1. Nursing Process
B244

2. The Nursing Process Assessment Diagnosis Planning Implementation
Setting Outcomes and Goals
Choosing interventions
Scientific rationales
Implementation
Evaluation

3. Assessment: 1st step Data Collection Subjective Objective
Assessment involves taking vital signs (TPR BP & Pain assessment.
Performing a head to toe assessment
Listening to the patient's comments and questions about his health status
Observing his reactions and interactions with others. It involves asking pertinent questions about his signs (observable) and symptoms (Non-observable), and listening carefully to the answers.
Subjective
Objective
reinforces subjective findings

4. Risk Assessment
Definition: used to determine longevity or a prognostic category involving life expectancy. Can be based on history, physical examination, and laboratory data.
Online risk assessment, what are some of YOUR risks?

5. Nursing Diagnosis: 2nd Step
Actual: 3 parts
Problem statement
Etiology Statement
Evidence statement (defining characteristics)
Risk for: 2 parts
Put risk factors as the etiology and no evidence statement is required
Health-Promotion: 3part
Focuses on being as health as possible as opposed to preventing disease

6. The Problem Statement
North American Nursing Diagnosis Association (NANDA)
NOT usually the same as a medical diagnosis
Amenable to nursing intervention
Validated by data

7. Etiology Statement The most probable reason for the problem statement.
A human response, NOT a medical diagnosis.
“related to” or R/T
Important: the etiology statement drives the type of nursing interventions.
Only for ACTUAL nursing problems (not “readiness for”)

8. Evidence Statement Gathered from assessment.
Supports the problem statement.
“as evidenced by” or AEB (defining characteristics)
Not needed with “Risk for” diagnoses

9. Sample Nursing Diagnoses
Patient with emphysema:
Ineffective breathing patterns R/T muscle weakness and fatigue secondary to chronic respiratory disease AEB rapid, shallow respirations.
Daughter caring for her elderly mother:
Caregiver role strain R/T unrealistic expectations of self AEB reporting feelings of frustrations and failure.
Child s/p appendectomy
Pain R/T surgical incision AEB rating pain at 6/10 on numeric scale.

10. What is wrong… …with each of these nursing diagnoses?
Myocardial infarction R/T high fat diet AEB chest pain
Fluid Volume deficit R/T vomiting
Sleep pattern disturbance AEB awakening 3 times per night

11. Planning Care: 3rd Step Determine expected outcomes (goals)
Assign priority to problems
A-B-C… (OR CAB )
Maslow’s hierarchy of needs
Potential versus actual
Specify behavioral outcomes
Determine what nursing can do (interventions)

12. Goal Statements Client centered “The client will…”
Specific and measurable
Time frame
Address the diagnosis

13. Critique these goals…
The nurse with check the client’s blood pressure every shift
The client with lose weight over the next 6 weeks
The client will be pain free during this shift
The client will understand how to check his blood glucose levels before discahrge

14. Interventions Independent (or dependent, interdependent)
Scientific basis (rationale)
Expected to move the client toward the goal (effectiveness)
Specific and action oriented

15. Implementation of Plan: 4th step
Cary-out plan
Modify as needed
Document care given
Most frequent interventions in health promotion:
Screening, education, counseling, crisis intervention

16. Rationales for Interventions
The reason why you are doing what you are doing.
Hint: If you can’t think of a reason, you probably shouldn’t be doing it!
Should be evidence-based (theory and/or research)
Requires a refernce

17. Evaluation: 5th step
How you know your interventions were effective or not
Think of the nursing process as a circle, from this point you re-assess and modify the plan as needed.

18. Nursing Diagnosis & Goal: Individual or Family?
ND: Health Seeking behavior: Nutrition
Goal: The client will eat 3 meals per day organized around the healthy plate for the next 6 weeks.
ND: Readiness for enhanced family process AEB expressed desire to eat more meals at home together
Goal: The family will eat 4 evening meals together per week for the next six weeks.