Nursing Process 5 steps

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Nursing Process 5 steps

• Assessment
• Nursing Diagnosis
• Planning
• Implementation
• Evaluation

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The Nursing Process

• is circular in nature
• is a process of constant change analysis

Assessment Evaluation Nursing
Diagnosis Implementation Planning
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The Nurse

• Assesses the clients condition
• Determines an appropriate nursing diagnosis
• Plans care based upon the assessment and
  diagnosis
• Implements the plan of nursing actions
• Evaluates the results of care
• Assesses, diagnoses, plans, implements

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During the Assessment Phase

• The nurse follows cues from client and uses all
  five senses in this process
• Collects
• Verifies
• Analyzes
• Communicates

Client Data
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An Assessment Database includes information about

• The clients
• perceived needs
• health problems
• related life experiences
• health practices and lifestyle
• goals and values
• expectations of the health care system

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Assessment Data

• Is obtained from the nurse-client relationship as
  well as from a variety of other sources
• Some other data sources include family members,
  health practitioners, clients medical records,
  and other records (e.g., childs school health
  record)

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The Nursing Diagnosis

• Is a statement that describes the clients actual
  or potential response to a health problem that a
  nurse is licensed and competent to treat
• Is based upon a detailed analysis of the
  assessment data
• A wellness diagnosis describes a response to a
  level of wellness that a client has a readiness
  to change or enhance.

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From Nursing Diagnosis To Outcome
Nursing Diagnosis
Goal Expected Outcome
Nursing Intervention
Client Choices Capabilities Resources
Creative Ideas Of The Nurse
Research Findings
Adapted from Fig. 12-6, p. 201 Potter Perry
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A Nursing Diagnosis may pertain to any of the
following client dimensions
Physical Developmental Social Emotional Spiritu
al Intellectual
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Types of Nursing Diagnostic Statements
(Carpenito-Moyet, 2004, p.15, Box 2-1)

• Three-part statement (Actual Nursing Diagnosis)
• e.g. Impaired Skin Integrity related to prolonged
  immobility secondary to fractured pelvis as
  evidenced by a 2 cm lesion on back.
• Two-part Statement (Risk for Diagnosis)
• e.g. Risk for Injury related to lack of awareness
  of hazards
• One-part Statement (Wellness Diagnosis)
• e.g. Readiness for enhanced nutrition

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Wellness Diagnoses11 Functional Health Patterns
Associated Positive Functioning Assessment
Statements

• positive health perception
• effective health management
• effective nutritional-metabolic pattern
• effective elimination pattern
• effective activity exercise pattern
• effective sleep rest pattern
• positive perceptual cognition pattern
• positive self perception pattern
• positive role relationship pattern
• positive sexuality reproductive pattern
• effective coping stress tolerance program
• positive value belief pattern

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Wellness Diagnoses(Carpenito-Moyet, 2004, p.12)

• Clinical judgement about an individual, group or
  community in transition from a specific level of
  wellness to a higher level of wellness
• 2 cues present
• Desire for increased wellness
• Effective present status or function
• Conclusion from assessment data which focuses on
  patterns of wellness, healthy responses or
  clients strengths

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Collaborative Problems(Carpenito-Moyet, 2004,
p.19)

• Physiologic complications that nurses monitor to
  detect onset or changes in status
• Nurses manage collaborative problems using
  physician-prescribed and nursing-prescribed
  interventions to minimize the complications of
  events

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• Nurses can prevent
• Pressure ulcers
• Thrombophlebitis
• Complications of immobility
• Aspiration
• Nurses can treat
• Stage I or II pressure ulcers
• Swallowing problems
• Ineffective cough
• Nurses cannot prevent
• Seizures
• Gastrointestinal Bleeding

• Nursing Dx (Risk for)
• Risk for Impaired Skin Integrity
• Risk for ineffective peripheral tissue perfusion
• Disuse syndrome
• Risk for aspiration
• Nursing Dx (Actual)
• Impaired Skin Integrity
• Impaired swallowing
• Ineffective airway clearance
• (Nursing and Medicinal)
• Collaborative Problems
• PC Seizures
• PC GI Bleeding

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• Nursing Diagnosis
• Both involves all steps of nursing process
• Assessment involves data collection to identify
  signs and symptoms of nursing diagnosis or risk
  factors for high risk nursing diagnosis

• Collaborative Problems
• Assessment focuses on determining physical
  stability or risk for instability
• Associated with specific pathology or treatment
• e.g. abdominal surgery
• PC Hemorrhage (hypovolemia)
• PC urinary retention

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• CASE STUDY
• (Lunney, 2001, p.101)

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Planning Nursing Care

• Planning is a phase of the nursing process in
  which
• Nursing diagnosis are identified and prioritized
• Client-centered goals and expected outcomes are
  established, and
• Nursing interventions are selected to achieve the
  goals and expected outcomes established

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OUTCOMES/GOALS

• An outcome is a measurable change of the clients
  human response to nursing care.
• Goals are designed to drive actions
• Goals are mutually agreed upon between nurse and
  client.

