Copyright © 2009 Wolters Kluwer Health | Lippincott Williams & Wilkins Chapter 2 Nursing Process

Copyright © 2009 Wolters Kluwer Health | Lippincott Williams & Wilkins Definition of the Nursing Process Organized sequence of problem-solving steps Used to identify and manage the health problems of clients Accepted standard for clinical practice: American Nurses Association (ANA) Framework for nursing care

Copyright © 2009 Wolters Kluwer Health | Lippincott Williams & Wilkins Characteristics of the Nursing Process Within the legal scope of nursing Based on knowledge Planned Client centered Goal directed Prioritized Dynamic

Copyright © 2009 Wolters Kluwer Health | Lippincott Williams & Wilkins

Assessment –First step of nursing process oSystematic collection of facts or data  Types of data  Objective data: observable and measurable facts, referred to as signs of disorder Steps of the Nursing Process

Copyright © 2009 Wolters Kluwer Health | Lippincott Williams & Wilkins Steps of the Nursing Process (cont’d) Assessment (cont’d) –Types of data (cont’d) oSubjective data: information only client feels and can describe; called symptoms –Sources of data: primary source–client; secondary sources–client’s family, reports, or discussion with other health care professionals

Copyright © 2009 Wolters Kluwer Health | Lippincott Williams & Wilkins Steps of the Nursing Process (cont’d) Assessment (cont’d) –Types of assessment oData base assessment  Initial information: client’s physical, emotional, social, and spiritual health  Obtained during admission interview and physical examination

Copyright © 2009 Wolters Kluwer Health | Lippincott Williams & Wilkins Steps of the Nursing Process (cont’d) Assessment (cont’d) –Types of assessment (cont’d) oFocus assessment  Information: details about specific problems; expands original data base

Copyright © 2009 Wolters Kluwer Health | Lippincott Williams & Wilkins Question Which of the following is a primary source for information? a. Client’s family b. Client c. Medical records d. Test results

Copyright © 2009 Wolters Kluwer Health | Lippincott Williams & Wilkins Answer b. Client The primary source for information is the client. The client’s family, test results, and medical records are secondary sources of information.

Copyright © 2009 Wolters Kluwer Health | Lippincott Williams & Wilkins Steps of the Nursing Process (cont’d) Assessment (cont’d) –Organization oInvolves grouping related information oNurses: organize assessment data; cluster related data using knowledge and past experiences

Copyright © 2009 Wolters Kluwer Health | Lippincott Williams & Wilkins Steps of the Nursing Process (cont’d) Diagnosis –Second step of the nursing process oIdentification of health-related problems oNursing diagnosis  Health issue that can be prevented, reduced, resolved, or enhanced through independent nursing measures

Copyright © 2009 Wolters Kluwer Health | Lippincott Williams & Wilkins Nursing diagnosis –Categorized into 5 groups: actual; risk; possible; syndrome; wellness oThe NANDA list  Authoritative organization for developing and approving nursing diagnoses

Copyright © 2009 Wolters Kluwer Health | Lippincott Williams & Wilkins oDiagnostic statement  Contains 3 parts:  Name of health-related issue or problem identified in the NANDA list

Copyright © 2009 Wolters Kluwer Health | Lippincott Williams & Wilkins  Etiology (its cause): phrase “related to”  Signs and symptoms: phrase “as manifested (or evidenced) by”

Copyright © 2009 Wolters Kluwer Health | Lippincott Williams & Wilkins  Potential diagnoses: “risk for”

Copyright © 2009 Wolters Kluwer Health | Lippincott Williams & Wilkins Diagnosis (cont’d) –Nursing diagnosis (cont’d) oDiagnostic statement (cont’d)  Potential nursing diagnoses: signs or symptoms not manifested Steps of the Nursing Process (cont’d)

Copyright © 2009 Wolters Kluwer Health | Lippincott Williams & Wilkins oCollaborative problem  Physiologic complications require both nurse- and physician- prescribed interventions

Copyright © 2009 Wolters Kluwer Health | Lippincott Williams & Wilkins

Planning –Third step of the nursing process oSetting priorities  Determine which problems require most immediate attention oEstablishing goals  Goal: expected or desired outcome Steps of the Nursing Process (cont’d)

Copyright © 2009 Wolters Kluwer Health | Lippincott Williams & Wilkins oShort-term goals:  Outcomes achievable in a few days to 1 week  Characteristics: developed from; client-centered

Copyright © 2009 Wolters Kluwer Health | Lippincott Williams & Wilkins  Measurable  Realistic  Target date for accomplishment  Predicted time  Time line for evaluation

Copyright © 2009 Wolters Kluwer Health | Lippincott Williams & Wilkins oLong-term goals  Desirable outcomes take weeks or months to accomplish

Copyright © 2009 Wolters Kluwer Health | Lippincott Williams & Wilkins –Selecting nursing intervention oto accomplish identified goals omust be safe; within legal scope of nursing practice; and compatible with medical orders oDocumenting plan of care

Copyright © 2009 Wolters Kluwer Health | Lippincott Williams & Wilkins –Communicating the plan of care oNurses share plan with nursing team members, client, and the client’s family oPermanent part of client’s medical record placed in client’s chart; nurses refer to it, review it, and revise it

Copyright © 2009 Wolters Kluwer Health | Lippincott Williams & Wilkins Implementation –Fourth step in the nursing process: carrying out the plan of care oRecord: quantity and quality of client response Steps of the Nursing Process (cont’d)

Copyright © 2009 Wolters Kluwer Health | Lippincott Williams & Wilkins Evaluation –Fifth and final step of the nursing process: nurses determine whether client has reached the goal –Analyze client’s response Steps of the Nursing Process (cont’d)