The Nursing
Process
Resources
Andrea Ackermann, Mount St. Mary
College, Critical-thinking-the-nursing-
process 2001.
[Link]
28,(2005
)
Sara-jo Wiscombe, Nursing Process
,Wallace Community College ,May 22,2001.
Tucker C, MODULE A INTRODUCTION TO
NURSING Process, August 21, 2002 .
The Nursing Process
An organizational framework for the
practice of nursing
Orderly, systematic
Central to all nursing care
Encompasses all steps taken by the
nurse in caring for a patient
Definition of the Nursing
Process
An organized sequence of problem-
solving steps used to identify and to
manage the health problems of clients
It is accepted for clinical practice
established by the American Nurses
Association
Benefits of Nursing Process
Provides an orderly & systematic method for
planning & providing care
Enhances nursing efficiency by standardizing
nursing practice
Facilitates documentation of care
Provides a unity of language for the nursing
profession
Is economical
Stresses the independent function of nurses
Increases care quality through the use of
deliberate actions
The Nursing Process
Utilizes The Following
Assessment
Nursing Diagnosis
Planning
Implementation
Evaluation
Characteristics of the
Nursing Process
Within the legal scope of nursing
Based on knowledge-requiring critical
thinking
Planned-organized and systematic
Client-centered
Goal-directed
Prioritized
Dynamic
Benefits of using the nursing
process
Continuity of care Increased client
Prevention of participation
duplication
Individualized Collaboration of
care
care
Standards of care
Being Accountable
Using critical thinking before taking
actions
Being responsible for your actions
Entering the professional role
Working at the level of your peers
Using the nursing process
Something to think about:
Nurses are responsible for a unique
dimension of healthcare – “ the
diagnosis and treatment of human
responses to actual or potential health
problems”
MARTHA ROGERS,
NURSE THEORIST
“When an apple is cut,
others see seeds in the
apple. We, as nurses,
see apples in the
seeds.”
What Are Your
Responsibilities?
Recognize health problems.
Anticipate complications.
Initiate actions to ensure appropriate
and timely treatment.
Begin to think CRITICALLY !!!!!!
Critical Thinking
MENTAL OPERATIONS –decision
making & reasoning
KNOWLEDGE-having the facts &
understanding the reason behind the
knowledge
ATTITUDES- curious/open-minded/non-
judgmental….
Critical Thinking
Critical thinking in nursing is an
essential component of professional
accountability and quality nursing
care.
Critical thinking is careful, deliberate,
and goal directed.
Assessment of Well-Being
Accordingto the World Health
Organization is well-being in
these domains:
Emotional
Physical
Social
Spiritual
Lets Get Started :
Nurse collects background info from
previous charts
Ensure environment is conducive
Arrange seating
Allow adequate time
Nurse introduces self
Identifies purpose of interview
Ensure confidentiality of information
Provide for patient needs before starting
TYPES OF INTERVIEWS
DIRECTED
NON-DIRECTED
THINGS THAT IMPAIR COMMUNICATION:
PRESENTING QUICK SOLUTIONS
UNWARRANTED CHEERFULNESS
FALSE REASSURANCE
GIVING ADVICE
CHANGING THE SUBJECT
ASSESSMENT
Observation
Interview
Types of questions
Environment (physical and
emotional) Spiritual
conciderations
Examination
Types of Data To Collect:
Objective data-observable and
measurable facts (Signs)
Subjective data-information that only
the client feels and can describe
(Symptoms)
CULTURAL DIVERSITY
MUST PROVIDE CARE CONGRUENT
WITH A CLIENT’S EXPECTATIONS
“This is not about you” ?
Respect INDIVIDUAL’S DIFFERENCES,
What is the significance of the problem
or illness to the client?
What does it mean in the
family/community?
COMMON Challenges:
Defense Mechanisms
COMPENSATION PROJECTION
DENIAL REPRESSION
DISPLACEMENT SUPPRESSION
RATIONALIZATION REGRESSION
Continued
THE NURSING PROCESS HELPS
NURSES UNDERSTAND THE
STRATEGIES CLIENTS USE IN
their attempt at coping:
This knowledge will help you
FURTHER INDIVIDUALIZE THEIR
CARE
Resources
Client
Other individuals
Previous records
Consultations
Diagnostics studies
Relevant literature
Assessment
Data base assessment –
comprehensive information you
gather on initial contact with the
person to assess all aspects of health
status.
Focus assessment – the data you
gather to determine the status of a
specific condition.
Sources of Data
Primary source: Client
Secondary source: Client’s family,
reports, test results, information in
current and past medical records, and
discussions with other health care
workers
Disease Prevention
Primary prevention – protection from
a disease while still in a healthy state.
Secondary prevention – early
detection and treatment of disease.
Tertiary prevention – prevent
complications and to maintain health
once the disease process has
occurred.
Verifying Data
Essential in critical thinking!!!!!
Measurable data
Double check personal observations
Double check equipment
Check with experts and team members
Recheck out-liers
Compare objective and subjective data
Clarify statements
Planning
Establish
the goals, interventions
and outcomes
General Guidelines for
Setting Priorities
1. Take care of immediate
life-threatening issues.
2. Safety issues.
3. Patient-identified issues.
4. Nurse-identified priorities based on
the overall picture, the patient as a
whole person, and availability of
time and resources.
Nurse Identified Priorities
Composite of all patient’s strengths
and health concerns.
Moral and ethical issues.
Time, resources, and setting.
Hierarchy of needs.
Interdisciplinary planning.
Identifying Client-centered
Outcomes
State what the patient will do
or experience at the completion
of care.
Give direction to the patient’s
overall care.
