Nursing Process: 5-Step Process Gail Ladwig, RN, MSN, CHTP Mosby items and derived items © 2011 by Mosby, Inc., an affiliate of Elsevier Inc.

2 Nursing Process: Definition  An organizing framework for professional nursing practice  Used in nursing to identify and treat the nursing diagnoses (problems) of a client

3 Mosby items and derived items © 2011 by Mosby, Inc., an affiliate of Elsevier Inc. Critical Thinking and the NP  Decision making for and with the client  The nurse processes and interprets the information that is gathered while performing the steps of the nursing process.

4 Mosby items and derived items © 2011 by Mosby, Inc., an affiliate of Elsevier Inc. Nursing Process: Quote Caring is major part of the process  “Caring is essential to curing and pervades all efforts to help an individual recover after an illness and be cured” (Leninger, 1996)

5 Mosby items and derived items © 2011 by Mosby, Inc., an affiliate of Elsevier Inc. Nursing Process: Quote  According to Leninger (1996), “Caring is the most important and central focus of nursing”

6 Mosby items and derived items © 2011 by Mosby, Inc., an affiliate of Elsevier Inc. Nursing Process: Quote  Watson and Ray (1988) advocate that “we first love and care for ourselves, so as a beginning nurse you are to believe in yourself, identify your strengths, and put your abilities to work.”

7 Mosby items and derived items © 2011 by Mosby, Inc., an affiliate of Elsevier Inc. Nursing Process: 5 Steps  Use the acronym ADPIE 1. Assessment 2. Diagnosis 3. Plan 4. Implementation 5. Evaluation

8 Mosby items and derived items © 2011 by Mosby, Inc., an affiliate of Elsevier Inc. Step One Assessment

9 Mosby items and derived items © 2011 by Mosby, Inc., an affiliate of Elsevier Inc. Assessment  Initial step of the nursing process  Collection of information about the client  Holistic and detailed  Supports critical thinking  Determines problems and strengths  Ongoing during all phases of nursing process

10 Mosby items and derived items © 2011 by Mosby, Inc., an affiliate of Elsevier Inc. Step One: Assessment Method  Assess the client: perform a thorough holistic nursing assessment  Use the format adopted by the facility or educational institution Nursing assessments may be based on conceptual models: Gordon’s functional health patterns, Orem’s self- care model, or Roy’s adaptation model Nursing assessments may be based on conceptual models: Gordon’s functional health patterns, Orem’s self- care model, or Roy’s adaptation model

11 Mosby items and derived items © 2011 by Mosby, Inc., an affiliate of Elsevier Inc. Assessment Sources of Information  Nursing assessment/heath history: client  Physical assessment: client  Medical records  Diagnostic test results  Health team members  Significant others if appropriate

12 Mosby items and derived items © 2011 by Mosby, Inc., an affiliate of Elsevier Inc. Obtain an Accurate Health History: Sample Questions  Ask open-ended questions:  “Describe what you are feeling.”  “Tell me about these symptoms?”  “How does it affect your daily routine?”  “What can we help you with?”

13 Mosby items and derived items © 2011 by Mosby, Inc., an affiliate of Elsevier Inc. Physical Assessment  Perform a thorough physical assessment  Medical model: head to toe or body system  Carefully assess each area for normal and abnormal findings  Inspect, auscultate, palpate, and percuss

14 Mosby items and derived items © 2011 by Mosby, Inc., an affiliate of Elsevier Inc. Critical Thinking  Look for normal and abnormal findings  Validate the data with the client  Validation “This is what I have noticed.” “This is what I have noticed.” “Does this describe how you feel?” “Does this describe how you feel?” “Tell me more.” “Tell me more.” “What can I do to help?” “What can I do to help?”

15 Mosby items and derived items © 2011 by Mosby, Inc., an affiliate of Elsevier Inc. Critical Thinking (Continued) Using the assessment information  Organize the information  Identify patterns in the assessment (highlight or underline problems)  Make a list of all problems and potential problems  Group like problems together  Make initial inferences or impressions  Prioritize the problems Use Maslow’s hierarchy Use Maslow’s hierarchyMaslow’s hierarchyMaslow’s hierarchy  Record and report the information

16 Mosby items and derived items © 2011 by Mosby, Inc., an affiliate of Elsevier Inc. Immediate Reporting of Assessment Information  Report and record information that requires immediate action.  Some examples Sharp unrelenting pain Sharp unrelenting pain Vital signs greatly deviated from normal Vital signs greatly deviated from normal Change in level of consciousness Change in level of consciousness  When in doubt, report.  Be prepared to immediately follow instructions that are given.

17 Mosby items and derived items © 2011 by Mosby, Inc., an affiliate of Elsevier Inc. Documentation  Record all information obtained from the health history and physical assessment.  Many institutions use computers for this purpose.

