The Nursing Process

Joy N. Bautista, RN, MPH, DRDM, MAN

Purpose
To give the highest level of quality care possible to patients throughout the lifespan, in different health stages, and in any healthcare setting.

Components

Nursing Process and Critical Thinking

The nursing process requires critical thinking especially in analyzing, organizing, and classifying various data that help the nurse arrive at better decisions related to the care of her patient. Using critical thinking, nurses develop a questioning attitude and delve into situations in order to seek possible explanations for what is happening.

Nursing Process and Problem-Solving

Acknowledgement of the existence of a problem Gathering of relevant information Identification of a specific solvable problem Development of a plan to solve the problem Carrying out the plan Evaluation of the results of the planned solution

Nursing Assessment
The purpose of assessment is to establish a database or a foundation of information about a clients physical, psychosocial, and emotional health in order to identify health-promoting behaviors as well as actual and/or potential health problems

Nursing Assessment: Objectives

Ascertain the clients functional abilities and absence or presence of dysfunction Assess the clients normal activities of daily living and lifestyle patterns Identify the clients strengths in order to provide the nurse and other members of the treatment team information about the skills, abilities, and behaviors of the client to promote the treatment of recovery process Form a therapeutic interpersonal relationship with the client Discuss health care concerns and goals with the client

Nursing Assessment: Steps

Data from different sources and not just the patient himself, is collected through different ways. The data gathered is validated for its truthfulness, accuracy, relevance, and completeness. The data gathered is organized into meaningful clusters or groups so that groups of information will point to similar possible nursing problems or diagnoses. Upon the classification and organization of this information, these will be interpreted into meaningful sentences so as to give the right direction for the planning of care for the patient. All data gathered should be well-documented

Nursing Assessment: Types

Comprehensive complete HHx, PE, review of psychosocial health, functional health patterns Focused limited in scope in order to concentrate on a particular need or health concern or on potential health risks Ongoing systematic follow-up or problems identified during a comprehensive or focused assessment

Nursing Assessment: Data Validation

This is done in order to avoid or minimize omissions, misunderstandings, and incorrect conclusions or inferences. Data can be validated through clarification with the patient himself, his significant others, or any other person who is knowledgeable of the patients condition. Data can also be validated by comparing it with normal or standard values.

Nursing Assessment: Data Organization

Data clustering allows the grouping of similar data together to identify any areas of the patients problems. Maslows hierarchy of needs Body systems model Functional health patterns Theory of self-care

Nursing Assessment: Data Interpretation

After data have been collected, the nurse can begin to develop impressions or inferences about the meaning of the data Distinguish between relevant and irrelevant data Determine whether and where there are gaps in the data Identify patterns of cause and effect

Nursing Diagnosis
The analysis and synthesis of the assessment data Nursing diagnosis is the clinical judgment about individual, family or community responses to actual or potential health problems or life processes and can provide the basis for the selection of nursing interventions to achieve specific client outcomes for which the nurse is accountable

Nursing Diagnosis vs. Medical Diagnosis

It recognizes situations that the nurse is licensed and qualified to treat and not the physician It focuses on the clients responses to actual or risk health problems or life processes not on his illness, injury or disease processes It varies as the clients responses and/or health problems changes, unlike in medical diagnosis where the diagnosis stays the same until a cure is realized or until the client dies

Nursing Diagnosis: Identification and Formulation

Are there problems in this situation? If yes, what are the specific problems? What are some of the possible causes of the problems? Is there a situation that involves risk factors? What are these risk factors involved? If preventive measures are not taken, will there be problems? If yes, under what circumstances will problems develop?

Nursing Diagnosis: Identification and Formulation

Has the client indicated a desire for a higher level of wellness in a particular area of function? What are the clients strengths? What cultural values and beliefs or cultural factors does the client have which can play a role in this situation? What data are available to answer these questions? Does the problem require more answers? If yes, what are some of the possible sources of data required?

Nursing Diagnosis: Components

Actual nursing diagnosis problem statement or diagnostic label that describes the clients response to an actual or potential health problem or a wellness condition Etiology related cause or contributor to the problem which can be identified by the NANDA description for the diagnosis Defining characteristics collected assessment data or clinical manifestations and usually connected to the first 2 components by the phrase as evidenced by

Nursing Diagnosis: Examples

2-part diagnostic statement Self-care deficit r/t sensory-perceptual impairment Alteration in tissue perfusion r/t hemodynamic alterations 3-part diagnostic statement Impaired gas exchange r/t ventilation perfusion mismatch as evidenced by a respiratory rate of 40 Ineffective breathing pattern r/t musculoskeletal impairment as evidenced by decreased chest wall expansion

