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The Nursing Process

Throughout your nursing career, you will be using the nursing process.
This module will guide you in understanding the nursing process steps
of assessment, analysis, planning, implementation, and evaluation.
You are responsible for:
1.
Studying the content of this module.
2.
Completing the practice exercises.
3.
Writing a care plan.
Objectives:
1.
Describe the relation between critical thinking and the nursing
process
2.
Identify and explain the components of the nursing process
3.
Discuss the major activities of the assessment phase
4.
Identify the activities of the nursing diagnosis
5.
Discuss the planning phase
6.
Discuss the activities of the implementation phase
7.
Describe the component of the evaluation phase
INTRODUCTION
This is a brief overview of the nursing process. In the topic of
pharmacology, nurses dont just give meds. They employ the nursing
process to assess the patient in order to determine if the patient
should have the medication, analyze the gathered data and make a
nursing diagnosis, plan a goal and actions, implement those actions to
reach the goal, and evaluate the results.
1.
Describe the relation between critical thinking and the
nursing process
What is critical thinking and why does it matter?
The nursing role requires an organized, purposeful, and disciplined
thinking process. We apply this thinking process in several ways:
Nurses are required to solve patient problems by critically
analyzing the factors associated with these problems. This
critical analysis allows the nurse to make better decisions.
Creativity is necessary to solve these problems.
Nurses dont just problem solve and make decisions, they make
observations, draw conclusions, create new ideas, evaluate, and
modify; to do this, critical thinking is employed.
Nurses may do things with little or no critical thinking from small
decisions to repetitive psychomotor skills. Higher-level critical thinking
comes into play, however, when the nurse must make a less-thanroutine decision. This is often called problem solving.

2.
Identify and explain the components of the nursing
process
A process is a series of planned actions or operations directed toward a
particular result or goal. It is a problem-solving procedure.
The nursing process is a systematic method of planning and providing
nursing care. It is a decision-making approach that promotes critical
thinking. The major purpose of the nursing process is to provide a
framework within which the needs of the patient can be met.
The nursing process consists of five steps or phases:
Assessing, Diagnosing, Planning, Implementing, and Evaluating.
Briefly stated, the steps are:
Assessing To gather information, organize it, validate it, and
document it.
Diagnosing To analyze data, identify the health problems, risks
and strengths, and formulate diagnostic statements.
Planning To determine the priorities of care and formulate
expected goals/outcomes, select nursing interventions, and write
nursing orders.
Implementation To complete the nursing actions necessary to
accomplish the goals, reassess the patient, determine the need
for assistance, delegation and supervision, and document the
nursing actions.
Evaluation To collect data about goals/outcomes, compare with
the planned goals/outcomes, determine the extent to which the
goals were accomplished; continue, modify, or terminate the
plan.
The nursing process is an adaptation of problem-solving techniques. It
can be viewed as parallel to yet separate from the medical process.
The medical process focuses on the disease and the nursing process is
directed toward the patients response to the disease or illness.
3.
Discuss the major activities of the assessment phase
The assessment phase is where information is gathered regarding the
patient for the purpose of identifying the patients needs, concerns,
problems, or human responses. It involves data collection,
organization, and validation.
Assessing is a continuous process carried out during all phases of the
nursing process. All phases of the nursing process depend on the
accurate and complete collection of data.

The assessment process involves four closely related activities:


