Nursing Process

NUR101Fall 2010Lecture #6 and #7K. Burger, MSEd, MSN, RN, CNE

PPP By: Sharon Niggemeier MSN, RN

Revised KBurger 8/06, 9/08,8/10

Nursing Process Specific to the nursing profession A framework for critical thinking It’s purpose is to:

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

Nursing Process Organized framework to guide practice Problem solving method - client focused Systematic- sequential steps Goal oriented- outcome criteria Dynamic-always changing, flexible Utilizes critical thinking processes

What are some critical thinking characteristics necessary for application of Nursing Process? Knowledge – science & skills Standards – use of EBP standards of

practice Experience – previous client experiences Attitudes – open-mindedness, creativity,

integrity, confidence,

Scientific Method of problem solving

ID problem Collect data Form hypothesis Plan of action Hypothesis testing Interpret results Evaluate 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

Assessment Diagnosis Planning Implementation Evaluation

Assessment First step of the Nursing Process Gather Information/Collect Data

Primary Source - Client / FamilySecondary 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) History includes: physical, emotional, social,

spiritual, intellectual dimensions. Considerations for the older adult & cultural

diverse client. Review this section in P & P Health Assessment:

Review of Systems Inspection Palpation Percussion Auscultation

Assessment-collecting data

Make sure information is complete & accurate

Validate prn Interpret and analyze data

Compare to “standard norms” Organize and cluster data

Example of Focused Assessment

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

Client diagnosed with hypertension B/P 160/90 2 Gm Na diet and antihypertensive

medications were prescribed Client statement “ I really don’t watch

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

Diagnosis Second 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 [Diagnostic Label]

the client’s response to a problem Etiology [Related Factors]

what’s causing/contributing to the client’s problem

Signs/Symptoms [Defining 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 (Related Factors)- determine what the problem is caused by or related to (R/T)...

Signs/Symptoms (Defining Characteristics)- state as evidenced by (AEB) the specific facts the problem is based on...

Example of Nursing Dx

Ineffective health maintenance

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 Actual

Imbalanced 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

WellnessReadiness for enhanced Family coping:

Health PromotionReadiness for enhanced immunization status

Planning

Third step of the Nursing Process This 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 problems Expected outcomes are identified Interventions (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

Planning- Types of goals

Short term goals Long term goals

Cognitive goals Psychomotor

goals Affective goals

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.

Think about this….

We have talked about the difference between cognitive, psychomotor and affective goals.

What type of goal is the statement on the previous slide?

Can you think of some goal statements in the other domains?

Planning-select interventions Interventions 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

Implemention The fourth step in the Nursing Process This is the “Doing” step Carrying out or delegating nursing

interventions (orders) selected during the planning step

This includes monitoring, teaching, further assessing, reviewing NCP, incorporating physicians orders and monitoring cost effectiveness of interventions

Utilize NIC as standard

DelegationFive Rights

Right task Right circumstance Right person Right communication Right supervision

NCSBN (1995)

Implementing- “Doing” Maintain prescribed diet (2

Gm Na) Administer antihypertensive

medications per MD order Obtain registered dietician

consult to teach client about 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

Monitor VS q4h

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.

Think about this….

We have learned about the 3 different types of nursing interventions:Independent – Dependent – Collaborative

Label each of the interventions on the previous slides as either I – D – or C

Evaluation Final step of the Nursing Process but

also done concurrently throughout client care A comparison of client behavior and/or

response to the established outcome criteria Continuous review of the nursing care plan Examines if nursing interventions are working Determines changes needed to help client

reach stated goals.

Evaluation Outcome 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.