1. Nursing Process
Part Three, 211 NUR

2. Learning Outcomes Describe the phases of the nursing process.
Identify major characteristics of the nursing process.
Identify the purpose of assessing.
Identify the four major activities associated with the assessing phase.

3. Learning Outcomes (cont'd)
Differentiate objective and subjective data and primary and secondary data.
Identify three methods of data collection, and give examples of how each is useful.
Compare closed and open-ended questions, providing examples and listing advantages and disadvantages of each

4. Nursing Process Defined as:
is a Systematic, rational method of planning to providing nursing care.
Is “A series of steps or acts that lead to accomplishment of some goal or purpose”

5. Goals of Nursing process
To identify Patient healthcare status, actual or potential health problems
To establish plans to meet the identified needs.
To deliver specific nursing interventions to address those needs.

6. Benefits of Nursing process
1. Improves quality of care Pts. Receive.
2. Promotes efficient use of time & resources.
Serves as framework for nurses’ accountability.
4. Enhances collaboration.
5. Continuity of care and Prevention of duplication.

7. Characteristics of the Nursing Process
Cyclic and dynamic rather than static.
Client centered.
Problem-solving and systems theory.
Decision making.
Interpersonal and collaborative.
Universal applicability.
Critical thinking skills.

8. MARTHA ROGERS, NURSE THEORIST
“When an apple is cut, others see seeds in the apple. We, as nurses, see apples in the seeds.”

9. 5 Steps in the Nursing Process
Assessment
Nursing Diagnosis
Planning
Implementing
Evaluating
Each step needs to be completed before we can progress further in the process

10. Figure 11-1 The nursing process in action.10

11. Figure 11-1 (continued) The nursing process in action.

12. Figure Assessing. 12

13. 1. Assessment Collecting data Organizing data Validating data
Documenting data

14. 1. Assessment Four types of assessment Initial nursing assessment
Problem-focused assessment
Emergency assessment
Time-lapsed reassessment

15. Types of Assessments Initial or Comprehensive Problem-Focused
Performed within a specified time period
Establishes complete database
Problem-Focused
Ongoing process integrated with care
Determines status of a specific problem

16. Types of Assessments (cont'd)
Emergency
Performed during physiologic or psychologic crises
Identifies life-threatening problems
Time-lapsed (on going)
Occurs several months after initial assessment
Compares current status to baseline

17. Small group questions
Baby Jane a 2 month infant goes into the doctor for her initial immunization and well baby check-up. What type of assessment should the nurse perform?
A. Comprehensive
B. Focused
C. Time-lapsed (on going)

18. A. Collecting Data
Gathering information about a client’s health status.
It must be both systematic and continuous.
Should include past history and current problem.
Can be subjective or objective.
From primary or secondary source.

19. Subjective Data Symptoms or covert data
Can be described only by person affected
Includes sensations, feelings, values, beliefs, attitudes, and perception of personal health status and life situations
Obtained through Nursing health history.

20. Objective Data Signs or overt data Detectable by an observer
Can be measured or tested against an accepted standard
Can be seen, heard, felt, or smelled
Obtained through observation or physical examination

21. Small Group Questions
4. Which of the following are objective data and which are subjective data.
A. Nausea
B. Vomiting
C. Unsteady gait
D. Anxiety
E. Bruises on the right arms and face
F. Temperature 101 F

22. Sources of Data Primary Source Secondary Sources The client
All other sources of data
Family members
Other health care providers
Medical records

23. Methods of Data Collection
Observing
Gathering data using the senses
Used to obtain following types of data:
Skin color (vision)
Body or breath odors (smell)
Lung or heart sounds (hearing)
Skin temperature (touch)

24. Methods of Data Collection
Interviewing
Planned communication or a conversation with a purpose
Used to:
Get or give information
Identify problems of mutual concern
Evaluate change
Teach
Provide support
Provide counseling or therapy

25. Closed and Open-ended Questions
Closed Question
Restrictive
Yes/no
Factual
Less effort and information from client
“What medications did you take?”
“Are you having pain now?”

