Nursing Process
Nursing Fundamentals
Introduction
• Nursing process
– is a systematic method of providing care to clients
– Allows nurses to communicate plans and activities
to
• Clients
• Other health care professionals
• Families
– Encourages orderly thought, analysis, planning
Overview of the Nursing Process
• Process:
– “A series of steps or acts that lead to
accomplishment of some goal or purpose”
• Purpose is to provide client care that is:
– Individualized
– Holistic
– Effective
– Efficient
Overview of the Nursing Process
• Consists of 5 steps
– Assessment
– Diagnosis
– Planning
– Implementation
– Evaluation
• Build on each other
• Not linear
• Nursing process is dynamic and requires
creativity in its application
– Steps remain the same
– Application and results different
• Used throughout the life span in any care
setting
Assessment
• Step #1
• Involves
– Collecting data (from variety of sources)
– Validating the data
– Organizing the data
– Interpreting the data
– Documenting the data
Assessment
• Purpose of assessment:
– Data collection
• Types of assessment:
– Comprehensive assessment
– Focused
– Ongoing
Assessment
• Comprehensive assessment
– Baseline
– Physical & psychosocial
Assessment
• Focused Assessment
– Limited in scope
– Screening for a specific problem
– Short stay
• Ongoing assessment
– Follow-up
– Monitoring and observation related to specific
problems
Assessment
• Sources of Data
– Primary sources
• Client
• Interview
• Physical examination
– Secondary sources
• Family members
• Other health care providers
• Medical records
Assessment
• Types of data
– Subjective
• Data from the client’s point of view
– Feelingsمشاعر, Perceptionsتصورات, Concernsمخاوف
• Main way to collect subjective data:
– Interview
– Objective
• Observable & measurable data
• Main way to collect objective data:
– Physical assessment
– Lab and diagnostic testing
Assessment
• Validating the Data
• Organizing the Data
• Interpreting the Data
– Relevant vs. irrelevant
– Gaps?
– Identify patterns
• Document the Data
Diagnosis
• Step 2 in the nursing process
– Formulating a nursing diagnosis
– Analysis and synthesis of data
• Nursing diagnosis:
– “A clinical judgment about individual, family or
community responses to actual or potential heal
problems / life processes.
– A nursing diagnosis provides the basis for
selection of nursing interventions to achieve
outcomes for which the nurse is accountable.”
Medical vs. Nursing diagnosis
Medical diagnosis Nursing diagnosis
Identifies conditions the Identifies situations the
MD(Doctor of Medicine) nurse is licensed &
is licensed & qualified to qualified to treat
treat
Focuses on illness, Focuses on the clients
injury or disease responses to actual or
processes potential health / life
problems
Medical vs. Nursing diagnosis
Medical diagnosis Nursing diagnosis
Remains constant Changes as the clients
until a cure is response and/or the health
effected problem changes
Medical vs. Nursing diagnosis
Medical diagnosis Nursing diagnosis
i.e. Breast cancer i.e. Knowledge deficit
Powerlessness
Grieving, anticipatory
Body image disturbance
Individual coping, ineffective
Planning & Outcome identification
• Step 3
– Types of planning
• Initial planning
• Ongoing planning
• Discharge planning
Planning & Outcome identification
• Identifying outcomes
– Goals
• An aim,
-Short term goals
• Hours to days (less than a week)
– Long term goals
• Weeks to months
Planning & Outcome identification
• Developing specific nursing interventions
– Independent nursing interventions
• No order needed
– Elevate edematous legs
– Interdependent nursing interventions
• In conjunction with an interdisciplinary team member
– Assist client with physical therapy exercises
– Dependent nursing interventions
• Require an order
– Administering of medications
• Prioritizing the nursing diagnosis
– Maslow’s hierarchy of needs
Maslow’s Hierarchy of Needs
Implementation
• 4th step:
– Execution of the nursing care plan
– Delegation
–DO IT
–DO IT RIGHT
–DO IT RIGHT NOW!
Evaluation
• 5th step
– Determining whether
the clients goals have
been met, partially
met or not met.