1. Nursing Fundamentals CHPTR 2
NURSING PROCESS
“The Recipe”

2. The Nursing Process A systematic method of providing care to clients.
It’s a system that nurses use to provide efficient and effective nursing care
If we didn’t use some sort of standardized care, nursing would be a chaotic mess

3. Who writes the plan RN should begin the plan and sign it
LPN can help and doesn’t need to sign it necessarily
The RN takes the lead role here

4. The 5-Step Nursing Process
Data collection (Assessment.)
Diagnosis.
Planning and outcome identification.
Implementation.
Evaluation.

5. The Nursing Process uses Critical Thinking
Critical thinking, problem-solving, and decision-making
These skills can be learned!

6. WHAT IS CRITICAL THINKING?
Critical thinking is a process of objective reasoning or analyzing facts to reach a valid conclusion
Critical thinking allows nurses to determine which problems are necessary to call the Dr. about or which fall into the domain of Nursing judgment (where you don’t need a Dr’s order)

7. Data Collection (assessment)

8. Purpose of Data collection (Assessment)
Why is data collection (assessment) important?

9. Data collection is important because it tells you facts about the patient.
Data collection 1st begins when you see the pt. for the 1st time and it cont’s until the pt. is released

10. It is during data collection period that the nurse collects info
It is during data collection period that the nurse collects info. to determine areas of abnormal function, risk factors that contribute to the pts health problems and it helps the nurse find the pts strengths

11. Sources of Data Primary Source: The client.
Secondary Source: The client’s family members, other health care providers, and medical records.

12. Types of Data
Subjective: it’s what the patient SAYS or STATES. This is also the symptoms someone c/o
Objective: it’s what you observe. It’s observable and measurable data obtained through physical examination and laboratory and diagnostic testing. This is also what signs the pt shows you

13. Is it: A=subjective B=objective
125lbs
“I’m starving”
greenish emesis
The Pt tell you he vomited
greenish fluid
Erythematous toe
“I’m burping a lot”
“my heart is racing”
“like a knife stabbing me”
Sleeps with 2 pillows
146/89
Pinpoint pupils
“He is so tired”
Pale, diaphoretic
O2 sat = 91% on room air

14. Is it: A=subjective B=objective
Pulse 125

15. Is it: A=subjective B=objective
“I’m starving”

16. Is it: A=subjective B=objective
Pt. tells you he vomited

17. Is it: A=subjective B=objective
Greenish emesis

18. Is it: A=subjective B=objective
Toe with erythema

19. Is it: A=subjective B=objective
Sleeping with 2 pillows

20. Is it: A=subjective B=objective
I’m burping a lot

21. Is it: A=subjective B=objective
He is so tired

22. Is it: A=subjective B=objective
Blood pressure 146/82

23. Is it: A=subjective B=objective
He is crying and depressed

24. Is it: A=subjective B=objective
Pale, diaphoretic

25. Is it: A=subjective B=objective
My husband is acting like such a baby, he is whining about everything

26. Types of Data Collection
Comprehensive - Provides baseline data including complete health history and current needs assessment.
Focused - Limited in scope in order to focus on a particular need or concern or potential risk.
Ongoing - Includes systematic monitoring and observation related to specific problems.

27. Organizing Data
Collected information must be organized to be useful.

28. Documenting Data Data collection must be recorded and reported.
Accurate and complete recording of your data collection is essential for communicating information to health care team.

29. Here is your client.
68 yr old male, lost wife three months ago, has not been out to his senior center since his wife died, loss of 15 lbs in 1month, disheveled appearance,
Write out some data you collected and decide if subjective or objective.

30. Diagnosis
A medical diagnosis is a clinical judgment by the physician that determines a specific disease, condition or pathological state.
A nursing diagnosis is a clinical judgment by the nurse about individual, family, or community responses to actual or potential health problems/life processes.