Nursing Diagnosis: Types

Actual An actual problem exists; often composed of the diagnostic label, related factors, and symptomatology Risk Potential problem or a problem that does not exist yet; composed of the phrase Risk for before the diagnostic label and a list of specific risk factors Wellness Clients expression of desire to attain a higher level of wellness in some area of function; preceded by the phrase Readiness for enhanced

Nursing Diagnosis: Guidelines

Should always be developed from the client data and not vice versa Should not be made to fit the client. Should be discussed with the client and his family upon formulation The list of nursing diagnoses is recorded on the clients medical record The list of nursing diagnoses is dynamic, meaning, it is ever-changing as more and more data are collected and as client goals and responses to interventions are evaluated

Nursing Diagnosis: NANDA-Approved Diagnoses

Activity/Rest - Ability to engage in necessary or desired activities of life (work and leisure) and to obtain adequate sleep and rest Activity intolerance Activity intolerance, Risk for Activity planning, Ineffective Disuse syndrome, Risk for Diversional activity, Deficient Fatigue Insomnia Sedentary lifestyle

Nursing Diagnosis: NANDA-Approved Diagnoses

Activity/Rest (cont) Mobility, Impaired bed Mobility, Impaired wheelchair Sleep, Readiness for enhanced Sleep deprivation Sleep pattern, Disturbed Transfer ability, Impaired Walking, Impaired

Nursing Diagnosis: NANDA-Approved Diagnoses

Circulation Autonomic dysreflexia Autonomic dysreflexia, Risk for Bleeding, Risk for Cardiac output, Decreased Intracranial adaptive capacity, Decreased Tissue perfusion, Ineffective peripheral Tissue perfusion, Risk for ineffective cardiac Tissue perfusion, Risk for ineffective cerebral Tissue perfusion, Risk for ineffective gastrointestinal Tissue perfusion, Risk for ineffective renal Shock, Risk for

Nursing Diagnosis: NANDA-Approved Diagnoses

Ego Integrity - Ability to develop and use skills and behaviors to integrate and manage life experiences Anxiety Anxiety, Death Behavior, Risk-prone health Body image, Disturbed Conflict, Decisional Coping, Defensive Coping, Ineffective Coping, Readiness for enhanced Decision-making, Readiness for enhanced

Nursing Diagnosis: NANDA-Approved Diagnoses

Ego Integrity (cont) Denial, Ineffective Dignity, Risk for compromised human Distress, Moral Energy field, Disturbed Fear Grieving Grieving, Complicated Grieving, Risk for complicated Hope, Readiness for enhanced Hopelessness

Nursing Diagnosis: NANDA-Approved Diagnoses

Ego Integrity (cont) Personal identity, Disturbed Post trauma syndrome Post trauma syndrome, Risk for Powerlessness Rape trauma syndrome Relationships, Readiness for enhanced Religiosity, Impaired Religiosity, Readiness for enhanced Religiosity, Risk for impaired Relocation stress syndrome

Nursing Diagnosis: NANDA-Approved Diagnoses

Ego Integrity (cont) Relocation stress syndrome, Risk for Resilience, Impaired individual Resilience, Readiness for enhanced Resilience, Risk for compromised Self-concept, Readiness for enhanced Self esteem, Chronic low Self esteem, Situational low Sorrow, Chronic Spiritual distress Spiritual distress, Risk for Spiritual wellbeing, Readiness for enhanced

Nursing Diagnosis: NANDA-Approved Diagnoses

Elimination Bowel incontinence Constipation Constipation, Perceived Constipation, Risk for Diarrhea Dysfunctional gastrointestinal motility Dysfunctional gastrointestinal motility, Risk for Elimination, Impaired urinary Readiness for enhanced urinary

Nursing Diagnosis: NANDA-Approved Diagnoses

Elimination (cont) Incontinence, Functional urinary Incontinence, Overflow urinary Incontinence, Reflex urinary Incontinence, Risk for urge urinary Incontinence, Stress urinary Incontinence, Urge urinary Urinary retention, Acute Urinary retention, Chronic

Nursing Diagnosis: NANDA-Approved Diagnoses

Food and Fluid Breastfeeding, Effective Breastfeeding, Ineffective Breastfeeding, Interrupted Dentition, Impaired Electrolyte imbalance, Risk for Failure to thrive, Adult Feeding pattern, Ineffective infant Fluid balance, Readiness for enhanced Fluid volume, Deficient hypertonic Fluid volume, Deficient hypotonic