1. Collecting data is the process of gathering information
about the patients health status.
2. Organizing data. To obtain data systematically, the
nurse uses an organized assessment framework, often
referred to as a nursing assessment.
3. Validating data is the act of double-checking or verifying
data to confirm that they are accurate and factual.
4. Recording data. To complete the assessment process,
the nurse records the data. Data are recorded in a factual
manner.
The assessment process must be organized so that nothing significant
is missed. Most nurses develop a particular sequence for assessing
patients.
The primary methods used to assess patients are observing (gathering
data by using the five senses), interviewing, (asking questions) and
examining (physical assessment).
Observing When the nurse first meets the patient to be
assessed, many observations are made. General
appearance details and verbal and non-verbal behaviors
can be seen during the observation.
Interviewing The directive interview is highly structured
and provides specific information. A non-directive
interview, or rapport-building interview, is used to build a
bond, problem solve, counsel, and perform appraisals.
The physical examination is a system data-collection
method that uses observational skills to detect health
problems. The nurse uses the techniques of inspection
(visual exam), auscultation (listening with a stethoscope),
palpation (touch), and percussion (tapping the body to
produce sounds). The manner by which the nurse collects
data during a physical exam should be logical and
organized.
Assessing the patient for medications should involve all three methods.
The nurse observes, interviews, and examines the patient to determine
the need of a medication. Just because a medication is ordered, does
not mean the patient should receive it. The nurse must know the
indications, side effects, and adverse effects of medications to
determine if the patient should have that medication or if adverse
effects are occurring and the medication should be held.
Exercise #1:
1.
A nurse is listening to a patients heart. This is an example of:

2.

a.
b.
c.
d.

Inspecting.
Auscultating.
Palpating.
Percussing.

In
a.
b.
c.
d.
e.

using the nursing process, the nurse would first:


Assess.
Diagnose.
Set a goal.
Implement actions.
Evaluate the response.

3.

Critical thinking is related to the process called:


a. Problem development.
b. Situation solving.
c. Problem solving.
d. Analysis.
4.
Identify the activities of nursing diagnosis
Diagnosing is the second phase of the nursing process. In this phase
the nurse uses critical thinking skills to summarize, analyze, and draw
conclusions from the data to determine what health problems the
patient may have or is at risk for.

In 1990, the North American Nursing Diagnosis Association


(NANDA) was established. It defines the term nursing diagnosis
as a clinical judgment about individual, family, or community
responses to actual and potential health problems/life
processes.
You may ask, Why do we need a system of NURSING diagnoses?
Well, we have a system like that for medical diagnoses. If I tell you I
have an appendicitis, we would instantly understand each other since
the definition of this medical diagnosis is standardized.
The purpose of NANDA is to define, refine, and promote a
taxonomy (classification system) of nursing diagnostic
terminology of general use to professional nurses.
This system of nursing diagnoses promotes communication
among nursing communities if a patient is moved between
different health care delivery systems, the nursing diagnosis will
travel with the patient and help explain health problems.

Registered nurses are responsible for making nursing diagnoses.


The domain of nursing diagnosis includes only those health
states that nurses are able and licensed to treat.

For example, nurses are not usually educated to diagnose and


treat diseases such as Hepatitis, yet they can diagnose and treat
Ineffective individual coping related to the disease.
Types of Nursing Diagnoses. There are different types of nursing
diagnoses:
An actual nursing diagnosis describes a human response to a
health problem that is currently being manifested. An actual
nursing diagnosis is based upon the presence of associated sings
and symptoms.
For example, Ineffective airway clearance is used if the
patient has trouble coughing up phlegm.
A risk nursing diagnosis is a clinical judgment made by the nurse
that a patient is more vulnerable to develop the problem than
others in the same or similar situation. The patient has not yet
developed the signs and symptoms of an actual problem.
For example, a patient who is HIV positive may be at risk
for acquiring an infection. An appropriate nursing
diagnosis would be Risk for infection.
Components of a Nursing Diagnosis. An actual nursing diagnosis
has three components:
1. The problem statement (NANDA)
2. The etiology (related to or R/T)
3. The defining characteristics (the signs and symptoms, as
evidenced by or AEB)
These components are written as:
NANDAR/TAEB
Heres one: Body image disturbance R/T below-the-knee
amputation AEB always having sheet over leg and not
caring for wound
Lets look at each component separately:
Problem statement: The NANDA describes the patients
health problem or response for which nursing therapy is given. It
describes the patients health status clearly and concisely in a
few words: Body image disturbance.
Etiology: The related factors describe the etiology or
likely cause of the problem. Etiology may include

