The Nursing Process

Practical Nursing

Canadian Valley Technology Center

Shandy Baggs, RN, BSN, MSN

What do you know?

1. Which step of the nursing process includes selecting actions to help meet the expected outcomes?

A. assessment B. nursing diagnosis C. Planning D. Implementation

2. Which step of the nursing process involves analyzing assessment data in order to identify specific problems for the patient?

A. Assessment B. Nursing diagnosis C. Planning D. Implementation

What do you know?

3. Assessing the patient’s response to care is the implementation step of the nursing process.

A. True B. False

4. The planning step involves setting goals as specific expected outcomes to help eliminate or diminish the identified problem.

A. True B. False

What do you know?

#5 Assessment step includes which of the following?

A. patient interview B. focused assessment C. chart review D. all of the above

#6 The carrying out of actions to help diminish the problem involves which step of the nursing process?

A. Assessment B. Nursing Diagnosis C. Planning D. Implementation

Objectives

Differentiate between the steps of the nursing process.

Discuss the importance of the steps of the nursing process.

Prioritize nursing diagnoses according to Maslow’s Hierarchy of Needs.

Plan appropriate nursing interventions that are specific and measurable.

Evaluate outcome of nursing interventions.

Steps of the Nursing Process

Assessment Nursing Diagnosis Planning Implementation Evaluation

Assessment

Methods of data collection Subjective data Objective data Analyzing data

Nursing Diagnosis

Etiologic factors=causes of the problem. Signs & Symptoms. Prioritization of problems according to

Maslow’s Hierarchy of Needs. NANDA nursing diagnoses list.

Planning

Goal- broad idea of what is to be achieved through nursing intervention.

Short-term goal=7-10 days Long-term goal=relate to rehabilitation Expected outcome-specific statement of

the goal the patient is expected to achieve as a result of nursing intervention.

Implementation

The carrying out phase Developing actions to help alleviate the

problem. Utilizing critical thinking. Identifying the rationale of the intervention.

Evaluation

The judgment of the effectiveness of the intervention or plan.

Patient’s response to the intervention (good or bad).

Determines whether the interventions were effective in helping the patient reach the expected outcome.

Is this a continuous process??

Prioritizing Nursing Diagnoses

Maslow’s Hierarchy of Needs (physiologic, safety/security, love/belonging, self-esteem, self-actualization)

ABC’s Pain…where does it fit? Consulting with the patient. Use of critical thinking and disease

process.

Test your skills at prioritizing problems. Patient is diagnosed with pneumonia. On O2 @

2L via NC. SpO2 is 85% on room air and 96% on O2. Assessment reveals crackles auscultated to all lobes. Cap refill sluggish. Respirations 26, shallow, labored, irregular. Productive cough of thick, yellow sputum. Complains of pain upon coughing. Rates 7 on scale 0-10. Gait unsteady. Tires easily and experiences SOB upon trips to the bathroom. Requires assistance with ADL’s. Has history of CHF, COPD, HTN.

What is your answer? Impaired gas exchange Ineffective breathing pattern Pain Decreased tissue perfusion Activity Intolerance Self-care deficit Risk for falls/injury

Time to Plan!!

What is our goals for this patient? Are they short-term or long-term? What are our expected outcomes?

Implementing Interventions

What are interventions needed for this patient?

Look at top priority nursing diagnoses. Look at goals and expected outcomes. Will they be effective? Make them specific and measurable!

What are interventions for this patient? Impaired gas exchange 1. Auscultate lung sounds every shift

and PRN noting for adventious sounds.

2. Monitor O2 saturation every 4 hours and PRN throughout the shift noting for levels less than 90%.

3. Teach and enforce to turn, cough, deep breath every 2 hours PRN throughout the shift noting for productive cough and adventitious lung sounds.

4. Teach and enforce incentive spirometer every 1 hour while awake PRN throughout the shift noting for level patient accomplishes.

Interventions continued

Ineffective breathing pattern 1. Assess respiratory rate and effort every 4 hours and PRN throughout the shift noting for rate >24, effort irregular, shallow or deep, and labored.

2. Assess O2 saturation every 4 hours and PRN throughout the shift noting for levels <90%.

3. Administer O2 @ 2L via NC to maintain O2 sats >90% throughout the shift.

4. Schedule rest periods and cluster care throughout the shift to not tire patient.

Interventions Continued

Pain 1. Instruct patient to notify when pain level is increasing and to not wait for pain to get too intense before intervention can be done.

2. Administer pain med as ordered PRN throughout the shift.

3. Teach guided imagery, relaxation techniques, distraction techniques PRN throughout the shift.

4. Assess pain level using the 0-10 pain scale every 4 hours and PRN throughout the shift noting for intensity, location, and duration.