18 Mosby items and derived items © 2011 by Mosby, Inc., an affiliate of Elsevier Inc. Confidentiality  Share only information that is of benefit to the nursing and medical team for planning care.  Always keep in mind that HIPAA laws must be followed. HIPAA  Keep notes safe.  Do not leave at site of interview.

19 Mosby items and derived items © 2011 by Mosby, Inc., an affiliate of Elsevier Inc. Confidentiality (Continued)  Client’s name should appear only on agency documents (do not put client's name on any notes used for classroom work).  Follow Health Insurance Portability and Accountability Act (HIPAA) guidelines regarding client confidentiality. HIPAA

20 Mosby items and derived items © 2011 by Mosby, Inc., an affiliate of Elsevier Inc. Step Two Nursing Diagnosis

21 Mosby items and derived items © 2011 by Mosby, Inc., an affiliate of Elsevier Inc. Nursing Diagnosis  Clinical judgment  Individual, family, or community  Response to actual or potential health problems or life processes  Basis for outcomes and interventions  The nurse is accountable. (NANDA-I [NANDA-International], 2009) (NANDA-I [NANDA-International], 2009)

22 Mosby items and derived items © 2011 by Mosby, Inc., an affiliate of Elsevier Inc. Nursing Diagnosis List  Select the appropriate nursing diagnosis for the client from NANDA-I’s approved list.  Nursing Diagnoses: Definitions and Classification 2009  List of 203 “approved nursing diagnoses”

23 Mosby items and derived items © 2011 by Mosby, Inc., an affiliate of Elsevier Inc. Critical Thinking and Nursing Diagnosis  Based on assessment information  Information is analyzed (Questions to Ask)  Can a change occur with a nursing intervention?  Does it fit the NANDA-I definition?  Are the defining characteristics in the assessment?

24 Mosby items and derived items © 2011 by Mosby, Inc., an affiliate of Elsevier Inc. Make a Nursing Diagnostic Statement: PES  Problem/nursing diagnosis  Etiology/related to statement  Signs and symptoms/defining characteristics

25 Mosby items and derived items © 2011 by Mosby, Inc., an affiliate of Elsevier Inc. Nursing Diagnosis: Critical Thinking  Does the selected diagnosis fit the NANDA definition?  Are the defining characteristics in the assessment?

26 Mosby items and derived items © 2011 by Mosby, Inc., an affiliate of Elsevier Inc. Document Selected Nursing Diagnosis on Nursing Plan of Care

27 Mosby items and derived items © 2011 by Mosby, Inc., an affiliate of Elsevier Inc. Step Three Planning Step Three Planning

28 Mosby items and derived items © 2011 by Mosby, Inc., an affiliate of Elsevier Inc. Planning  Step done after the nursing diagnosis is determined  This step consists of writing measurable client outcomes and nursing interventions to accomplish the outcomes.  These outcomes and interventions are designed to change the client’s nursing diagnosis/problem.

29 Mosby items and derived items © 2011 by Mosby, Inc., an affiliate of Elsevier Inc. Planning Steps: Outcomes, Interventions  Write measurable client outcomes.  Identify nursing interventions to accomplish the outcomes.

30 Mosby items and derived items © 2011 by Mosby, Inc., an affiliate of Elsevier Inc. Planning: Critical Thinking Outcomes and Interventions  Outcomes  What does the client hope to accomplish?  How should these client outcomes be prioritized?  How will the outcomes be measured?  How long will it take? Interventions  What nursing interventions can the nurse do to help the client with satisfactory outcomes?  Who will assist the client? The nurse? The nurse? Ancillary personnel? Ancillary personnel?

31 Mosby items and derived items © 2011 by Mosby, Inc., an affiliate of Elsevier Inc. Definition: NOC (Nursing Outcome Classification) Standardized Language NOC  An individual, family, or community state, behavior, or perception that is measured along a continuum in response to nursing intervention(s)  The outcomes are variable concepts that can be measured along a continuum.  Outcomes are stated as concepts that reflect a patient, family caregiver, family, or community actual state rather than expected goals. (Moorhead, 2004)

32 Mosby items and derived items © 2011 by Mosby, Inc., an affiliate of Elsevier Inc. Planning: Outcomes  Set client-centered short-term and long-term goals/outcomes.  Prioritize by what is most important.  Use Maslow’s hierarchy.

33 Mosby items and derived items © 2011 by Mosby, Inc., an affiliate of Elsevier Inc. Outcomes: Critical Thinking and Outcomes  Questions  Does it come from the nursing diagnosis?  Is it measurable?  Does the client agree to it?  Is it realistic?  Is it attainable?  Is there a time frame?  Does it provide direction for care?