31. Nursing Diagnosis is a Three Part Statement
The name of the health-related issue or problem identified in the NANDA list (see the inside back cover of your book)
Etiology - the cause or contributor to the problem.
Signs and Symptoms

32. TYPE OF DIAGNOSES
You must state whether your nursing problem is one of the following:
An actual problem
A risk for a problem to occur
And then you must relate it to something

33. If a pt is obese, you would say it’s an ACTUAL problem
Therefore, you would say that the nursing diagnoses for this pt is: over-nutrition related to the lack of education

34. If your patient had troubling swallowing, you would say:
Potential for aspiration related to difficulty swallowing Or
Possible airway obstruction related to difficulty swallowing

35. Here is your client.
68 yr old male, lost wife three months ago, has not been out to his senior center since his wife died, loss of 15 lbs in 1month, disheveled appearance,

36. Types of Nursing Diagnosis
Actual nursing diagnosis: A problem exists; it is composed of the diagnostic label, related factors, and signs and symptoms.
Hi Risk nursing diagnosis: A problem does not yet exist, but special risk factors are present.

37. Here is your client.
68 yr old male, lost wife three months ago, has not been out to his senior center since his wife died, loss of 15 lbs in 1month, disheveled appearance,
Write a nursing diagnosis
___________ r/t ____________ # # #3

38. Planning
Set nursing goals
Nursing Orders

39. Here is your client.
68 yr old male, lost wife three months ago, has not been out to his senior center since his wife died, loss of 15 lbs in 1month, disheveled appearance,
Write a goal related to the diagnosis

40. Intervention
A nursing intervention is an action performed by the nurse that helps the client achieve the results specified by the goals and expected outcomes.
It’s what you are ACTUALLY GOING TO DO OR CARRY OUT

41. Types of Nursing Interventions
Specific order - written by physician or nurse especially for an individual client.
Standing order - A standardized intervention written, approved and signed by a physician that is kept on file to be used in predictable situations or in circumstances requiring immediate attention.
Protocol - A series of standing orders or procedures.

42. Here is your client.
68 yr old male, lost wife three months ago, has not been out to his senior center since his wife died, loss of 15 lbs in 1month, disheveled appearance,
What interventions will you plan to do or have others do?

43. WHAT DO YOU DO WITH ALL THE INFO. COLLECTED?
You write a nursing care plan
This plan tells others how to care for the pt. IN A SYSTEMATIC, CONSISTENT WAY
Nurses won’t have to reinvent the wheel everyday that they care for this pt.

44. The Nursing Care Plan
A written guide that organizes data about a client’s care into a formal statement of the strategies that will be implemented to help the client achieve optimal health.

45. Implementation execution of the nursing care plan
It’s what YOU ARE ACTUALLY GOING TO DO

46. Evaluation
determining whether client goals have been met, partially met, or not met.
It is in this stage that you will decide what needs to be changed to make the goal happen even more
It’s improvement after you see how it’s going

47. Here is your client.
3 weeks later…gain 2 lbs……states “ I went to the senior center twice last week and had lunch.
Evaluate progress

48. Take blood pressure every 3 hours
A. Data collection
B. Diagnosis
C. Planning
D. Implementation
E. Evaluation

49. Instruct client to self medicate
A. Data collection
B. Diagnosis
C. Planning
D. Implementation
E. Evaluation

50. Client state “ I exercise every day”
A. Data collection
B. Diagnosis
C. Planning
D. Implementation
E. Evaluation

51. Client will eat 75% of meal with assist
A. Data collection
B. Diagnosis
C. Planning
D. Implementation
E. Evaluation

52. Anxiety related to hospitalization
A. Data collection
B. Diagnosis
C. Planning
D. Implementation
E. Evaluation

53. Goal met-Client was able to state signs and symptoms of infection
A. Data collection
B. Diagnosis
C. Planning
D. Implementation
E. Evaluation

54. The nursing assistants are taking the patients blood pressure now.
A. Data collection
B. Diagnosis
C. Planning
D. Implementation
E. Evaluation

55. CHARTING In the world of nursing…
“if it’s not written, it was never done”
This turns into legal issues
Just because you did it and didn’t chart it, means it was NEVER done.

56. IN REVIEW So what is the Nursing Process anyway
The fact that you have to do all the parts: D-D-P-I-E…takes a long time to get through therefore, it’s a process
Get it? It’s a process…NURSING PROCESS
And why do we take time out of our busy schedule to do this process….so nursing care can be consistent and not forgotten

57. PRIORITY
Remember that you may be able to choose 10 NANDAS for 1 pts problems but you really should only use the top 2 or maybe 3 at the most
You prob. Won’t have time to write more than 3

58. Remember…
The interventions you write down in order to care for the pt come from:
The Dr.s order
Your own idea of what you think needs to be done
Every nurse MUST follow the Dr.s orders. You don’t have to follow every intervention made by a nurse 

59. THE END