Patient behaviors not nurse
behaviors!!
“The patient will…”
DIAGNOSIS
Sort, cluster, analyze information
Identify potential problems and
strengths
Write statement of problem or
strength
Risk of infection related to
compromised nutrition
Nursing Diagnosis (cont.)
Potential for effective breastfeeding
related to knowledge level and
support system
Prioritize the problems
Not a medical diagnosis
Steps for deriving outcomes
from Nursing Diagnosis
Look at the first clause of the nursing
dx and restate in a statement that
describes improvement, control or
absence of the problem.
Risk for infection r/t surgical
procedure.
The client will demonstrate no signs
or symptoms of infection.
Components of Outcomes
Subject: who is the person expected to
achieve the outcome?
Verb: what actions must the person take to
achieve the outcome?
Condition: under what circumstances is
the person to perform the actions?
Performance criteria: how well is the
person to perform the actions?
Target time: by when is the person
expected to be able to perform the actions?
Nursing Interventions
Road maps directing the best ways to
provide nursing care.
Evidence based nursing.
1. Monitor health status.
2. Minimize risks.
3. Resolve or control a problem.
4. Assist with ADLs.
5. Promote optimum health and
independence.
Interventions
Direct interventions: actions
performed through interaction
with clients.
Indirect interventions: actions
performed away from the client,
on behalf of a client or group of
clients.
Nursing Diagnosis
Healthissue that can be prevented,
reduced, resolved, or enhanced
through independent nursing
measures
Documenting the Plan of
Care
To ensure continuity of care, the plan
must be written and shared with all health
care personnel caring for the client.
Consists of:
1. Prioritized nursing
diagnostic statements.
2. Outcomes.
3. Interventions.
Documentation
Clear and concise
Appropriate terminology
Usually on a designated form
Physical assessment
Usually by Review of Systems
• Overview of symptoms
• Diet
• Each body system
Documentation
Use patient’s own words in subjective
data – enclose in “ ___” (quotation
marks)
Avoid generalizations – be specific
Don’t make summative statements –
describe - e.g. patient is being ornery
should be patient resists instruction or
patient states “Don’t talk to me, I don’t
care about that”
Evaluation
1. Determining outcome achievement
2. Identifying the variables affecting
outcome achievement
3. Deciding whether to continue,
modify, or terminate the plan
Determining Outcome
Achievement
Must be aware of outcomes set for the client.
Must be sure patient is ready for evaluation.
Is patient able to meet outcome criteria?
Is it:
Completely met?
Partially met?
Not met at all?
Record in progress in notes.
Update care plan.
Identifying Variable Affecting
Outcome Achievement
Maintain individuality of care plan:
1. Is the plan realistic for the client?
2. Is the plan appropriate at the time for
this particular client?
3. Were changes made in the plan when
needed?
4. How does the client feel about the plan?
Predict, Prevent, and
Manage
Focus on early intervention
Based on research
Predict and anticipate problems
Look for risk factors
Diagnostic Statements
Name of the health-related issue or
problem as identified in the NANDA list
Etiology (its cause)
Signs and Symptoms
The name of the nursing diagnosis is
linked to the etiology with the phrase
“related to,” and the signs and symptoms
are identified with the phrase “as
manifested (or evidenced) by”
Collaborative Problems-
Nurse’s Responsibility
Correlating medical diagnoses or
medical treatment measures with the
risk for unique complications
Documenting the complications for
which clients are at risk
Making pertinent assessments to
detect complications
Continued
Reporting trends that suggest
development of complications
Managing the emerging problem with
nurse- and physician-prescribed
measures
Evaluating the outcomes
The Nursing Process
Nursing Diagnosis
Judgment or conclusion about the risk for—
or actual—need/problem of the patient
NANDA format
NANDA – North American
Nursing Diagnosis Association
Identifies nursing functions
Creates classification system
Establishes diagnostic labels
Risk of infection related to compromised
nutritional state
Potential complication of seizure disorder
related to medication compliance
Planning
The process of prioritizing nursing
diagnoses and collaborative problems,
identifying measurable goals or
outcomes, selecting appropriate
interventions, and documenting the
plan of care.
The nurse consults with the client
while developing and revising the plan.
Setting Priorities
Determine problems that require
immediate action
Maslow’s Hierarchy of Human Needs
Short-Term Goals
Outcomes achievable in a few days or 1
week
Developed form the problem portion of
the diagnostic statement
Client-centered
Measurable
Realistic
Accompanied by a target date
Long-Term Goals
Desirableoutcomes that take weeks
or months to accomplish for client’s
with chronic health problems
The Nursing Process
Planning
Identification of goals and outcome criteria
Prioritization
Time frame
Selecting Nursing
Interventions
Planning the measures that the client
and nurse will use to accomplish
identified goals involves critical
thinking.
Nursing interventions are directed at
eliminating the etiologies.
Selecting an intervention
The nurse selects strategies based on
the knowledge that certain nursing
actions produce desired effects.
Nursing interventions must be safe,
within the legal scope of nursing
practice, and compatible with medical
orders.
Communicating The Plan
The nurse shares the plan of care with
nursing team members, the client, and
client’s family.
The plan is a permanent part of the
record.
Evaluation
The way nurses determine whether a
client has reached a goal.
It is the analysis of the client’s
response, evaluation helps to
determine the effectiveness of nursing
care.
The Nursing Process
Evaluation
Ongoing part of the nursing process
Determining the status of the goals
and
outcomes of care
Monitoring the patient’s response to
drug therapy
Documentation
Clear and concise
Appropriate terminology
Usually on a designated form
Physical assessment
Usually by Review of Systems
• Overview of symptoms
• Diet
• Each body system