Nursing Process

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Nursing Process

• Basic Nursing Essentials for Practice, 5th
  edition
• Potter Perry Chapter 6
• Dr. Louise Pitts
• Anita Kovalsky, RN, MNEd
• Evaluation Section by Sandra Gallagher, RN, MSN

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Nursing Process Overview

• What is the nursing process?
• Systematic, deliberate problem solving steps
• Dynamic back and forth steps, always changing
• Humanistic body, mind, spirit
• Outcome-focused

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Nursing AssessmentStep 1

• Establish database about clients
• Perceived needs
• Health problems responses to problems
• Related experiences
• Health practices, lifestyle,
• Health goals
• Client strengths
• Database establishes basis for Nursing Diagnosis
  Plan of Care

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Nurses Assessment Tools

• Critical thinking
• Knowledge from other disciplines
• Communication skills
• Assessment skills
• Prior life clinical experience
• Application of standards of practice
• Client attitudes
• Problem solving skill

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Data Collection Approaches

• Comprehensive
• General to specific
• Full history functional health patterns
• physical assessment head-to-toe, systems
• Problem-Focused
• Begin assessment with problem area expand out
  to relevant areas needing assessment

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Data collection

• Determine which data should be collected
• Data - descriptive, concise, complete
• Verbal skills to ask appropriate questions
• Observation skills used to collect non-verbal
• Inaccurate, incomplete, inappropriate data leads
  to incorrect identification of client problem!!!

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Types of Data

• Subjective
• Clients perceptions about health problems
• Objective
• Observations or measurements made by data
  collector

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Sources of Data

• Client
• Family significant others
• Health care team members
• Medical records
• Other records
• Literature review
• Nurses experience

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Methods of Data Collection

• Interview
• Use communication skills, verbal non-verbal
• Nursing health history
• Organized interview
• Functional focus
• Physical assessment
• Head-to-toe
• System-focused

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Formulating Nursing Judgments

• Data Interpretation and Validation
• Data clustering
• Data Documentation

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Documentation of data

• Last part of assessment
• Several forms used for documentation
• Health history
• Graphic sheets Flow sheets
• Nursing Kardex
• Acuity Recording Systems
• Standardized Care Plans
• Discharge Summary forms

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NURSING DIAGNOSIS

• STEP 2

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Evolution of Nursing Diagnosis

• Nursing Diagnosis as a label 1950 introduced
• Why?
• To change from medical model to nursing
• Emphasize independent practice of nursing
• How?
• 1973 first national conference to classify
  nursing diagnoses
• 1982 North American Nursing Diagnosis
  Association (NANDA) established

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Nursing Diagnosis is

• Statement describing
• clients ACTUAL or POTENTIAL
• response to a health problem
• that the nurse is licensed and competent to treat

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Process for formulating diagnostic statement
Nursing Diagnosis

• Decision Making Steps after data collected
• Identify and validate pertinent data
• Analysis interpretation of data
• Identify clients needs
• Formulate nursing diagnostic statement

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Data Analysis Interpretation

• Recognize patterns or trends
• Compare with normal standards
• Cluster set of data (signs symptoms)
• Defining characteristics/criteria that support

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Nursing Diagnosis Statement(NANDA)

• Problem
• Actual or potential response to a health problem
• Etiology -- RT
• Condition that causes or is associated with a
  clients actual or potential response to the
  health problem
• Can be altered or resolved by nursing actions
• Signs/Symptoms
• Supports the problem and etiology

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Sources of Diagnostic Error

• Collecting
• Interpreting Analysis
• Clustering
• Labeling

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Nursing vs Medical Diagnosis

• Nursing
• Focus on nursing needs of client
• Response to a disease
• Medical
• Identifies a specific disease state

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Avoiding Correcting Errors when formulating
Nursing Diagnosis

• Identify clients response not med dx
• Identify NANDA statement rather than the symptom
• Identify treatable etiology
• Identify problem caused by treatment or
  diagnostic study rather than tx or dx study
  itself
• (cont. next slide)

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Avoiding Correcting Errors when formulating
Nursing Diagnosis

• Identify client response to equipment rather than
  equipment itself
• Identify clients problems rather than the
  nurses problems
• Identify the client problem rather than the
  nursing intervention

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Avoiding Correcting Errors when formulating
Nursing Diagnosis contd.