5. Instruct use of pillow splint when coughing PRN throughout the shift.

Evaluations

What was the result? What was the patient’s response? Not to be a restatement of the

intervention. Must be specific.

Evaluations of interventions

Impaired gas exchange1. Auscultate lung sounds every shift

and PRN noting for adventious sounds.

2. Monitor O2 saturation every 4 hours and PRN throughout the shift noting for levels less than 90%.

3. Teach and enforce to turn, cough, deep breath every 2 hours PRN throughout the shift noting for productive cough and adventitious lung sounds.

4. Teach and enforce incentive spirometer every 1 hour while awake PRN throughout the shift noting for level patient accomplishes.

1. Auscultated crackles to all 5 lobes throughout the shift.

2. O2 saturation remained 95-96% on O2 @ 2L via NC throughout the shift. When NC was off to go to the BR, O2 sat was 88% on RA. O2 reapplied when back to bed and raised to 95-96% within 5 minutes.

3. Performed TCDB throughout the shift. Productive cough of small, thick, yellow sputum. Auscultated course crackles prior to TCDB and fine crackles after TCDB.

4. Reached volume goal every time throughout the shift. Stated, “this is hard but I feel it helps me get better breaths of air.”

Evaluations continued

Ineffective breathing pattern

1. Assess respiratory rate and effort every 4 hours and PRN throughout the shift noting for rate >24, effort irregular, shallow or deep, and labored.

2. Assess O2 saturation every 4 hours and PRN throughout the shift noting for levels <90%.

3. Administer O2 @ 2L via NC to maintain O2 sats >90% throughout the shift.

4. Schedule rest periods and cluster care throughout the shift to not tire patient.

1. Respiratory rate remained 20-22 bpm, shallow, and labored throughout the shift.

2. O2 saturation remained 95-96% on O2 @ 2L via NC. When taken off to go to BR, O2 sats 88%. When O2 reapplied O2 sats increased to 95-96% within 5 minutes.

3. O2 @ 2L via NC remained on throughout the shift and O2 sats remained 95-96% with exceptions of getting up to the BR.

4. Care clustered throughout the shift with rest periods for patient. No SOB visualized upon getting up to the BR and chair this shift.

Evaluations continued Pain

1. Instruct patient to notify when pain level is increasing and to not wait for pain to get too intense before intervention can be done.

2. Administer pain med as ordered PRN throughout the shift.

3. Teach guided imagery, relaxation techniques, distraction techniques PRN throughout the shift.

4. Assess pain level using the 0-10 pain scale every 4 hours and PRN throughout the shift noting for intensity, location, and duration.

5. Instruct use of pillow splint when coughing PRN throughout the shift.

1. Notified of pain increasing throughout the shift to stay on pain management schedule. Stated, “it helps to ask for relief before it gets too bad.”

2. Lortab 7.5 mg po administered every 6 hours as ordered throughout the shift. Reports pain level at a 6 prior to med. Reports pain level a 2 forty-five minutes after med.

3. Reports reading books and watching TV helps to distract pain. Rates pain at a 3 with this technique. Reports “the others don’t work and I don’t want to do them.”

4. Pain rated at a 5-6 throughout the shift when coughing. Sharp pain lasting while coughing and short period of time after coughing.

5. Reports pillow splint helps with pain when coughing. Rates pain at a 3 with this technique.

Practice Time

The patient is diagnosed with CHF. The patient is edematous in the extremities, 3+ pitting edema, dyspneic, fatigued, tachycardic, hypertension, sluggish cap refill, crackles and rhonchi auscultated to lungs, SOB with activity. Has O2 @ 3L via NC. On strict I & O, and on fluid restriction of 1200cc/day. Weak peripheral pulses, strong apical pulse. IV heplock to right hand.

Nursing Diagnoses… Number by Priority Decreased Cardiac Output Impaired Gas Exchange Fluid Volume Overload Activity Intolerance Risk for falls/injury Risk for skin integrity

Name those nursing interventions

Decreased cardiac output

Impaired gas exchange

Fluid volume overload

Interventions

Decreased Cardiac Output 1. Assess VS noting for increase or decrease in BP, pulse, and respirations

2. Auscultate apical pulse noting for rate, rhythm, and strength every 4 hours and PRN throughout the shift.

3. Assess peripheral pulses and cap refill noting for rhythm, strength and time to refill every shift and PRN.

Interventions Cont

Impaired gas exchange 1. Assess lung sounds noting for adventious sounds every 4 hours and PRN throughout the shift.

