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Nursing Process

Nursing Process
Specific to the nursing profession
A framework for critical thinking
Its purpose is to:

Diagnose and treat human responses to
actual or potential health problems
Nursing Process
Organized framework to guide practice
Problem solving method - client focused
Systematic- sequential steps
Goal oriented- outcome criteria
Dynamic-always changing, flexible
Utilizes critical thinking processes

Scientific Method of problem solving
ID problem
Collect data
Form hypothesis
Plan of action
Hypothesis testing
Interpret results
Evaluate findings
Advantages of Nursing Process
Provides individualized
care
Client is an active
participant
Promotes continuity of
care
Provides more effective
communication among
nurses and healthcare
professionals

Develops a clear and
efficient plan of care
Provides personal
satisfaction as you see
client achieve goals
Professional growth as
you evaluate
effectiveness of your
interventions
5 Steps in the Nursing Process
Assessment
Nursing
Diagnosis
Planning
Implementing
Evaluating
Assessment
First step of the Nursing Process
Gather Information/Collect Data
Primary Source - Client / Family
Secondary Source - physical exam, nursing
history, team members, lab reports, diagnostic
tests..
Subjective -from the client (symptom)
I have a headache
Objective - observable data (sign)
Blood Pressure 130/80
Assessment-collecting data
Nursing Interview (history)
Health Assessment -Review of Systems
Physical Exam
Inspection
Palpation
Percussion
Auscultation


Assessment-collecting data
Make sure information is complete &
accurate
Validate prn
Interpret and analyze data
Compare to standard norms
Organize and cluster data


Example of Assessment
Obtain info from nursing assessment,
history and physical (H&P) etc...

Client diagnosed with hypertension
B/P 160/90
2 Gm Na diet and antihypertensive
medications were prescribed
Client statement I really dont watch my
salt Its hard to do and I just dont get it
Nursing Diagnosis
Second step of the Nursing Process

Interpret & analyze clustered data

Identify clients problems and strengths

Formulate Nursing Diagnosis (NANDA :
North American Nursing Diagnosis
Association)-Statement of how the client is
RESPONDING to an actual or potential
problem that requires nursing intervention
Nsg Dx vs MD Dx
Within the scope of
nursing practice
Identify responses
to health and illness
Can change from
day to day
Within the scope of
medical practice
Focuses on curing
pathology
Stays the same as
long as the disease
is present
Formulating a Nursing Diagnosis
Composed of 3 parts:
Problem statement- the clients response
to a problem
Etiology- whats causing/contributing to the
clients problem
Defining Characteristics- whats the
evidence of the problem
Nursing Diagnosis
Problem( Diagnostic Label)-based on your
assessment of client(gathered
information), pick a problem from the
NANDA list...
Etiology- determine what the problem is
caused by or related to (R/T)...
Defining characteristics- then state as
evidenced by (AEB) the specific facts the
problem is based on...
Example of Nursing Dx
Ineffective therapeutic regimen
management
R/T difficulty maintaining lifestyle changes
and lack of knowledge
AEB B/P= 160/90, dietary sodium
restrictions not being observed, and client
statements of I dont watch my salt Its
hard to do and I just dont get it.
Types of Nursing Diagnoses
Actual
Imbalanced nutrition; less than body requirements
RT chronic diarrhea, nausea, and pain AEB height
55 weight 105 lbs.
Risk
Risk for falls RT altered gait and generalized
weakness
Wellness
Family coping: potential for growth RT
unexpected birth of twins.
Collaborative Problems
Require both nursing interventions and medical
interventions
EXAMPLE: Client admitted with medical dx of
pneumonia
Collaborative problem = respiratory insufficiency
Nsg interventions: Raise HOB, Encourage C&DB
MD interventions: Antibiotics IV, O2 therapy

Planning
Third step of the Nursing Process
This is when the nurse organizes a nursing care
plan based on the nursing diagnoses.
Nurse and client formulate goals to help the
client with their problems
Expected outcomes are identified
Interventions (nursing orders) are selected to aid
the client reach these goals.

Planning Begin by
prioritizing client problems

Prioritize list of
clients nursing
diagnoses using
Maslow
Rank as high,
intermediate or low
Client specific
Priorities can change

Planning
Developing a goal and outcome statement
Goal and outcome
statements are client
focused.
Worded positively
Measurable, specific
observable, time-limited,
and realistic
Goal = broad statement
Expected outcome =
objective criterion for
measurement of goal
Utilize NOC as standard

EXAMPLE
Goal:
Client will achieve
therapeutic management
of disease process.
Outcome Statement:
AEB B/P readings of
110-120 / 70-80 and client
statement of
understanding importance
of dietary sodium
restrictions by day of
discharge.