26. Closed and Open-ended Questions (cont'd)
Specify broad topic to discuss
Invite longer answers
Get more information from client
Useful to change topics and elicit attitudes

27. The Interview Setting Time Place Client free of pain
Limited interruptions
Place
Private
Comfortable environment
Limited distractions

28. The Interview Setting (cont’d)
Seating Arrangement
Hospital
Office or clinic
Group
Distance
Comfortable
Language
Use easily-understood terminology

29. Methods of Data Collection
Examining (physical examination)
Systematic data-collection method
Uses observation and inspection, auscultation, palpation, and percussion
Vital signs, height and weight

30. b. Organizing data Nursing Models Framework
Gordon’s functional health pattern framework
Orem’s self-care model
Roy’s adaptation model

31. b. Organizing data Wellness Models Nonnursing Models
Body systems model
Maslow’s Hierarchy of Needs
Developmental theories

32. Validating Data Assessment complete
Objective and related subjective data agree
Additional data overlooked
Avoiding jumping to conclusions
Cues: subjective & objective
Inferences = nurse’s interpretation of the cues

33. Documenting Record client data
Record factual manner not interpreting by nurse
Record subjective data with quotes in client’s own words

34. Question
Which of the following behaviors would indicate that the nurse was utilizing the assessment phase of the nursing process, to provide nursing care?
Propose hypotheses
Generate desired outcomes
Reviews results of laboratory tests
Documents care

35. Question
Which of the following elements is best categorized as secondary subjective data?
The nurse measures a weight loss of 10 pounds since the last clinic visit.
Spouse states the client has lost all appetite.
The nurse palpates edema in lower extremities.
Client states severe pain when walking up stairs.

36. 2. Diagnoses

37. Figure 12-1 Diagnosing. The pivotal second phase of the nursing process.37

38. Nursing diagnosis:
“A clinical judgment about individual, family or community responses to actual or potential heal problems / life processes.
A nursing diagnosis provides the basis for selection of nursing interventions to achieve outcomes for which the nurse is accountable.”

39. Diagnoses Diagnosing refers to the reasoning process
Diagnosis is a statement or conclusion regarding the nature of a phenomenon
Diagnostic labels are the standardized NANDA names
Nursing diagnosis is the problem statement consisting of the diagnostic label plus etiology

40. Types of Nursing Diagnoses
Actual Diagnosis
Problem presents at the time of the assessment
Presence of associated signs and symptoms
Risk Diagnosis
Problem does not exist
Presence of risk factors

41. Types of Nursing Diagnoses (cont'd)
Health Promotion Diagnosis
Preparedness to implement behaviors to improve their health condition
Example: Readiness for enhanced Nutrition
Wellness Diagnosis
Describes human responses to levels of wellness in an individual, family, or community
Example: Readiness for Enhanced Family Coping

42. Components of a Nursing Diagnosis
Problem statement (diagnostic label)
Describes the client’s health problem or response
Qualifiers added to give additional meaning
Etiology (related factors and risk factors)
Identifies one or more probable causes of the health problem

43. Components of a Nursing Diagnosis
Defining characteristics
Cluster of signs and symptoms indicate the
presence of a particular diagnostic label (actual diagnoses)
Actual nursing diagnoses client’s have signs and symptoms
For risk for nursing diagnoses no subjective or objective data

44. Nursing Diagnoses
A statement of nursing judgment based on education, experience, expertise and licensed to treat
Describes human response, a client’s physical, sociocultural, psychological, and spiritual responses to an illness or a health problem
Changes when client’s responses change

45. Medical Diagnoses Made by a physician Refers to a disease process
Remains the same for as long as the disease process is present

46. Ex: Diagnosis Nursing diagnosis Medical diagnosis
Breathing patterns, ineffective
Chronic obstructive pulmonary disease
Activity intolerance
Cerebrovascular accident
Pain
Appendectomy
Body image disturbance
Amputation
Body temperature, risk for altered
Strep throat

47. Steps in Diagnostic Process
Analyzing Data
Compare data against standards
Cluster cues
Identify gaps
Identifying health problems, risks, and strengths
Formulating diagnostic statements

48. Writing Nursing Diagnoses
Basic Two-Part Statement
Problem (P)
Etiology (E)
Basic Three-Part Statement
Signs and symptoms (S) what’s the evidence of the problem.