2. Assess respiratory rate, rhythm, and effort noting for increases, struggles every 4 hours and PRN throughout the shift.

3. Assess O2 sats every 4 hours and PRN throughout the shift.

Interventions Cont.

Fluid volume overload 1. Weight patient daily noting for an excessive weight gain or loss.

2. Monitor and maintain a strict I & O throughout the shift.

3. Educate and maintain fluid restrictions of 600cc throughout this shift.

Evaluations

Decreased Cardiac output1. Assess VS noting for increase

or decrease in BP, pulse, and respirations

2. Auscultate apical pulse noting for rate, rhythm, and strength every 4 hours and PRN throughout the shift.

3. Assess peripheral pulses and cap refill noting for rhythm, strength and time to refill every shift and PRN.

1. VS @ 0700: BP 136/84, P100, R24 1100: BP 130/80, P96, R22. VS decreased showing no marked signs of condition worse.

2. AP 100 @0700 AP96 @1100. Strong, and regular at both times.

3. 2+PPPx 4 extremities and equal and regular bilaterally. Cap refill sluggish throughout the shift.

Evaluations Cont.

Impaired gas exchange1. Assess lung sounds noting

for adventious sounds every 4 hours and PRN throughout the shift.

2. Assess respiratory rate, rhythm, and effort noting for increases, struggles every 4 hours and PRN throughout the shift.

3. Assess O2 sats every 4 hours and PRN throughout the shift.

1. Crackles heard x 5 lobes throughout the shift.

2. Respirations 24, even regular, shallow @ 0700 and 22, even regular and labored @ 1100.

3. O2 sats @ 0700, 96% on O2 @ 3L. 1100 O2 sats 97% on O2 @ 3L.

Evaluations Cont.

Fluid volume overload1. Weight patient daily noting

for an excessive weight gain or loss.

2. Monitor and maintain a strict I & O throughout the shift.

3. Educate and maintain fluid restrictions of 600cc throughout this shift.

1. Standing weight 205LB. Yesterday weight 207 LB. Weight loss of 2 LB. No signs of additional fluid overload.

2. Intake: oral 500cc, IV 50cc. Output: 400cc. BM x 1 soft formed stool. No additional signs of fluid overload.

3. Water pitcher kept at 300cc for this shift. Fluid intake with meals totaled 200cc, IV included 50cc for a shift total input of 550cc. This is under the restriction of 600 for this shift.

What did you learn?

#1 Your expected outcomes help determine what nursing care is to be done in hopes to help the problem. Which step of the nursing process does this occur?

A. Assessment B. Nursing Diagnosis C. Planning D. Implementation

#2 Critical thinking and understanding of the disease process is essential in determining the plan of care for a patient?

A. True B. False

What did you learn?

#3 Is the following nursing intervention complete? Assess vital signs every four hours throughout the shift.

A. yes B. no

#4 At risk for infection takes priority over the nursing diagnosis of activity intolerance.

A. True B. False

What did you learn?

#5 Prioritize the following nursing diagnoses.

1. Self-care deficit2. Pain3. Ineffective airway clearance4. Risk for infection A. 1,3,2,4 B. 2,3,1,4 C. 3,2,1,4 D. 3,2,4,1

#6 Intervention includes: turn patient and encourage deep breathing and coughing every 2 hours throughout the shift. Evaluation includes: turned patient every 2 hours and instructed patient to deep breath and cough. This is a complete intervention and evaluation.

A. True B. False

What did you learn?

#7 Expected outcome includes patient will not experience injury throughout the shift. Interventions should include:

A. keep pathways free and clear throughout the shift.

B. Keep all needed items within reach throughout the shift.

C. Assist when getting out of bed throughout the shift.

D. All of the above.

#8 Which of the following evaluations to the interventions from #7 are complete?

A. Pathways kept free and clear.

B. All needed items within reach throughout the shift.

C. Assistance required to get out of bed throughout the shift. No falls this shift.

D. None of the above.

What did you learn?

#9 Your number 1 nursing diagnosis for your patient yesterday was pain. Today upon assessment, patient rated pain at a 0 throughout the morning. What is your next step to take?

A. continue with current plan. B. add another nursing diagnosis

to the plan. C. go to your RN and ask her for a

nursing diagnosis to follow. D. look at current plan and choose

another diagnosis as priority for this patient.

#10 Which of the following interventions are complete?

A. Weight patient B. Assess VS every 4 hours

throughout the shift. C. Assess lung sounds noting for

adventious sounds every 4 hours throughout the shift.

D. Assess SpO2 noting to keep sats > 95%.