• Identify the client problem rather than the goal
• Make professional rather than prejudicial
  judgments
• Avoid legally inadvisable statements
• Identify problem AND etiology
• Identify ONLY one problem in dx

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Advantages of nursing dx

• Facilitate communication among nurses
• Help prioritize client needs
• Used for charting
• Serve as focus for quality improvement
• Helps improve quality of care

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Limitations of nursing dx

• Language can be verbose
• Contain jargon not understood by other disciplines

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Summary Nursing Diagnosis

• This is second step of NURSING PROCESS
• To follow..planning
• which is setting goals and determining what
  nursing actions should be taken

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QUESTIONS

• 3 Part NANDA Related to Etiology as Manifested
  By.signs and symptoms
• Two part statement is what?
• Where do related factors come from?

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STOP!!!! Work in groups on Mrs. Sussex video
(additional info in syllabus Appendix J) and
Nursing Diagnosis Study Guides
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NOW.take 2 minutes and write one question about
something that is unclear to you. Give to me
before leaving class today.
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Planning Implementing Nursing Care

• Steps 3 4

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Planning can be done..

• Initially on admission/assessment
• On ongoing status daily - as deliver care
  acquire more data
• For discharge (discharge planning) started on
  admission to begin plans for discharge
• ALL PLANNING COLLABORATIVE, INVOLVE
  CLIENT/FAMILY

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Planning

• Category of nursing behaviors in which
• Client-centered goals expected outcomes
  established
• Nursing interventions selected to achieve goals
  outcomes of care
• Priorities are set

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Establishing Priorities

• Nurse uses Critical Thinking to establish
  priorities
• Rank nursing dx in order of importance to
  establish priority
• High Emergent physiological needs which are life
  threatening
• Medium non-emergent, non-life threatening
• Low needs not directly related to
  illness/prognosis

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Goal Setting

• Goals are
• Guideposts to interventions criteria for
  evaluation
• Purpose of goals/expected outcomes?
• Provide direction for individualized nursing
  interventions
• Set standards for intervention effectiveness
• Mutually established with client/family

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Goals

• Client-centered
• Short-term
• Less than a week
• What will be accomplished immediately
• Long-term
• Over weeks or months
• Often after discharge

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Expected Outcome

• What is expected outcome?
• Specific, step-by-step objective leading to goal
  attainment
• And leading to resolution of etiology of problem
  (nur dx)
• Is measurable
• Are desired responses of clients condition
• Determine when goals met

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Functions of Outcomes

• Provide direction for nursing activities
• Provide projected time span for goal attainment
• Suggest resources needed to attain goal
• Serve as criteria to evaluated effectiveness of
  nursing actions

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Writing Goals Outcomes

• Client-centered
• Singular Factors
• Observable Factors
• Measurable Factors
• Time-limited Factors
• Mutual Factors
• Realistic Factors

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Implementation carrying out the plan of
interventions

• Nurse-initiated
• Physician-initiated
• Collaborative

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EVALUATION

• Step 5
• The final phase of the Nursing
• Process

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What purpose does this 5th step serve?

• It measures the pts response to nursing
  interventions and clients progress towards
  achieving goals
• It supports the effectiveness of nursing practice
  which is client centered and client-driven
• It tells us if the client benefits from the
  intervention (s) ?

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How is critical thinking used in evaluation?

• I must reflect on client responses to
  interventions, and determine efficacy
• I must know characteristics of improved
  family/group dynamics
• I must apply regulatory standards of care in
  evaluation
• Analysis of my findings are required

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Goals, outcomes and the evaluation phase

• Goals look at expected responses that indicate
  resolution of the problem
• Expected Outcomes the result of a goal-oriented
  process
• Evaluation of the goals of care tells us if
  our nursing care has solved the
  problempreventing poss. problems and
  maintaining a healthy state

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My pts goal is met!! What to do? What to do?

• If it is determined that the goals have been met,
  the care plan may be noted as discontinued and
  noted that goal/outcome was met

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I have an unmet goal!!!

• 1. Identify the variables that altered the goal
  achievement
• A) Did the clients status change ?
• B) Did I omit a step ?
• 2. Re-assess
• 3. Formulate a new
• Nursing Diagnosis
• 4. Revise care plan

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Heres to all your goals being met!
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How do I communicate this data??

• .so glad you asked!

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LEARNING ACTIVITYSyllabus, Appendix L, pg.
167In small groupsread case study and answer
questions 1 2 for each case.