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Basic Nursing: Foundations of
Skills & ConceptsChapter 9
NURSING
PROCESS
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The Nursing Process
A systematic method of providing care to clients.
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The 5-Step Nursing Process
Assessment. Diagnosis.
Planning and outcome identification.
Implementation. Evaluation.
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Assessment or Data Collection
The first step in the nursing process involves thefollowing:
Collecting data.
Validating data.
Organizing data. Interpreting data.
Documenting data
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Purpose of Assessment
To establish a database concerning a clientsphysical,
psychosocial, and emotional health.
To identify health-promoting behaviors as wellas actual and/or
potential health problems.
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Types of Assessment
Comprehensive - Provides baseline data including completehealth
history and current needs assessment.
Focused - Limited in scope in order to focus on a particular
needor concern or potential risk.
Ongoing - Includes systematic monitoring and observationrelated
to specific problems.
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Sources of Data
Primary Source: The client.
Secondary Source: The clients family members,
other health care providers, and medicalrecords.
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Types of Data
Subjective: Data from clients (and sometimes familys) point
of
view. Includes feelings, perceptions, and concerns. Collected
by
the interview.
Objective: Also called signs. Observable and measurable data
obtained through physical examination and laboratory
anddiagnostic testing.
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Validating Data
Validation prevents omissions,misunderstandings, and incorrect
inferences and
conclusions.
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Organizing Data
Collected information must be organized to beuseful.
Data Clustering is a useful tool to identify issues.
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Interpreting Data
Three critical components: Distinguishing between relevant and
irrelevant
data
Determining whether and where there are gapsin the data
Identifying patterns of cause and effect
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Documenting Data
Assessment data must be recorded andreported.
Accurate and complete recording of assessmentdata is essential
for communicating information
to health care team.
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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 about individual,
family, or community responses to actual or potential health
problems/life processes.
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Nursing Diagnosis Questions
Are there problems here?
If so, what are the specific problems?
What are some possible causes?
Is there a situation involving risk factors?
What are the risk factors? What are the clients strengths?
What data are available to answer these questions?
Is more data needed?
If so, what are the possible sources of further data?
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Nursing Diagnosis is a Two-Part
Statement
A problem statement or diagnostic label thatdescribes the
clients response to an actual orpotential health problem or
wellness condition.
And the etiology - the related cause orcontributor to the
problem.
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Nursing Diagnosis is a Three-Part
Statement
Includes first two parts ofT
wo-Part Statement:the diagnostic label and the etiology.
Also includes defining characteristics, the
collected data, also known as signs andsymptoms, subjective and
objective data, andclinical manifestations.
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Types of Nursing Diagnosis
Actual nursing diagnosis: A problem exists; it is composed of
the
diagnostic label, related factors, and signs and symptoms.
Risk nursing diagnosis: A problem does not yet exist, but
specialrisk factors are present.
Wellness nursing diagnosis: Indicates clients desire to
attainhigher level of wellness in some area of function.
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Planning and Outcome Identification
Planning combines with outcome identification tocomprise the
third step of the nursing process.
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Three Phases of Planning
Initial Planning: developing a preliminary plan of care by
the
nurse who performs the admission assessment.
Ongoing Planning: continuous updating of clients plan of
care.
Discharge Planning: Involves critical anticipation and
planning
for clients needs after discharge.
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Tasks Involved with Planning
Prioritizing list of nursing diagnoses.
Identifying and writing client-centered long- and short-term
goals
and outcomes.
Developing specific nursing interventions.
Recording entire nursing plan in clients record.
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Intervention
A nursing intervention is an action performed bythe nurse that
helps the client achieve the
results specified by the goals and expected
outcomes.
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Categories of Nursing Interventions
Independent: Actions initiated by nurse that do not require
direction or an order from another health care professional
Interdependent: Actions implemented in collaborative manner
bynurse in conjunction with other health care professionals
Dependent: Actions that require an order from a physician
orother health care professional.
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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
immediateattention.
Protocol - A series of standing orders or procedures.
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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
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The Nursing Care Plan
A written guide that organizes data about aclients care into a
formal statement of the
strategies that will be implemented to help the
client achieve optimal health.
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Implementation
This fourth step of the nursing process involvesthe execution of
the nursing care plan derived
during the Planning phase.
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Evaluation
This fifth step of the nursing process,determining whether
client goals have been met,
partially met, or not met.
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Nursing Audit
The process of collecting and analyzing data toevaluate the
effectiveness of nursing
interventions.
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The Nursing Process
is CriticalT
hinking
Critical thinking, problem-solving, and decision-making are
important in the use of the nursing
process.
These skills can be learned!
