The Nursing Process (1/7)

*** Nursing process is holistic and humanistic. It addresses the human response to
medical conditions. These are the steps to organize and prioritize patient care
*Assessing—collecting, validating, and communicating of patient data
Assessment components:
-visual assessment, interview (ask questions), physical portion
(head to toe)
-** formulate opinion based on what uou saw, what patient said,
and what you find during phys. assessment
*Diagnosing—analyzing patient data to identify patient strengths and
problems
*Planning—specifying patient outcomes (goals) and related nursing
interventions
-Set REALISTIC goals
*Implementing—carrying out the plan of care
-Nursing actions AKA intervention
*Evaluating—measuring extent to which patient achieved outcomes
-important because if not completed, we don’t know if the actions we
put in place are successful or not
-if one drug isn’t working, through the evaluation phase you will
find that out the you can contact HCP for a different drug
***A crucial component of nursing process, a care plan serves as a road map that
guides all nurses involved in a patient’s care.
*The care plan also communicates vital patient information to the entire
health care team. The care plan contains detailed instructions for achieving
the goals established for the patient.
*It helps you think critically, solve problems, and make care decisions
tailored to each patient’s individual needs. The nursing process requires you
to systematically analyze patient data, make inferences, draw conclusions
about patient problems, devise a care plan to address those problems,
implement the plan, evaluate the plan’s effectiveness, and revise the plan if
necessary.
 Characteristics: Nursing Process
o Systematic—part of an ordered sequence of activities
 Cant just jump from step to step
o Dynamic—great interaction and overlapping among the five steps
o Interpersonal—human being is always at the heart of nursing
o Outcome oriented—nurses and patients work together to identify
outcomes
 If meds aren’t working change them
o Universally applicable—a framework for all nursing activities
 Benefits of the Nursing Process
o Patient
 Scientifically based, holistic individualized patient care
 Continuity of care
 Clear, efficient, cost-effective plan of action
o Nurse
 Opportunity to work collaboratively with other healthcare
workers
 Satisfaction of making a difference in lives of patients
 Opportunity to grow professionally
o Critical Thinking & Clinical Reasoning
 In order for clinical reasoning to occur, you have to have knowledge
to make decisions
 Is purposeful, informed, outcome-focused thinking
 Is driven by patient, family, and community needs
 Is based on principles of nursing process and scientific method
 Uses both intuition and logic, based on knowledge, skills, and
experience
 Novice nurses use book
 Experienced nurses based on EBP to make decisions
 Requires strategies that make the most of human potential
 Is constantly reevaluating, self-correcting, and striving to improve
 and modifying to improve
 Assessing=gathering data (from patient, from family/friends (HIPPA Permitting),
parents of minors are patients too)
o Children may not know their medical history but they can still answer some
questions
 Novice nurses WRITE plan of care
o Experienced nurses brainstorm mentally
 Assessment
o Systematic, dynamic way to collect and analyze data about a patient
o Includes physiological, psychological, sociocultural, spiritual, economic,
and life-style factors
o Primary source of information is from the patient
 Types of Assessments
o Initial Nursing Assessment
 Shortly performed after patient is admitted to the health care
facility
o Focused Assessment
 Information gathered about a diagnosed condition
 Ex: patient is admitted, you see pt having shortness of
breath stop full assessment and focus on respiratory
tract then proceed with the rest
o Emergency Assessment
 Patient doesn’t look good, call code or rescue team for help
o Time-lapse Assessment
 Compares a current assessment to a baseline assessment
 Their first/initial nursing assessment
o Future info is compared to the baseline
 Data Collection
o Purpose
 Health status
 Health problem identification
o Types
 Subjective
 Exactly what the patient tells us no paraphrase  direct
quote
o “I have HTN” or “I fell down the stairs”
o **Pain is whatever the patient tells you
 Objective
 What we asses]
o Vital signs, labs, assessment data, observations
(dandruff, etc)
 **Patient is primary source of data, observations and past medical
records help too**
o Methods of Collection
 Examination
 Observation
 Interviewing
o Characteristics
 Purposeful
 Complete
 Factual and accurate
 Relevant
 o Sources
 Patient
 Family/significant other
 Patient record
 Other healthcare professionals
 Nursing and other healthcare literature
 Objective Data vs. Subjective Data
o Objective data
 Observable and measurable data that can be seen, heard, or felt by
someone other than the person experiencing them
 For example, elevated temperature, skin moisture, vomiting
o Subjective data
 Information perceived only by the affected person
 For example, pain experience, feeling dizzy, feeling anxious
 The Skill of Nursing Observation
o Determines the patient’s current responses
 Physical
 Emotional
o Determines the patient’s current ability to manage care
o Determines the immediate environment and its safety
o Determines the larger environment
 Hospital
 Community
 Successful Interview Techniques
o Focus on the patient during the interview.
o Listen to the patient attentively.
 Listening is the key to communication
o Ask about patient’s main problem first.
 Find patients main problem
o Pose questions and comments in appropriate manner.
 Open-ended questions so patients can elaborate (stay away from
yes/no questions)….rather, say “tell me about …”
o Avoid comments and questions that impede communication.
o Use silence and touch appropriately.
 Know who you can touch based on culture
 Ask for permission
 Types of Questions Used in Interview
o Open-ended—allow patient to verbalize freely
o Closed—elicit specific information
o Validating—validate what is heard
 Ask family members to validate
o Clarifying—avert misconceptions
o Reflective—encourage patient to elaborate on thoughts and feelings
o Sequencing—place events in chronological order
o Directing—obtain more patient information
 Documentation of Data
o DOCUMENT EVERYTHING
 In court, if it wasn’t documented, it wasn’t completed
o Immediately give verbal reporting of data whenever a critical change in
the patient’s health status is assessed.
o Enter initial database into computer or record in ink on designated forms
the same day patient is admitted.
o Summarize objective and subjective data in concise, comprehensive, and
easily retrievable manner.
o Use good grammar and standard medical abbreviations.
 No made up abbreviations, only standard medical ones allowed
o Whenever possible, use patient’s own words.
o Avoid nonspecific terms subject to individual interpretation or definition.
 Purposes of the Diagnosing Step
o Identify how an individual, group, or community responds to actual or
potential health and life processes.
o Identify factors that contribute to, or cause, health problems (etiologies).
o Identify resources or strengths upon which the individual, group, or
community can draw to prevent or resolve problems.
 Nursing Concerns and Responsibilities
o Recognizing signs and symptoms of common health problems and those
that may indicate the need for more expert diagnosis
o Predicting problems in those at risk and taking steps to manage risks and
prevent complications
o Identifying human responses and promoting optimum function,
independence, and quality of life
o Initiating actions and referrals in a timely way to ensure appropriate,
qualified treatment
 Types of Diagnises
o Nursing diagnosis
 Describes patient problems nurses can treat independently
 Patient is in pain with no medication order: so nurse takes action
and initiates communication w/ HCP to request order after doing
everything in his/her scope of practice for the patient
o Medical diagnosis
 Describes problems for which the physician directs the primary
treatment
 Dependent action of the nurse
o Something nurse does, but they have to depend on
HCP
 Ex: patient complains of pain, nurse checks for
medication order, the order is dependent on
the physician
o Collaborative problems
  Managed by using physician-prescribed and nursing-prescribed
interventions
 Work together to reacha common decision in best interest of
patient
 Ex: doc is ready to discharge patient, but nurse thinks
another day may be beneficial to the patient

