Nursing Process

Nursing Process

Nursing Process

Specific to the nursing profession

A framework for critical thinking

It’s 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

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

AssessmentNursing

DiagnosisPlanningImplementingEvaluating

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

To elicit as many symptoms as possible, the nurse should use open-ended rather than yes/no questions.

Examples:

“Describe what you are feeling”

“How long have you been feeling this way?”

“When did the symptoms start?”

“Describe the symptoms”

This type of questions will encourage the client to give more information about his or her situation.

Listen carefully for cues and record relevant information.

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 ofAssessment

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 don’t watch my salt” “ It’s hard to do and I just don’t get it”

Nursing Diagnosis

Second step of the Nursing Process

Interpret & analyze clustered data

Identify client’s 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

Diagnosis Statement

A working of nursing diagnosis may have two or three parts.

The three-part system consists of the nursing diagnosis, the “related to” statement, and the defining characteristics.

PES system:P (problem) - The nursing diagnosis, the label; a

concise term or phrase that represent a pattern of related cues

E (etiology) – “Related to” phrase or etiology; related cause or contributor to the problem

S (symptoms) –Defining characteristics phrase; symptoms that the nurse identified in the assessment

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

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 don’t watch my salt” “It’s hard to do and I just don’t get it”.

Types of Nursing Diagnoses

ActualImbalanced nutrition; less than body requirements RT chronic diarrhea, nausea, and pain AEB height 5’5” weight 105 lbs.

RiskRisk for falls RT altered gait and generalized weakness

WellnessFamily coping: potential for growth RT unexpected birth of twins.

Case study:

A 73-year-old man has been admitted to the unit with a diagnosis of chronic obstructive pulmonary disease (COPD). He states that he has “difficulty breathing when walking short distances”. He also states that his “heart feels like it is racing” at the same time. He states that he is “tired all the time”, and while talking to you he is continually wringing his hands and looking out the window.

Step II: Nursing DiagnosisPart 1 (Problem)

Interpretation of information:

“difficulty breathing when walking short distances”= dyspnea

“heart feels like it is racing”= dysrythmia

“tired all the time”= fatigue

In Section II we can find the nursing diagnosis Activity intolerance listed with these symptoms.

Step II: Nursing Diagnosis

To validate that the diagnosis Activity intolerance is appropriate for the client, we have to read NANDA definition of the nursing diagnosis.

When reading, ask Does this definition describe the symptoms demonstrated by the client? If the appropriate nursing diagnosis has been selected, the definition should describe the condition that has been observed.

Activity intolerance

NANDA Definition

Insufficient physiological or psychological energy to endure or complete required or desired daily activities.

Defining Characteristics

Verbal report of fatique or weakness; abnormal heart rate or blood pressure response to activity; exertional discomfort or dyspnea; electrocardiografic changes reflecting dysrhytmias or ischemia

Related factors (r/t)

Bed rest or immobility; generalized weakness,; sedentary lifestyle; imbalance between oxygen supply and demand

Part 2 (Etiology)“Reated to” Phrase

This phrase states what may be causing or contributing to the nursing diagnosis, commonly referred to as the etiology.

Ideally the etiologe, or cause, of the nursing diagnosis is something that can be treated by a nurse. When this is the case, the diagnosis is identified as an independent nursing diagnosis. If medical Intervention is also necessary, it might be identified as a collabarative diagnosis.

For each suggested nursing diagnosis, the nurse should refer to the statements listed under the heading “Related Factors”

Part 3 (Symptoms)Defining Characteristic phrase

It consist of the signs and symptoms that have been gathered during the assessment phase. Signs and symptoms are labeled as defining characteristics in Section III.

The use of identifying defining characteristics is similar to the process the physician uses when making a medical diagnosis

Writing a Nursing Diagnosis Statement

P - Activity intolerance

E – “Related to” imbalance between oxygen supply and demand

S – Verbal reports of fatique, exertional dyspnea (“difficulty breathing when walking”), and dysrythmia (“racing heart ”)

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 client’s nursing diagnoses using Maslow

Rank as high, intermediate or low

Client specific Priorities can

change

PlanningDeveloping 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

Goals

PT. will walk 50 ft.

Pt. will eat 75% of meals

Pt. will be OOB 2-4 Hrs.

Pt. will maintain HR <100

To 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 can’t 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 interventionsA goal is agreed uponThe nurse performs a physical assessmentA revision is made to the NCPThe nurse administers antibiotic

medicationA 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 0-10Skin pink, warm and dryUrine output 300mL/8 hr“My wife doesn’t come to visit very

often”Dressing clean, dry and intact.

NCLEX Time

The nurse records the following subjective data in the client’s 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 don’t 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