pathophysiology of the disease, patient behaviors, or


environmental factors.
For example:
Ineffective airway clearance, related to weak
cough
Impaired cardiac tissue perfusion, related to
narrowed coronary arteries
Dysfunctional coping, related to denial of
medical diagnosis
Remember, Medical Diagnoses refer to disease processes,
whereas Nursing Diagnoses describe a patients responses
to a health problem. So, the R/T statement CANNOT be a
medical diagnosis.
Defining Characteristics: The cluster of signs and
symptoms prove the presence of a particular diagnostic label
(the NANDA diagnosis). These must be measurable signs and
symptoms not low blood pressure instead 98/46; not
abnormal breath sounds instead wheezing in anterior upper
lobes. These defining characteristics are listed in care plan
books and textbooks.
Risk Nursing Diagnoses are different. For risk diagnoses, there
are NO defining characteristicsthe problem has not actually occurred!
Therefore, a risk diagnosis would be:
Risk for fluid volume imbalance R/T exercising in 110
degree heat
Priority setting. Priority setting is the process of establishing a
preferential order for nursing diagnoses.
Life-threatening problems, such as loss of respiratory or cardiac
functioning, are designated as high priority.
Health-threatening problems, such as acute illness and
decreased coping ability, are usually assigned medium priority.
A low-priority problem is one that requires minimal nursing
support.
Exercise #2
1.
An appropriate actual nursing diagnosis for a patient with
difficulty breathing is:

a.
b.
c.
d.
2.
is:

Ineffective breathing pattern.


Ineffective breathing pattern R/T pneumonia.
Ineffective breathing pattern R/T inflammation of the lungs.
Ineffective breathing pattern R/T inflammation of the lungs
AEB RR 24, wheezes, shortness of breath.

An appropriate risk nursing diagnosis for a patient after a stroke

a.
Risk for
b.
Risk for
c.
Risk for
eyesight.
d.
Risk for
eyesight AEB
falling.
5.

injury.
injury R/T stroke.
injury R/T weakness on right side, decreased
injury R/T weakness on right side, decreased

Discuss the planning phase

Once the assessment data have been collected, analyzed, and the
nursing diagnosis has been identified, the nurse moves on to the
planning phase of the nursing process.
The nurse refers to the assessment findings and diagnostic statements
for direction in formulating patient goals and designing the nursing
strategies required to treat the patients health problems.
The nurse sets a goal (or outcome) for each nursing diagnosis. The
goal is a desired outcome or change in patient behavior. It should be
specific, measurable, and include a time frame for attainment. When
the goal is achieved, the patients problem described in the nursing
diagnosis is solved.
Components of the Goal
1. Subject
2. General behavior that is desired
3. Time frame
4. Specific indicators (evidence)
Subject: The goal is patient-directed. Begin the goal statement
with Patient will
General behavior: The behavior that is desired is a REVERSAL of
the problem as seen in the nursing diagnosis.
Restate the NANDA portion of the nursing diagnosis in a positive
manner:

For example, if the nursing diagnosis is Activity


intolerance R/T sedentary lifestyle AEB not being able to
walk over 40 feet without shortness of breath; the goal
would start with Patient will have improved activity
tolerance (the NANDA statement has been made
positive).
Time frame: Goals may be short term or long term. In a hospital,
many of the patients goals are short term the nurse can evaluate the
patient more frequently and accurately. Long-term goals are often
used for patients who have chronic health problems or who live in longterm facilities.
Specific indicators (evidence): This indicates the standard to
which the patient will be evaluated as to whether the goal has been
met or not. These criteria MUST be measurable specific to speed,
accuracy, distance, quality, etc.
For example, if the nursing diagnosis is Activity
intolerance R/T sedentary lifestyle AEB not being able to
walk over 40 feet without shortness of breath; the goal
would be Patient will have improved activity tolerance
within 2 days as evidenced by (AEB) able to walk 50 feet
without shortness of breath
Exercise #3:
Write a complete goal statement for each nursing diagnosis:
1.
Acute constipation R/T current drug therapy AEB no bowel
movement for 4 days.
2.

