Nursing Process

Potter and Perry

Chapter 7

 

Developed by

 June  Mair, RN, MSN

Nursing Process Overview

n   Integrates elements of critical thinking

n   Used to identify, diagnose, and treat human responses to health and illness (ANA,2003)

n   It is dynamic and requires creativity for its application

n   Involves overlapping steps that build on each other

Five Steps of the Nursing Process

n    Assessment

 

n    Data collection

 

n    Planning

 

n    Implementation

 

n    Evaluation

 

Assessment
Step #I

n    Establishing  a database by:

    > Collecting data

       - subjective versus objective

    > Interviewing/ taking a health history

       - subjective and organized

     >  Performing a physical examination

        - vital signs, patient’s behavior,    diagnostic and laboratory data, medical records

Clustering Data

n Grouping the pieces of the data that are similar

n This helps to separate one problem from another

Types of Data

n  Subjective

    Client’s perceptions about health problems.  Example “I feel tired and weak”

n  Objective

     Observations or measurements made by  data collector.  Example, Blood pressure, vital signs

Documentation of Data

n Last part of Assessment

   Data will be clearly, accurately, recorded

 

n Different types of  forms are used such as flow sheets, initial assessment form

Nursing Diagnosis

n The focus:

n Diagnose  and treat human responses

n   Care for patients

n   Holistic – effects on whole person

n   Teach patients to become more independent in their daily activities

 

 

 

Nursing Diagnosis
Step # 2

n  Statement describing  the patient’s actual or potential  response to a health problem

n  Types of diagnoses:

        > Actual

        >Risk

        > Wellness

n  Diagnostic format

 

Nursing Diagnosis cont’d

n   ACTUAL – one that is perceived or experienced by the patient.  Example Skin breakdown because of lying in one position for prolonged periods

n   POTENTIAL (RISK)   - determined by nurse making clinical judgment.  Example, patient with skin breakdown is at risk for infection

Nursing Diagnosis cont’d

n  Mind mapping: graphic  representation of

   the connections between nursing diagnoses that are related to the patient’s health care problem

n  Concept map: visual representation of patient problems and interventions that shows relationship to one another

 

 

 

 

Formulation of Nursing Diagnoses

n   Nursing diagnoses format:

  >  Diagnostic label

  >  Related factor

n   Sources of errors

  >  Data collection

  >  Interpretation and analysis

  >  Data clustering

Nursing Diagnoses cont’d

n   Actual nursing diagnosis indicates a problem exists

n   It is composed of the NANDA, related factors, and signs and symptoms

n   A risk nursing diagnosis (potential problem) indicates the problem does not exist yet

n   The NANDA is preceded by ”Risk for” with  the related factors, and no signs or symptoms

Summary  - Nursing Diagnosis

n   Diagnosis: Apply the appropriate NANDA label to the problem (what needs to be changed)

n   Etiology – factors causing or contributing to actual problem or risk  (related factors)

n   Defining characteristics  - signs and/ or symptoms

 Actual  - (3 part statement), signs/ symptoms are added - 

 Risk – (2 part statement), no signs/symptoms are added

 

 

 

 

 

 

Planning
Step # 3

n   Setting realistic, patient-centered goals with outcome criteria and targeted dates

n   Establishing  care priorities

n   Identifying actions for preventing, correcting or relieving  health problems

n   Selecting interventions to accomplish  expected outcomes

n   Choosing Nursing care plan

n   Consulting other healthcare professionals

 

Planning

n   Begins with first contact with patient

n   Ongoing –

n   Independent – nurse monitors, prevents, Example, nurse teaches patient to cough and deep breathe

n   Dependent – physician initiated, Example medication administration

 

Establishing priorities

n   Rank nursing diagnosis in order of importance

n   Patients will have different types of priority needs

n   High – life threatening if untreated Example  - breathing, bleeding

n   Medium -  non-life threatening

   Example – pressure ulcer

 

 

 

Goal Setting

n   Goals and outcomes are used interchangeably

n   Goals:  Broad statements “client will achieve pain control”

n   Outcome: specific measurable criteria.

   “Patient will gain 5 lbs. in one week”

  *Goals/ outcomes provide direction and use of nursing intervention

 

Goals cont’d

n   Keep it short and simple

n   Base it on only one Nursing diagnosis

n   Designate a specific time in which to achieve the outcome

n   Short term  - immediate or less than a week

n   Long term – after discharge, over weeks or months (home, rehab.)

Writing Goals / Outcomes

n   Client centered

n   Singular factors – address one behavior

n   Observable factors – subjective and/or  objective assessment

n   Measurable factors – behavioral terms “report”, “eat”, “state”

n   Time limited  - “within 30 minutes”

n   Get patient’s cooperation

n   Realistic factors “Can patient lose 10 lbs in one day?” 

 

 

 

 

 

Implementation

n   Carrying out the plan of interventions Types of Nursing interventions

n    Protocols and standing orders

    preplanned and preprinted

    (cover common actions required for a particular medical diagnosis, treatment or diagnostic test)

n   Implementation process

   Reviewing and revising the care plan

n   Organizing resources and care delivery

n   Anticipating and preventing complications

 

Implementation cont’d

n   Nurse communicates plan of care to patient and other members of health care team

n   Carries out planned interventions

n   Documents on flow sheets or nurse’s progress notes

 

Implementation cont’d

n   Communicating nursing interventions

n   Implementation skills

   > cognitive skills

   > interpersonal skills

   > psychomotor skills

   > delegation, supervision, and evaluation of staff

 

 

 

 

Evaluation

n   Final phase of the Nursing Process

n   Did it work?

n   Which orders were or were not helpful in achieving the goals?

n   Nurse determines the patient’s progress using the goals/outcomes as criteria

n   Compares results or responses to the goals

 

Evaluation Cont’d

n   Critical thinking skills

n    Five steps of objective evaluation

  - identify evaluative criteria and standards

  - collect data

  - interpret and summarize findings

  - document findings

  - terminate, continue or revise the care plan  

 

Care Plan Revision and Critical Thinking

n   Discontinuing a care plan

n   Modifying a care plan

   >  Reassessment

   >  Nursing Diagnosis

   >  Goals and expected outcomes

   >  Interventions

n    Appropriateness of care

n   Correct application of interventions

 

 

 

 

Patient’s Goal is met or unmet

n   What must I do?

   The care plan may be noted that the goal or outcome was met or discontinued

n   The goal is unmet, what must I do?

        Identify the variables that altered the

      goal achievement

        Re-assess

        Formulate a new Nursing Diagnosis

        Revise care plan

GOAL MET!!!!!!!!

 

LEARNING ACTIVITY
Syllabus, Appendices
L (pg. 161) & M (pg. 167)

In small groups…read case study and answer questions 1 & 2 for each case.