34 Mosby items and derived items © 2011 by Mosby, Inc., an affiliate of Elsevier Inc. Document Selected Outcomes on Nursing Plan of Care

35 Mosby items and derived items © 2011 by Mosby, Inc., an affiliate of Elsevier Inc. NIC (Nursing Intervention Classification)  The nursing interventions classification (NIC) is a comprehensive, standardized language describing treatments that nurses perform in all settings and in all specialties.  The classification includes both physiological and psychosocial interventions and covers all nursing specialties. (Bulechek, Butcher, McCloskey Dochterman 2004)

36 Mosby items and derived items © 2011 by Mosby, Inc., an affiliate of Elsevier Inc. Interventions: How to Select Appropriate Ones  Criteria for interventions  Activity done for and with client  Accomplishes outcomes  Removes or reduces related factors that contributed to the nursing diagnosis  Individualized  Specific/safe

37 Mosby items and derived items © 2011 by Mosby, Inc., an affiliate of Elsevier Inc. Interventions (Continued)  Road map to guide nursing care  The more clearly a nurse writes an intervention, the easier it will be to complete the journey and arrive at the destination of successful client outcomes.

38 Mosby items and derived items © 2011 by Mosby, Inc., an affiliate of Elsevier Inc. Evidence-Based Nursing Interventions  A set of interventions or guidelines that have been shown to be effective in helping clients  EBN looks at standard protocol and determines if the protocol is effective based on gathered evidence.

39 Mosby items and derived items © 2011 by Mosby, Inc., an affiliate of Elsevier Inc. Planning Interventions: Critical Thinking Questions to ask  ASK  What nursing interventions can the nurse do to help the client with satisfactory outcomes?  Who will assist the client? The nurse? Ancillary personnel?  What equipment is needed?  How long will the intervention take?  How often should the intervention be done?  What is the evidence to support its effectiveness?

40 Mosby items and derived items © 2011 by Mosby, Inc., an affiliate of Elsevier Inc. Document Interventions on Nursing Plan of Care

41 Mosby items and derived items © 2011 by Mosby, Inc., an affiliate of Elsevier Inc. Step Four Implementation

42 Mosby items and derived items © 2011 by Mosby, Inc., an affiliate of Elsevier Inc. Implementation ACTION  Initiation of the nursing care plan  Performing the nursing interventions  Delegation of appropriate nursing interventions  Using skills  Psychomotor  Interpersonal  Cognitive  Performing continuous assessment

43 Mosby items and derived items © 2011 by Mosby, Inc., an affiliate of Elsevier Inc. Implementation: Critical Thinking ASK  How did the client tolerate the intervention?  Were there any identified problems?  Was any additional equipment needed?  Was the time frame appropriate?  Were the appropriate personnel involved?

44 Mosby items and derived items © 2011 by Mosby, Inc., an affiliate of Elsevier Inc. ReportandDocument

45 Step Five Evaluation

46 Mosby items and derived items © 2011 by Mosby, Inc., an affiliate of Elsevier Inc. Evaluation  Although evaluation is listed as the last phase of the nursing process, it is actually an integral part of each phase and something that is done continually.  Client’s outcomes are evaluated to see if they are satisfactory.  If the outcomes were not satisfactory, then the nursing process is begun again with assessment to determine the reason why the outcomes were not satisfactory.

47 Mosby items and derived items © 2011 by Mosby, Inc., an affiliate of Elsevier Inc. Evaluation: Critical Thinking ASK  Check the client outcomes.  Were the outcomes satisfactory?  Is an additional assessment needed?  Were the outcomes realistic?  Was the right nursing diagnosis selected?  Does the nursing care plan need to be modified?

48 Mosby items and derived items © 2011 by Mosby, Inc., an affiliate of Elsevier Inc. Evaluation: Critical Thinking (Continued)  When using EBN, it is at this point that it is determined whether the practice that was followed was effective.  Necessary revisions may be made at this time.

49 Mosby items and derived items © 2011 by Mosby, Inc., an affiliate of Elsevier Inc. Summary  Review  Steps of the nursing process (ADPIE)  Assessment  Diagnosis  Planning  Implementation  Evaluation

50 Mosby items and derived items © 2011 by Mosby, Inc., an affiliate of Elsevier Inc. Final Reminder  Document and report.  “If you didn’t chart it, you didn’t do it.”

51 Mosby items and derived items © 2011 by Mosby, Inc., an affiliate of Elsevier Inc. Good Job  You have mastered the nursing process.  You have delivered safe, effective care to your client.  Be proud of your work and profession.

52 Mosby items and derived items © 2011 by Mosby, Inc., an affiliate of Elsevier Inc. References  Bulechek G, Butcher H, McCloskey Dochterman J: Nursing intervention classification (NIC), ed 5., St. Louis, Mosby,  Leininger M: Culture care theory, research, and practice. Nurs Sci Q 9(2): 71 – 78,  Moorhead S, Johnson M, Maas M et al: Nursing outcomes classification (NOC), ed 4., St. Louis, Mosby,  Watson J, Ray M (Eds.): The ethics of care and the ethics of cure: Synthesis in chronicity. New York, NLN, 1998.