Impaired physical mobility R/T right arm cast AEB unable to


move right arm above waist.

3.

Impaired communication R/T language barrier AEB unable to


understand medication prescription directions.

6.

Discuss the activities of the implementation phase

After developing a plan of care based on the assessing and diagnosing


phases, the nurse then puts the plan in action. It is the actual
initiation of the plan providing the nursing care required to meet the
patients needs. These treatments include nurse-initiated treatments,
physician-initiated treatments, and performance of the daily essential
functions for the patient.

Nursing implementations (also known as actions, interventions,


strategies, or nursing orders) are identified and written during the
planning step of the nursing process; however, they are actually
performed during the implementation phase.
Selecting Nursing Implementations
There are LOTS of implementations to choose from. You must select
the nursing implementations that relate to the specific patient goal
which is specific to the nursing diagnosis. The nurse implementations
chosen should focus on eliminating or reducing the etiology (cause) of
the nursing diagnosis (the second portion of the diagnostic statement)
and observing for signs/symptoms (the third portion of the diagnostic
statement).
Kinds of Nursing Implementations
Independent implementations those activities that nurses are
licensed to initiate on the basis of their knowledge, skills, and
experience. They include physical care, ongoing assessment,
emotional support and comfort, teaching, counseling,
environmental management, and making referrals to other
health care professionals.
Dependent implementations those activities carried out under
the physicians orders or supervision, or according to certain
routines. Medical orders commonly include orders for
medications, intravenous therapy, diagnostic tests, treatment,
diet, and activity.
Collaborative implementations those actions the nurse carries
out in collaboration with other health care team members, such
as physical therapists, social workers, dietitians, and physicians.
These reflect the overlapping responsibilities of, and collegial
relationships between health personnel.

Types of Nursing Implementation


You will select implementations to meet the patients goal by
monitoring (assessing, monitoring, observing), managing,
(interventions, treatments, actions), and teaching (instructing,
demonstrating).

For example, for a goal regarding improved breathing pattern,


here are some of the implementations that could be written:
Monitoring implementations
Assess breath sounds every 4 hours
Monitor weight daily
Observe for hives after medication administration
Managing implementations
Keep head of bed up at all times
Administer furosemide twice a day
Encourage use of incentive spirometry three times a day
Administer ordered oxygen at 2 liters/minute via nasal
cannula at all times
Teaching implementations
Demonstrate deep breath exercises daily
Teach side effects of theophylline daily
Demonstrate use of pursed-lip breathing daily
Notice: Each implementation indicates how frequently to carry out the
activity: every 4 hours, daily, twice a day, etc.
This patient also has a wound, needs help walking, and is on other
medications. Some implementations that would be carried out for the
patient but not included in the breathing pattern care plan would be:
Change dressing every day, Demonstrate use of walker daily.
Recording the nursing actions. After carrying out the nursing
orders, the nurse completes the implementing phase by recording the
interventions, along with the patient responses, in the nursing progress
notes.
Exercise #4
1.

The nurse has written the goal, Patient will have decreased pain
with 8 hours AEB patient reports pain at 2 on pain scale of 1-10.
An appropriate implementation would be:
a.
Assess breath sounds every 2 hours.
b.
Place in position of comfort.
c.
Instruct how to deep breathe.
d.
Administer insulin according to sliding scale.

2.

The implementation of Assess ability to cough every 2 hours


would be appropriate for:

a.
A goal of Patient will have decreased pain.
b.
A nursing diagnosis of Impaired tissue integrity.
c.
A goal of Patient will have improved airway clearance
within 8 hours
AEB productive cough.
d.
A nursing diagnosis of Ineffective airway clearance R/T
pneumonia.
7.