49. Nursing Diagnosis
Problem( Diagnostic Label)-based on your assessment of client…(gathered information), pick a problem from the NANDA list...
Etiology- determine what the problem is caused by or related to (R/T)...
Defining characteristics- then state as evidenced by (AEB) the specific facts the problem is based on...

50. Example of Nursing Dx Ineffective therapeutic regimen management
R/T difficulty maintaining lifestyle changes and lack of knowledge
AEB B/P= 160/90, dietary sodium restrictions not being observed, and client statements of “ I don’t watch my salt” “It’s hard to do and I just don’t get it”.
Based on our assessment of the client with hypertension who wasn’t following the prescribed low salt diet this is an example of a nsg dx.
First part is the clients problem taken from the NANDA list
Second part is a reason why the client has the problem
Third part is the evidence of the problem

51. Table 12-6 Guidelines for Writing a Nursing Diagnostic Statement51

52. Question
In the diagnostic statement “Excess fluid volume related to decreased venous return as manifested by lower extremity edema (swelling),” the etiology of the problem is which of the following?
Excess fluid volume
Decreased venous return
Edema
Unknown

53. Question
Which of the following nursing diagnoses contains the proper components?
Risk for caregiver role strain related to unpredictable illness course
Risk for falls related to tendency to collapse when having difficulty breathing
Impaired communication related to stroke
Sleep deprivation secondary to fatigue and a noisy environment

54. 3. Planning

55. Figure Planning. The third phase of the nursing process, in which the nurse and client develop client goals/desired outcomes and nursing interventions to prevent, reduce, or alleviate the client’s health problems. 55

56. Initial Planning Developed the initial comprehensive plan of care
Planning should be initiated after the initial assessment

57. Ongoing Planning Done by all nurses who work with the client
Individualization of initial care plan
Also occurs at the beginning of a shift

58. Discharge Planning
Process of anticipating and planning for needs after discharge
Addressed in each client’s care plan
Begins at first client contact
Involves comprehensive and ongoing assessment

59. The Planning Process Consists of following activities:
Setting priorities
Establishing client goals/desired outcomes
Selecting nursing interventions
Writing individualized nursing interventions on care plans

60. Setting Priorities
Establishing a preferential sequence for addressing nursing diagnoses and interventions
High priority (life-threatening)
Medium priority (health-threatening)
Low priority (developmental needs)

61. Maslow’s Hierarchy of Needs

62. Goals/Desired Outcomes
Goals are broad statements about the client’s status
Desired outcomes are more specific, observable criteria used to evaluate whether the goals have been met

63. Table 13-2 Deriving Desired Outcomes from Nursing Diagnoses63

64. Components of Goal/Desired Outcome Statements
Subject: who is the person expected to achieve the outcome?
Verb: what actions must the person take to achieve the outcome?
Condition: under what circumstances is the person to perform the actions?
Performance criteria: how well is the person to perform the actions?
Target time: by when is the person expected to be able to perform the actions?

65. Guidelines for Writing Goals/Desired Outcomes
SMART Specific
Measurable
Attainable
Relevant
Time Bound
Pt will walk 50 ft.
Pt will maintain HR<100
Pt will state pain level is acceptable 6 (0-10)

66. Guidelines for Writing Goals/Desired Outcomes
Must be realistic
Ensure compatibility with the therapies of other professionals
Derive from only one nursing diagnosis
Use observable, measurable terms
Make sure client considers them to be important and values them.

