Chapter 2 Nursing Process - WordPress.com€¦ · Steps of the Nursing Process (cont’d) •Assessment (cont’d) –Types of data (cont’d) oSubjective data: information only client

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Chapter 2

Nursing Process


Definition of the Nursing ProcessDefinition 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


Characteristics of the Nursing ProcessCharacteristics of the Nursing Process

• Within the legal scope of nursing

• Based on knowledge

• Planned

• Client centered

• Goal directed

• Prioritized

• Dynamic


• Assessment

– First step of nursing process

o Systematic collection of facts or data

Types of data

Objective data: observable and measurable facts, referred to as signs of disorder

Steps of the Nursing ProcessSteps of the Nursing Process


Steps of the Nursing Process (cont’d)Steps of the Nursing Process (cont’d)

• Assessment (cont’d)

– Types of data (cont’d)

o 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


QuestionQuestion

• Is the following statement true or false?

Objective data, consisting of information that only the client feels and can describe, are called symptoms. An example is pain.


AnswerAnswer

False.

Objective data are observable and measurable facts and are referred to as signs of a disorder. Subjective data consists of information that only the client feels and can describe, and are called symptoms




– Types of assessment

o Data base assessment

Initial information: client’s physical, emotional, social, and spiritual health

Obtained during admission interview and physical examination




– Types of assessment (cont’d)

o Focus assessment

Information: details about specific problems; expands original data base

Repeated frequently or on a scheduled basis


QuestionQuestion

• Which of the following is a primary source for information?

a. Client’s family

b. Client

c. Medical records

d. Test results


AnswerAnswer

b. Client

The primary source for information is the client. The client’s family, test results, and medical records are secondary sources of information.




– Organization

o Involves grouping related information

o Nurses: organize assessment data; cluster related data using knowledge and past experiences



• Diagnosis

– Second step of the nursing process

o Identification of health-related problems

o Nursing diagnosis

Health issue that can be prevented, reduced, resolved, or enhanced through independent nursing measures



• Diagnosis (cont’d)

– Nursing diagnosis (cont’d)

– Categorized into 5 groups: actual; risk; possible; syndrome; wellness

o The NANDA list

Authoritative organization for developing and approving nursing diagnoses




o Diagnostic statement

Contains 3 parts:

Name of health-related issue or problem identified in the NANDA list






o Diagnostic statement (cont’d)

Etiology (its cause): phrase “related to”

Signs and symptoms: phrase “as manifested (or evidenced) by”






Potential diagnoses: “risk for”

Uncertainty: “possible”

Wellness diagnoses: “potential for enhanced”





Potential nursing diagnoses: signs or symptoms not manifested

Possible nursing diagnoses: data incomplete






Syndrome diagnoses and wellness diagnoses are one-part statements; they are not linked with an etiology or signs and symptoms

Steps of the Nursing Process (cont’dSteps of the Nursing Process (cont’d))




o Collaborative problem

Physiologic complications require both nurse- and physician-prescribed interventions

Written using the abbreviation potential complication (PC)



• Planning

– Third step of the nursing process

o Setting priorities

Determine which problems require most immediate attention

o Establishing goals

Goal: expected or desired outcome



• Planning (cont’d)

– Establishing goals (cont’d)

o Short-term goals:

Outcomes achievable in a few days to 1 week

Characteristics: developed from; client-centered





o Short-term goals (cont’d)

Characteristics (cont’d)

Measurable

Realistic

Target date for accomplishment





o Short-term goals (cont’d)

Characteristics (cont’d)

Predicted time

Time line for evaluation





o Long-term goals

Desirable outcomes take weeks or months to accomplish

o Goals for collaborative problems

Written for the nurse





o Goals for collaborative problems (cont’d)

Focus: what the nurse will monitor, report, record, or do to promote early detection and treatment




– Selecting nursing intervention

o Planning measures: to accomplish identified goals involves critical thinking

o Planned interventions: must be safe; within legal scope of nursing practice; and compatible with medical orders




– Documenting plan of care

o Plan of care: written by hand; standardized form; computer generated; based on an agency’s written standards or clinical pathways

o Nursing order: performing nursing interventions; providing specific instructions




– Documenting plan of care (cont’d)

o Standardized care plan: preprinted; computer generated

o Agency-specific standards for care and clinical pathways: indicate activities provided to ensure quality, consistent care




– Communicating the plan of care

o Nurses share plan with nursing team members, client, and the client’s family

o Permanent part of client’s medical record placed in client’s chart; nurses refer to it, review it, and revise it



• Implementation

– Fourth step in the nursing process: carrying out the plan of care

– Implementation of:

o Medical records: legal evidence

o Record: quantity and quality of client response



• Evaluation

– Fifth and final step of the nursing process: nurses determine whether client has reached the goal

– Analyze client’s response



QuestionQuestion

• Is the following statement true or false?

Evaluation is the fifth and final step in the nursing process.


AnswerAnswer

True.

Evaluation, the fifth and final step in the nursing process, is the way by which nurses determine whether a client has reached a goal. The other steps in the nursing process are assessment, diagnosis, planning, and implementation.


Use of the Nursing ProcessUse of the Nursing Process

• Standard for clinical nursing practice

• Nurse practice act

– Holds nurses accountable for demonstrating all the steps in the nursing process

– To do less implies negligence


Concept MappingConcept Mapping• Method of organizing information in graphic

or pictorial form

• Formats used: spider diagram, hierarchy, linear flow chart

• Uses:

– Enables students to integrate previous knowledge with newly acquired information


Concept Mapping (cont’d)Concept Mapping (cont’d)

• Uses (cont’d):

– Increases critical thinking and clinical reasoning skills

– Enhances retention of knowledge

– Correlates theoretical knowledge with nursing practice

– Helps students recognize information

– Promotes better time management

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Chapter 2 Nursing Process - WordPress.com€¦ · Steps of the Nursing Process (cont’d) •Assessment (cont’d) –Types of data (cont’d) oSubjective data: information only client