ormu!ate) a!cu!ate

Se!ect) hoose

(ncrease/Decrease) Stan&) Fa!k

E3amp!es of passive ver"s (not measura"!e%

7n&erstan&) Know) -ee!) Accept

86
E3amp!e ?

7n&erstan&s insu!in therap$ within C@

hours,
87
E3amp!e =

Ie5uires no remin&ers from staff

regar&ing &ietar$ restrictions,
88
*!anning++(nterventions
<, Deve!op specific nursing actions
(interventions%# genera! e3amp!esK

Ongoing assessment

!ient teaching

Assistance with AD8

A&ministration of me&s

*erformance of treatments

o!!a"oration with hea!th team

89
*!anning++(nterventions

A!! nursing actions shou!& "e "ase& on

scientific princip!es

(n&ivi&ua!i.e& to c!ient

Specifica!!$ a&&ress etio!og$ of the nursing

&iagnosis,
90
*!anning++(nterventions

Nursing (nterventions !assification (N(%

4 ?BB=

omprehensive stan&ar&i.e& !anguage that

&escri"es treatments that nurses perform,

urrent!$ contains C@: interventions,

91
The are *!an

*rovi&e written &irections rather than wor&

of mouth

Ensure continuit$ of care

(&entif$ priority set of pro"!ems

*rovi&e means of review an& eva!uation of

care

Demonstrate accounta"i!it$ of professiona!

nurse
92
The are *!an
onstipation related to &iet !acking in proper nutrients an& !ack of
know!e&ge (&iet an& regu!ar ha"its% as evidenced by reports of no
>/ for ; &a$s) firm & &isten&e& a"&omen) an& c/o a"&omina!
&iscomfort an& fee!ing of fu!!ness,
Esta"!ish/regain norma! pattern of "owe! functioningL(soft) forme& "rown >/ 5
other &a$ 4norm for pt% within =C hours,
State : foo&s high in fi"er (that he !ikesLor can to!erate% "$ the en& of nutritiona!
e&ucation provi&e& "$ nurse,
Determine pt !ikes an& &is!ikes regar&ing foo& groups an& specific foo&s,
Ieview &ietar$ gui&e!ines that promote regu!ar "owe! movements (foo&s
high in fi"er%
Assist pt to make a &ai!$ routine that inc!u&es proper &iet an& f!ui&s,
Assist pt to start on "owe! regimen
Determine activities that pt is intereste& in to raise activit$ !eve!
(mp!ementation

arr$ing out the p!an,

ommunicating the p!an to other mem"ers of

the team,

T$pes of Nursing actionsK &epen&ent)

in&epen&ent) inter&epen&ent
94

T$pes of nursing actionsK

(e"endent 4 nee& an or&er

*h$sician6s or&ers

*rotoco!s

Stan&ing or&ers

)nde"endent 4 nurses perform without &irection from

others

)nterde"endent 4 actions mutua!!$ agree& upon "$

nursing & another team mem"er# co!!a"orative
interventions
95
Eva!uation

-ina! phase of the nursing process,

/easures the patient6s response to nursing

actions as we!! as the patient6s progress towar&
achieving goa!s

Ongoing process that can take p!ace at an$ step

in the process,

9ui&es the nurse in which actions are effective

or not,
96
Eva!uation

SourcesK

Direct o"servation of c!ient

0er"a! communication with c!ient/fami!$

*h$sica! assessment of c!ient

Ieports from other mem"ers of team

Ieview of !a" reports) recor&s) etc,

97
Eva!uation

Outcomes ma$ "e

/et

*artia!!$ met

Not met

(f outcomes not met) ana!$.e & reapp!$

nursing process/mo&if$ as nee&e&,

Ongoing eva!uation
98
ritica! Thinking &
the Nursing *rocess

*ro"!em+so!ving is the most c!ose!$

re!ate& component of critica!
thinking to the nursing process,
99