***Delagation

 Steps of Data Interpretation and Analysis

o Recognizing significant data
 Comparing data to standards
o Recognizing patterns or clusters
o Identifying strengths and problems
o Reaching conclusions
 No problem
 Possible problem
 Actual or potential problem
 Clinical problem other than nursing diagnosis
 Formulation of Nursing Diagnoses
o Problem—identifies what is unhealthy about patient
 Addresses the human response
 NANDA nursing diagnosis
o Etiology—identifies factors maintaining the unhealthy state
 Related to (r/t)
 CAUSE
o Defining characteristics—identifies the subjective and objective data that
signal the existence of a problem
 As evidence by (AEB)
o EXAMPLE: Acute pain r/t myocardial ischemia AEB C/O of radiating chest
pain to neck and left jaw, …
 Goal and Outcome Identification and Planning Step
o Establish priorities.
o Identify and write expected patient outcomes.
o Select evidence-based nursing interventions.
o Communicate the plan of care.
 A Formal Plan of Care Allows the Nurse:
o Individualize care that maximizes outcome achievement
 Discharge education start at ADMISSION of the patient
 So patient knows how to care for themselves at home
o Set priorities
o Facilitate communication among nursing personnel and colleagues
o Promote continuity of high-quality, cost-effective care
o Coordinate care
o Evaluate patient response to nursing care
o Create a record used for evaluation, research, reimbursement, and legal
reasons
o Promote nurse’s professional development
 Delegation be sure not to delegate to someone who doesn’t have adequate
training (delegate w/in their scope of practice)
o You cant delegate to a CNA to assess a patient bc they cant
o You can ask a CNA to drain and measure urine in a bag
o
 LPN needed to do assessment at least once every 24 hours
 o  However, cannot do initial assessment, admit, or discharge patient or
administer blood to patient
PRIORITIZE
A
B
C
V
P

Maslows Hierarchy of Needs

 Physiologic needs
o Blood, fluids, emergency care
 Safety needs
o Bed in lowest position, fall risk protocol, medication side effects (give pt
button to press b4 standing up)
 Love and belonging needs