Describe the components of the Evaluation phase

Evaluation is the final phase of the nursing process. Evaluation is


defined as the judgment of the effectiveness of nursing care to meet
the patient goal. The nurse compares the patients behavioral
responses following implementations with the measurable aspects of
the patients goal.
Components of the evaluation
1. Goal judged (met, partially met, not met)
2. Evidence (how can you tell?)
3. Contributing factors (reasons goal was met, partially met, or not
met)
4. Modification (changes that need to be made)
Goal judged: There are 3 possible judgments about the patient
reaching the goal:
Goal met (all of the indicators in the goal were reached)
Goal partially met (some of the indicators in the goal
were reached or progress was made toward reaching the
indicators)
Goal not met (no indicator was reached and no progress
was made toward reaching any of the indicators)
Evidence: The results of assessing each indicator in the goal is
discussed.
For example, in the case of a patient with impaired airway
clearance, the goal could read:
Patient will have improved airway clearance during
postoperative period AEB expectorates sputum easily
and breaths sounds are clear.
The evaluation statement could read one of three ways:
1. The goal was met AEB can easily expectorate
sputum and lungs have clear breath sounds

2. The goal was partially met AEB cannot easily


expectorate sputum but breath sounds are clear
3. The goal was not met AEB cannot easily
expectorate sputum and wheezing remains
Contributing factors:
The nurse then determines WHY the goal was met, only partially
met, or not met at all. Maybe there was not enough time to
carry out all of the implementations, maybe there was great
family support and the patient was encouraged to continue
walking which helped, maybe the pain medication was not
effective, maybe the antibiotic had only been given twice, maybe
the dietician was consulted about a change in the diet. These,
and many others, could all contribute to WHY or WHY NOT the
goal was met.
Modification:
Revision and modification of the nursing process is part of the
evaluation process. It provides a feedback mechanism that
starts the entire chain of event ALL OVER AGAIN. Whether or not
goals were met, there are a number of decisions to make about
continuing, modifying, or terminating nursing care.
Nursing diagnoses that were resolved (the goal was met)
require no further nursing implementation.
Nursing diagnoses that still need implementation (goal was
partially or not met) require modification. Perhaps new
goals need to be set, maybe the original goal was
unrealistic, and/or maybe new implementations need to be
written.
For example: To continue the evaluation of the partially met goal
statement:
Contributing factors Wrong antibiotic according to lab
results; Patient able to understand teaching; Patient
slightly motivated to improve.
Modification Consult with physician about changing
antibiotic; Continue goal for additional day; Encourage
family to help with patients motivation.
To summarize, the nursing process will be utilized throughout your
career. It is a systematic, logical sequence of steps beginning with
assessing the patient, analyzing the data, planning a goal and actions,
implementing those actions, and concluding with an evaluation that
judges the effectiveness of the process.

You are now ready to write a care plan!


Answer Sheet
Exercise #1
1.
2.
3.
Exercise #2
1.
2.
Exercise #3
1.
2.
3.
Exercise #4
1.
2.
Exercise #5
Write a nursing care plan on an actual patient with actual signs and
symptoms.
Select one of the NANDA diagnoses. Write a complete nursing
diagnosis (actual or risk its your choice)
Write a complete goal
Write 2-4 monitor, 2-4 manage, and 2-4 teach implementations
(remember, they must specifically connect to the goal)
Make an evaluation statement if the patient had PARTIALLY MET
the goal (be sure to give evidence, contributing factors, and
modification)
Submit your care plan to your instructor in person. You will receive feedback regarding
your care plan.
CONGRATULATIONS!!!!
References:
De Laune, S, Ladner, P.; Fundamentals of Nursing; Standard and Practice 2nd edition.
Delamar; a division of Thompson Learning; New York 2002.
Dillon, Patricia Nursing Health Assessment: a critical thinking, case studies approach 2nd
edition. F.A. Davis Company, Philadelphia 2007.
Hilton, Penelope. Fundamentals of Nursing Skills. Whur Publisher, London, 2006

Lippincott Manual of Nursing practice 8th edition. Lippincott Williams and Wilkins
(2006).
Prepared by: Asst. Professor 1 Jennifer Tan-Mansing RN; MAN