Nursing Process

NUR101Fall 2008Lecture #6 and #7K. Burger, MSEd, MSN, RN, CNE

PPT By: Sharon Niggemeier RN MSN Revised KBurger 8/06 Revised JBorrero 09/08

Nursing ProcessSpecific to the nursing professionA framework for critical thinkingIt’s purpose is to:

“Diagnose and treat human responses to actual or potential health problems”

Nursing ProcessOrganized framework to guide practiceProblem solving method - client focusedSystematic- sequential stepsGoal oriented- outcome criteriaDynamic-always changing, flexibleUtilizes critical thinking processes

Scientific Method of problem solving

ID problemCollect dataForm hypothesisPlan of actionHypothesis testingInterpret resultsEvaluate findings

Advantages of Nursing Process

Provides individualized care

Client is an active participant

Promotes continuity of care

Provides more effective communication among nurses and healthcare professionals

Develops a clear and efficient plan of care

Provides personal satisfaction as you see client achieve goals

Professional growth as you evaluate effectiveness of your interventions

5 Steps in the Nursing Process

AssessmentNursing

DiagnosisPlanningImplementingEvaluating

Assessment

First step of the Nursing ProcessGather Information/Collect Data

Primary Source - Client / Family Secondary Source - physical exam, nursing

history, team members, lab reports, diagnostic tests…..

Subjective -from the client (symptom) • “I have a headache”

Objective - observable data (sign)• Blood Pressure 130/80

Assessment-collecting data

Nursing Interview (history)Health Assessment -Review of SystemsPhysical Exam

Inspection Palpation Percussion Auscultation

Assessment-collecting data

Make sure information is complete & accurate

Validate prnInterpret and analyze data

Compare to “standard norms”Organize and cluster data

Example of Assessment

Obtain info from nursing assessment, history and physical (H&P) etc…...

Client diagnosed with hypertensionB/P 160/902 Gm Na diet and antihypertensive

medications were prescribedClient statement “ I really don’t watch my

salt” “ It’s hard to do and I just don’t get it”

Nursing DiagnosisSecond step of the Nursing Process

Interpret & analyze clustered data

Identify client’s problems and strengths

Formulate Nursing Diagnosis (NANDA : North American Nursing Diagnosis Association)-Statement of how the client is RESPONDING to an actual or potential problem that requires nursing intervention

Nsg Dx vs MD Dx

Within the scope of nursing practice

Identify responses to health and illness

Can change from day to day

Within the scope of medical practice

Focuses on curing pathology

Stays the same as long as the disease is present

Formulating a Nursing Diagnosis

Composed of 3 parts:Problem statement- the client’s response

to a problemEtiology- what’s causing/contributing to the

client’s problemDefining Characteristics- what’s the

evidence of the problem

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...

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”.

Types of Nursing Diagnoses

ActualImbalanced nutrition; less than body requirements RT chronic diarrhea, nausea, and pain AEB height 5’5” weight 105 lbs.

RiskRisk for falls RT altered gait and generalized weakness

WellnessFamily coping: potential for growth RT unexpected birth of twins.

Collaborative Problems

Require both nursing interventions and medical interventions

EXAMPLE: Client admitted with medical dx of pneumonia

Collaborative problem = respiratory insufficiency

Nsg interventions: Raise HOB, Encourage C&DB

MD interventions: Antibiotics IV, O2 therapy

Planning Third step of the Nursing ProcessThis is when the nurse organizes a nursing care

plan based on the nursing diagnoses. Nurse and client formulate goals to help the

client with their problemsExpected outcomes are identifiedInterventions (nursing orders) are selected to aid

the client reach these goals.

Planning – Begin by prioritizing client problems

Prioritize list of client’s nursing diagnoses using Maslow

Rank as high, intermediate or low

Client specific Priorities can change

PlanningDeveloping a goal and outcome statement

Goal and outcome statements are client focused.

Worded positively Measurable, specific

observable, time-limited, and realistic

Goal = broad statement Expected outcome =

objective criterion for measurement of goal

Utilize NOC as standard

EXAMPLE

Goal:Client will achieve therapeutic management of disease process….

