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