Nursing Process

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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

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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

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Steps of the Nursing Process

• Assessment
• Diagnosis
• Planning
• Implementation
• Evaluation

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Assessment

• Systematic collection of facts or data

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Types of Data

• Objective data-observable and measurable facts
  (Signs)
• Subjective data-information that only the client
  feels and can describe (Symptoms)

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Sources of Data

• Primary source Client
• Secondary source Clients family, reports, test
  results, information in current and past medical
  records, and discussions with other health care
  workers

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Types of Assessments

• Data base assessment
• Focus assessment

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Organization of Data

• Grouping of related information
• Organization of assessment data into small groups
  to be analyzed

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Nursing Diagnosis

• Health issue that can be prevented, reduced,
  resolved, or enhanced through independent nursing
  measures
• Nursing Diagnosis Caregories
• Actual
• Risk
• Possible
• Syndrome
• Wellness

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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

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Collaborative Problems

• Physiologic complications whose treatment
  requires both nurse- and physician-prescribed
  interventions.
• They are an interdependent domain of nursing
  practice

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Collaborative Problems-Nurses 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
• Reporting trends that suggest development of
  complications
• Managing the emerging problem with nurse- and
  physician-prescribed measures
• Evaluating the outcomes

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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.

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Setting Priorities

• Determine problems that require immediate action
• Maslows Hierarchy of Human Needs

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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

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Long-Term Goals

• Desirable outcomes that take weeks or months to
  accomplish for clients with chronic health
  problems

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Goals for Collaborative Problems

• Goals for collaborative problems are written from
  a nursing rather than from a client perspective.
• The focus on what the nurse will monitor, report,
  record, or do to promote early detection and
  treatment.

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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.
• 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.

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Nursing Orders

• Directions for a clients care
• Identifying what, when, where, and how for
  performing nursing interventions
• Nursing orders are signed to be accountable

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Communicating The Plan

• The nurse shares the plan of care with nursing
  team members, the client, and clients family.
• The plan is a permanent part of the record.

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Implementation

• Carrying out the plan of care
• The nurse implements medical orders and nursing
  orders
• Implementation involves the client and one or
  more health care team
• The information in the chart shows a correlation
  between the plan and the care that has been
  provided.
• Nurses are accountable for carrying out nursing
  orders and physician orders.

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Evaluation

• The way nurses determine whether a client has
  reached a goal.
• It is the analysis of the clients response,
  evaluation helps to determine the effectiveness
  of nursing care.

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