67. Types of Nursing Interventions
Independent interventions
Those activities nurses are licensed to initiate (i.e., physical care, ongoing assessment)
Dependent interventions
Activities carried out under physician’s orders or supervision, or according to specified routines

68. Types of Nursing Interventions (cont'd)
Collaborative interventions
Actions nurse carries out in collaboration with other health team members
Reflect overlapping responsibilities of health care team

69. Criteria for Choosing Appropriate Interventions
Safe and appropriate for the client’s age, health, and condition
Achievable with the resources available
Congruent with the client’s values, beliefs, and culture
Congruent with other therapies
Based on nursing knowledge and experience or knowledge from relevant sciences

70. Writing individualized Nursing Interventions
Date when they are written
Verb
Action verb starts the interventions and must be precise
Conditions
Modifiers
Time element
How long or how often the nursing action is to occur

71. Question
The nurse selects the nursing diagnosis of Risk for Impaired Skin Integrity related to immobility, dry skin, and surgical incision. Which of the following represents a properly stated outcome/goal? The client will:
Turn in bed q2h.
Report the importance of applying lotion to skin daily.
Have healthy intact skin during hospitalization.
Use a pressure-reducing mattress.

72. 4. Implementation

73. Figure Implementing. The fourth phase of the nursing process, in which the nurse implements the nursing interventions and documents the care provided. 73

74. The Nursing Process - Implementing
Based on first three phases
Assessing
Diagnosing
Planning
Provides the basis for the nursing actions performed during the implementing step
Provides actual nursing activities and client responses are examined during evaluating phase

75. Successful Implementation
To implement care successfully, nurses need:
Cognitive skills
Interpersonal skills
Technical skills

76. Cognitive Skills (Intellectual)
Problem solving
Decision making
Critical thinking
Creativity

77. Interpersonal Skills Verbal and nonverbal
Effectiveness depends largely with ability to communicate
Therapeutic communication
Necessary for caring, comforting, advocating, referring, counseling, and supporting

78. Interpersonal Skills (cont'd)
Include conveying knowledge, attitudes, feelings, interest
Appreciation of the client’s cultural values and lifestyle

79. Technical Skills Purposeful “hands-on” skills
Often called tasks, procedures, or psychomotor skills
Psychomotor refers to physical actions that are controlled by the mind, not reflexes
Require knowledge and frequently manual dexterity

80. Five Activities of the Implementing Phase
Reassessing the client
Determining the nurse’s need for assistance
Implementing nursing interventions
Supervising delegated care
Documenting nursing activities

81. Reassessing the Client
Reassess to make sure the intervention is still needed
Client’s condition may have changed

82. Determining the Nurse’s Need for Assistance
Unable to implement the nursing activity safely
Assistance will reduce stress on the client
Lacks the knowledge or skills to implement a particular nursing activity

83. Implementing Nursing Interventions
Base on scientific knowledge
Clearly understand interventions
Adapt activities to the individual client
Implement safe care
Provide teaching, support, and comfort

84. Implementing Nursing Interventions (cont'd)
Be holistic
Respect the dignity of the client and enhance self esteem
Encourage active client participation

85. Supervising Delegated Care
Responsible for the client’s overall care
Validates and responds to any adverse findings or client responses

86. 5. Evaluation

87. Documenting Nursing Activities
Record nursing interventions and client responses
Must not be recorded in advance

88. Figure Evaluating. The final phase of the nursing process, in which the nurse determines the client’s progress toward goal achievement and the effectiveness of the nursing care plan. The plan may be continued, modified, or terminated. 88

89. Components of the Evaluation Process
Collecting data related to the desired outcomes (NOC indicators)
Comparing the data with outcomes
Relating nursing activities to outcomes
Drawing conclusions about problem status
Continuing, modifying, or terminating the nursing care plan

90. EVALUATION & REASSESSMENT
1. Goal met
2. Goal partially met
3. Goal not met
4. Goal in progress
Reassessment= the entire plan of care (data, ND, goal/O, Nsg orders) must be reassessed

91. Documentation Clear and concise Appropriate terminology
Usually on a designated form
Physical assessment
Usually by Review of Systems
Overview of symptoms
Diet
Each body system

92. Reference
Kozier & Erb's Fundamentals of Nursing by Audrey T Berman, Samuel Merritt CollegeShirlee Snyder, Nevada State CollegeGeralyn Frandsen, EdD, MSN, RN, Maryville University