Outcome Statement:AEB B/P readings of 110-120 / 70-80 and client statement of understanding importance of dietary sodium restrictions by day of discharge.

Planning- Types of goals

Short term goalsLong term goalsCognitive goalsPsychomotor goalsAffective goals

Goals are patient-centered and SMART

Specific Measurable Attainable Relevant Time BoundPt will walk 50 ft.Pt will eat 75% of mealPt will be OOB 2-4hrsPt will maintain HR<100Pt will state pain level is acceptable 6 (0-10)

Planning-select interventionsInterventions are selected and written.The nurse uses clinical judgment and

professional knowledge to select appropriate interventions that will aid the client in reaching their goal.

Interventions should be examined for feasibility and acceptability to the client

Interventions should be written clearly and specifically.

Interventions – 3 types

Independent ( Nurse initiated )- any action the nurse can initiate without direct supervision

Dependent ( Physician initiated )-nursing actions requiring MD orders

Collaborative- nursing actions performed jointly with other health care team members

ImplementionThe fourth step in the Nursing ProcessThis is the “Doing” stepCarrying out nursing interventions (orders)

selected during the planning stepThis includes monitoring, teaching, further

assessing, reviewing NCP, incorporating physicians orders and monitoring cost effectiveness of interventions

Utilize NIC as standard

Implementing- “Doing”

Monitor VS q4hMaintain prescribed diet

(2 Gm Na)Teach client amount of

sodium restriction, foods high in sodium, use of nutrition labels, food preparation and sodium substitutes

Teach potential complications of hypertension to instill importance of maintaining Na restrictions

Assess for cultural factors affecting dietary regime

Implementing – “Doing”

Teach the client- hypertension can’t be cured but it can be controlled.

Remind the client to continue medication even though no S/S are present.

Teach client importance of life style changes: (weight reduction, smoking cessation, increasing activity)

Stress the importance of ongoing follow-up care even though the patient feels well.

Evaluation- To determine effectiveness of NCPFinal step of the Nursing Process but

also done concurrently throughout client careA comparison of client behavior and/or response

to the established outcome criteriaContinuous review of the nursing care plan Examines if nursing interventions are workingDetermines changes needed to help client reach

stated goals.

EvaluationOutcome criteria met? Problem resolved!Outcome criteria not fully met? Continue

plan of care- ongoing.Outcome criteria unobtainable- review each

previous step of NCP and determine if modification of the NCP is needed.

Were the nsg interventions appropriate/effective?

Evaluation

Factors that impede goal attainment:

Incomplete databaseUnrealistic client outcomesNonspecific nsg interventionsInadequate time for clients to achieve

outcomes.

CheckpointIdentify which stage of the nursing processis being described below:

The nurse writes nursing interventionsA goal is agreed uponThe nurse performs a physical assessmentA revision is made to the NCPThe nurse administers antibiotic medicationA statement is written that outlines the clients

response to a potential health problem

S and O Data Quiz

RR 22/min, even unlabored“I can only walk 3 blocks before my legs start to

hurt”Pain rated 3 on a scale of 0-10Skin pink, warm and dryUrine output 300mL/8 hr“My wife doesn’t come to visit very often”Dressing clean, dry and intact.

NCLEX Time

The nurse records the following subjective data in the client’s medical record:

A.Breath sounds clear to auscultationB.Amber urine in sufficient quantitiesC.Pain intensity 8 out of 10D.Skin warm and dry

NCLEX Time

When interviewing a client, the nurse uses the following open-ended style sentence:

A.Do you have any concerns right now?B.Is your family worried about you being in the

hospital?C.How many times do you get up to go to the

bathroom at night?D.What do you mean when you say, “I don’t feel

quite right?”

NCLEX Time

In order for an actual nursing diagnosis to be valid it must have one or more supporting:

A.Laboratory resultsB.Diagnostic dataC.Defining characteristicsD.Medical diagnoses

NCLEX Time

Nursing diagnoses are aimed at identifying client problems that are treatable by _______.

A.The physicianB.The nurseC.Invasive techniquesD.Complementary strategies