 Elements of Comprehensive Planning

o Initial
 Developed by the nurse who performs the nursing history and
physical assessment
 Addresses each problem listed in the prioritized nursing diagnoses
 Identifies appropriate patient goals and related nursing care
o Ongoing
 Carried out by any nurse who interacts with patient
 Keeps the plan up to date
 States nursing diagnoses more clearly
 Develops new diagnoses
 Makes outcomes more realistic and develops new outcomes as
needed
 Identifies nursing interventions to accomplish patient goals
o Discharge
 Carried out by the nurse who worked most closely with the patient
 Begins when the patient is admitted for treatment
 Uses teaching and counseling skills effectively to ensure home care
behaviors are performed competently
 Maslow’s Hierarchy of Needs
o Physiologic needs
o Safety needs
o Love and belonging needs
 o Self-esteem needs
o Self-actualization needs
 **Long Term- requires a longer period to be achieved and may be
used as discharge goals
 **Short-term- may be accomplished in a specific period of time
 Categories of Outcomes
o Cognitive—describes increases in patient knowledge or intellectual
behaviors
o Psychomotor—describes patient’s achievement of new skills
o Affective—describes changes in patient values, beliefs, and attitudes
 Parts of a Measurable Outcome
o Subject/verb (Patient will be…)
o Conditions (…free of pain…)
o Performance criteria (…AEB no C/O pain…)
o Target time (…within the first hour of admission.)
 Types of Nursing Interventions
o Nurse-initiated—actions performed by a nurse without a physician’s
order
 Independent actions
 Protocols
 Standing orders
o Physician-initiated—actions initiated by a physician in response to a
medical diagnosis but carried out by a nurse under doctor’s orders
 Dependent actions
o Collaborative—treatments initiated by other providers and carried out by
a nurse
 Dependent actions
 Actions Performed in Nurse-Initiated Interventions
o Monitor health status.
o Reduce risks.
o Resolve, prevent, or manage a problem.
o Facilitate independence or assist with ADLs.
o Promote optimum sense of physical, psychological, and spiritual well-
being.
 Structured Care Methodologies
o Procedure—set of how to action steps
o Standard of care—description of acceptable level of patient care
o Algorithm—set of steps used to make a decision
o Clinical practice guideline—statement outlining appropriate practice for
clinical condition or procedure
 Types of Plans of Care
o Kardex plans of care
o Computerized plans of care
o Case management plans of care
o Clinical pathways, care maps
o Student plans of care
 o Concept map care plan
 Implementing the Care Plan
o Determine the patient’s new or continuing need for assistance.
o Promote self-care.
o Assist the patient to achieve valued health outcomes.
 Essentials of Effective Delegation
o Know your state and institutional policies on delegation.
o Be clear on the difference between nursing process and nursing tasks.
o Know the training and background of the unlicensed assistive personnel.
o Know the patient’s needs and what he or she is at risk for.
o Know what clinical cues the UAP should be alert for and why.
o Assess which tasks can be safely delegated.
o Have the UAP repeat your instructions to be sure you have communicated
them clearly.
o Make frequent walking rounds to assess patients.
o When talking with the patient, members of the patient’s family, or UAPs,
listen for cues that indicate changes in the patient’s condition.
o Take frequent mini-reports for the UAP.
o Evaluate the UAP’s performance and the patient’s response.
 Evaluations
o Allows achievement of outcomes
o Directs nurse–patient interactions
o Measures patient outcome achievement
o Identifies factors to achieve outcomes
o Modifies the plan of care, if necessary
 Action Based on Outcome Achievement
o Terminate plan of care when expected outcome is achieved.
o Modify plan of care if there are difficulties achieving outcomes.
o Continue plan of care if more time is needed to achieve outcomes.
 Four Types of Outcomes: Evaluating
o Cognitive—increase in patient knowledge
 Asking patient to repeat information or apply new knowledge
o Psychomotor—patient’s achievement of new skills
 Asking the patient to demonstrate new skill
o Affective—changes in patient values, beliefs, and attitudes
 Observing patient behavior and conversation
o Physiologic—physical changes in the patient
 Using physical assessment skill to collect and compare data
 Evaluative Statements
o Decide how well outcome was met (met, partially met, or not met).
o List patient data or behaviors that support this decision.
 Revisions in the Plan of Care
o Delete or modify the nursing diagnosis.
o Make the outcome statement more realistic.
o Increase the complexity of the outcome statement.
o Adjust time criteria in outcome statement.
 o Change nursing interventions.
 Improving Professional Performance
o Peer review
o Quality assurance programs
o Structure evaluations
o Process evaluations
o Outcome evaluations
o Quality improvement
o Nursing audit
o Concurrent and retrospective evaluations
 Major Premises of Quality Improvement
o Focus on organizational mission
o Continuous improvement
o Customer orientation
o Leadership commitment
o Empowerment
o Collaboration/crossing boundaries
o Focus on process
o Focus on data and statistical thinking
 Questions to Ensure a Firm Commitment to Evaluation
o What are the patient’s outcomes?
o What are nursing’s values?
o How can these values be formalized in standards and evaluative criteria?
o What data exist to determine whether criteria are met?
o How can these data best be collected, analyzed, and interpreted?
o To what courses of actions do the findings lead?
 Determining Adequacy of Evaluation Step
o Evaluate patient achievement of desired outcomes.
o Review how the process is used.
o Revise the plan of care if necessary.
o Participate in quality-assurance programs.