Planning- Types of goals
Short term goals
Long term goals
Cognitive goals
Psychomotor goals
Affective goals

Goals are patient-centered and
SMART
Specific
Measurable
Attainable
Relevant
Time Bound
Pt will walk 50 ft.
Pt will eat 75% of meal
Pt will be OOB 2-4hrs
Pt will maintain HR<100
Pt will state pain level is acceptable 6 (0-10)
Planning-select interventions
Interventions are selected and written.
The nurse uses clinical judgment and
professional knowledge to select
appropriate interventions that will aid the
client in reaching their goal.
Interventions should be examined for
feasibility and acceptability to the client
Interventions should be written clearly and
specifically.

Interventions 3 types
Independent ( Nurse initiated )- any
action the nurse can initiate without direct
supervision
Dependent ( Physician initiated )-nursing
actions requiring MD orders
Collaborative- nursing actions performed
jointly with other health care team members
Implemention
The fourth step in the Nursing Process
This is the Doing step
Carrying out nursing interventions (orders)
selected during the planning step
This includes monitoring, teaching, further
assessing, reviewing NCP, incorporating
physicians orders and monitoring cost
effectiveness of interventions
Utilize NIC as standard
Implementing- Doing
Monitor VS q4h
Maintain prescribed diet
(2 Gm Na)
Teach client amount of
sodium restriction, foods
high in sodium, use of
nutrition labels, food
preparation and sodium
substitutes
Teach potential
complications of
hypertension to instill
importance of
maintaining Na
restrictions
Assess for cultural
factors affecting
dietary regime
Implementing Doing
Teach the client-
hypertension cant be
cured but it can be
controlled.
Remind the client to
continue medication
even though no S/S
are present.

Teach client importance
of life style changes:
(weight reduction,
smoking cessation,
increasing activity)
Stress the importance of
ongoing follow-up care
even though the patient
feels well.


Evaluation- To determine
effectiveness of NCP
Final step of the Nursing Process but
also done concurrently throughout client care
A comparison of client behavior and/or response
to the established outcome criteria
Continuous review of the nursing care plan
Examines if nursing interventions are working
Determines changes needed to help client reach
stated goals.

Evaluation
Outcome criteria met? Problem resolved!
Outcome criteria not fully met? Continue
plan of care- ongoing.
Outcome criteria unobtainable- review each
previous step of NCP and determine if
modification of the NCP is needed.
Were the nsg interventions
appropriate/effective?

Evaluation
Factors that impede goal attainment:

Incomplete database
Unrealistic client outcomes
Nonspecific nsg interventions
Inadequate time for clients to achieve
outcomes.
Checkpoint
Identify which stage of the nursing process
is being described below:

The nurse writes nursing interventions
A goal is agreed upon
The nurse performs a physical assessment
A revision is made to the NCP
The nurse administers antibiotic medication
A statement is written that outlines the clients
response to a potential health problem
S and O Data Quiz
RR 22/min, even unlabored
I can only walk 3 blocks before my legs start to
hurt
Pain rated 3 on a scale of 0-10
Skin pink, warm and dry
Urine output 300mL/8 hr
My wife doesnt come to visit very often
Dressing clean, dry and intact.
NCLEX Time
The nurse records the following subjective
data in the clients medical record:
A.Breath sounds clear to auscultation
B.Amber urine in sufficient quantities
C.Pain intensity 8 out of 10
D.Skin warm and dry
NCLEX Time
When interviewing a client, the nurse uses the
following open-ended style sentence:
A.Do you have any concerns right now?
B.Is your family worried about you being in the
hospital?
C.How many times do you get up to go to the
bathroom at night?
D.What do you mean when you say, I dont feel
quite right?
NCLEX Time
In order for an actual nursing diagnosis to be
valid it must have one or more supporting:
A.Laboratory results
B.Diagnostic data
C.Defining characteristics
D.Medical diagnoses
NCLEX Time
Nursing diagnoses are aimed at identifying
client problems that are treatable by
_______.
A.The physician
B.The nurse
C.Invasive techniques
D.Complementary strategies