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GOALS

• Nursing Diagnosis
• Client centered
• Related to human response
• Client goals serve as criteria for measuring
  effectiveness of care plan

• Collaborative Problems
• Nurse focused/ team focused
• Nurse will manage or minimize
• Nurse accountability includes
• Maintaining for physiologic instability
• Consulting standing orders and protocols and
  physician to obtain new orders
• Perform specific actions to manage reduce
  severity of an event or situation
• Evaluate client response

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Goals are developed using the acronym SMART

• S Specific
• M Measurable
• A Achievable
• R Realistic
• T Time Oriented

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Nursing Diagnosis Goal

• Nursing Diagnosis Anxiety related to altered
  visual perceptions 2 to schizophrenia as
  evidenced by pacing, crawling on floor down the
  hall, increased respiratory rate, startle
  response
• Goal Client will verbalize a decrease in anxiety
  from a 3 to a 1 and respiratory rate of 20 as
  evidenced by decreased pacing, by the end of the
  shift.

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Wellness Diagnosis

• Dx Readiness for enhanced family processes
• Goals The family will eat breakfast together 5
  days/ week for the next 6 months.

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Collaborative Problem

• PC Fluid/ Electrolyte Imbalance
• Goal Fluid and electrolyte imbalance will be
  managed and minimized.

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• NOC
• NIC
• ICN

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Goals can be

• Short term e.g. by end of shift
• Long term e.g. by discharge

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Planning Specific Nursing Interventions

• Nursing Interventions are selected to assist the
  client to move from his/her present level of
  functioning (as stated in the nursing diagnosis)
  to a level of functioning described in the
  goal(s) and expected outcome statement(s)

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Types of Nursing Interventions

• Nurse Initiated
• Nurses autonomous response to client needs
• Physician Initiated
• Nurse carries out written physician orders
• Collaborative Interventions
• Involves interventions by other (non-nurse)
  specialized members of the care team

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Each Nursing Care Plan

• Is unique to an individual client
• Constantly changes due to changes in client
  status, and other variables
• Varies in format from one clinical setting to
  another
• May be written or electronic

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Nursing Care includes

• Supporting the person (conveying acceptance,
  listening, etc.)
• Sharing knowledge
• Facilitating learning personal development
• Helping the person build support networks
• Providing a supportive environment
• All nursing actions take place in the context of
  the patient/ client relationships with health
  professionals and the health care team members.

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Nursing Implementation

• Any action taken by the nurse to help the client
  reach the identified goals and expected outcomes
• Pertains to nursing behaviours specific to the
  initiation and completion of nursing care
• Interactions are directed at managing the
  etiology component of the nursing diagnosis

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Implementation(Carpenito-Moyet, 2004, p.46)

• The skills and knowledge necessary for
  implementation usually focus on
• Performing the activity for or assisting client
  (DO)
• Performing nursing assessments to identify new
  problems or monitor status of existing problems
  (ASSESS)
• Teaching to help clients gain new knowledge
  (TEACH)
• Assisting clients to make decisions about their
  own healthcare
• Conselling with referring to other health care
  professionals
• Provide specific treatment actions to remove,
  reduce or resolve health problems
• Assist clients to perform activities themselves
• Assist clients to identify risks or problems and
  to explore options

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Implementation actionsare varied and include

• Assessing/ Reassessing
• Performing or assisting
• Directing the performance of activities (such as
  activities of daily living)
• Counselling and teaching
• Providing direct care
• Recording and evaluating

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After Implementation

• The nurse writes in the clients record a brief
  description of
• a nursing assessment,
• specific nursing actions carried out,
• and the clients response to nursing care

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Critical Pathway

• This is a specific type of care plan that
• Is multidisciplinary in nature
• Predicts the client outcomes and nursing
  interventions to be met for selected clients over
  a projected length of stay (or a number of home
  visits for clients with a specific case type)
• Example critical pathway for post-natal recovery
  of an uncomplicated delivery