1. Chapter 2 Nursing Process

2. 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

3. Characteristics of the Nursing Process
Within the legal scope of nursing
Based on knowledge
Planned
Client centered
Goal directed
Prioritized
Dynamic

5. Steps of the Nursing Process
Assessment
First step of nursing process
Systematic collection of facts or data
Types of data
Objective data: observable and measurable facts, referred to as signs of disorder

6. Steps of the Nursing Process (cont’d)
Subjective 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

7. Steps of the Nursing Process (cont’d)
Types of assessment
Data base assessment
Initial information: client’s physical, emotional, social, and spiritual health
Obtained during admission interview and physical examination

8. Steps of the Nursing Process (cont’d)
Focus assessment
Information: details about specific problems; expands original data base

9. Question Which of the following is a primary source for information?
a. Client’s family
b. Client
c. Medical records
d. Test results

10. 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.

11. Steps of the Nursing Process (cont’d)
Assessment (cont’d)
Organization
Involves grouping related information
Nurses: organize assessment data; cluster related data using knowledge and past experiences

12. Steps of the Nursing Process (cont’d)
Diagnosis
Second step of the nursing process
Identification of health-related problems
Nursing diagnosis
Health issue that can be prevented, reduced, resolved, or enhanced through independent nursing measures

13. Nursing diagnosis
Categorized into 5 groups: actual; risk; possible; syndrome; wellness (table 2-2)
The NANDA list
Authoritative organization for developing and approving nursing diagnoses (see last page)

14. Diagnostic statement
Contains 3 parts:
Name of health-related issue or problem identified in the NANDA list

15. Etiology (its cause): phrase “related to”
Signs and symptoms: phrase “as manifested (or evidenced) by”
(E.g., BOX 2-5)

16. Potential diagnoses: “risk for”
Potential nursing diagnoses: no signs or symptoms

17. Collaborative problem
Physiologic complications require both nurse- and physician- prescribed interventions

19. Steps of the Nursing Process (cont’d)
Planning
Third step of the nursing process
Setting priorities
Determine which problems require most immediate attention (table 2-4)
Establishing goals
Goal: expected or desired outcome

20. Short-term goals:
Outcomes achievable in a few days to 1 week

21. Characteristics of short-term goal
developed from the problem portion of diagnostic statement;
client-centered
Measurable
Realistic
Target date for accomplishment
(Box 2-7)

22. Long-term goals
Desirable outcomes take weeks or months to accomplish (with chronic problems)

23. Selecting nursing intervention
to accomplish identified goals
must be safe; within legal scope of nursing practice; and compatible with medical orders

24. Documenting plan of care
Communicating the plan of care
Nurses share plan with nursing team members, client, and the client’s family
Permanent part of client’s medical record placed in client’s chart; nurses refer to it, review it, and revise it

25. Steps of the Nursing Process (cont’d)
Implementation
Fourth step in the nursing process: carrying out the plan of care
Record: quantity and quality of client response

26. Steps of the Nursing Process (cont’d)
Evaluation
Fifth and final step of the nursing process: nurses determine whether client has reached the goal
Analyze client’s response (outcomes table 2-5) ………………………………….. End