Nursing Diagnosis: NANDA-Approved Diagnoses

Food and Fluid (cont) Fluid volume, Deficient isotonic Fluid volume, Excess Fluid volume, Risk for deficient Fluid volume, Risk for imbalanced Glucose, Risk for unstable blood Liver function, Risk for impaired Nausea Nutrition, Imbalanced: less than body requirements

Nursing Diagnosis: NANDA-Approved Diagnoses

Food and Fluid (cont) Nutrition, Imbalanced: more than body requirements Nutrition, Risk for imbalanced: more than body requirements Nutrition, Readiness for enhanced Oral mucous membrane, Impaired Swallowing, Impaired

Nursing Diagnosis: NANDA-Approved Diagnoses

Hygiene Self-care, Readiness for enhanced Self-care deficit, Bathing Self-care deficit, Dressing Self-care deficit, Feeding Self-care deficit, Toileting Self-neglect

Nursing Diagnosis: NANDA-Approved Diagnoses

Neurosensory Confusion, Acute Confusion, Risk for acute Confusion, Chronic Infant behavior, Disorganized Infant behavior, Readiness for enhanced organized Infant behavior, Risk for disorganized Memory, Impaired Neglect, Unilateral

Nursing Diagnosis: NANDA-Approved Diagnoses

Neurosensory Peripheral neurovascular dysfunction, Risk for Sensory perception, Disturbed visual Sensory perception, Disturbed auditory Sensory perception, Disturbed kinesthetic Sensory perception, Disturbed gustatory Sensory perception, Disturbed tactile Sensory perception, Disturbed olfactory

Nursing Diagnosis: NANDA-Approved Diagnoses

Pain Comfort, impaired Comfort, Readiness for enhanced Pain, Acute Pain, Chronic

Nursing Diagnosis: NANDA-Approved Diagnoses

Respiration Airway clearance, Ineffective Aspiration, Risk for Breathing pattern, Ineffective Gas exchange, Impaired Ventilation, Impaired spontaneous Ventilator weaning response, Dysfunctional

Nursing Diagnosis: NANDA-Approved Diagnoses

Safety Allergy response, Latex Allergy response, Risk for latex Body temperature, Risk for imbalanced Contamination Contamination, Risk for Death syndrome, Risk for sudden infant Environment interpretation syndrome, Impaired Falls, Risk for Health maintenance, Ineffective Home maintenance, Impaired

Nursing Diagnosis: NANDA-Approved Diagnoses

Safety (cont) Hyperthermia Hypothermia Immunization status, Readiness for enhanced Infection, Risk for Injury, Risk for Injury, Risk for perioperative positioning Jaundice, Neonatal Maternal/fetal dyad, Risk for disturbed Mobility, Impaired physical Poisoning, Risk for

Nursing Diagnosis: NANDA-Approved Diagnoses

Safety (cont) Protection, Ineffective Self-mutilation Self-mutilation, Risk for Skin integrity, Impaired Skin integrity, Risk for impaired Suffocation, Risk for Suicide, Risk for Surgical recovery, Delayed Thermoregulation, Ineffective

Nursing Diagnosis: NANDA-Approved Diagnoses

Safety (cont) Tissue integrity, Impaired Trauma, Risk for Violence, Other-directed Violence, Risk for other-directed Violence, Self-directed Violence, Risk for self-directed Wandering, Sporadic Wandering, Continual

Nursing Diagnosis: NANDA-Approved Diagnoses

Sexuality Childbearing process, Readiness for enhanced Sexual dysfunction Sexuality pattern, Ineffective

Nursing Diagnosis: NANDA-Approved Diagnoses

Social Interaction Attachment, Risk for impaired Caregiver role strain Caregiver role strain, Risk for Communication, Impaired verbal Communication, Readiness for enhanced Conflict, Parental role Coping, Ineffective community Coping, Readiness for enhanced community Coping, Compromised family Coping, Disabled family

Nursing Diagnosis: NANDA-Approved Diagnoses

Social Interaction (cont) Coping, Readiness for enhanced family Family processes, Dysfunctional Family processes, Interrupted Family processes, Readiness for enhanced Loneliness, Actual or Risk for Parenting, Impaired Parenting, Readiness for enhanced Parenting, Risk for impaired Role performance, Ineffective Social interaction, Impaired Social isolation

Nursing Diagnosis: NANDA-Approved Diagnoses

Teaching/Learning Development, Risk for delayed Growth, Risk for disproportionate Growth and development, Delayed Health behavior, Risk-prone Health management, Ineffective self Knowledge deficit (specify) Knowledge (specify), Readiness for enhanced Noncompliance, Adherence (specify) Noncompliance, Ineffective (specify)

Nursing Diagnosis: NANDA-Approved Diagnoses

Teaching/Learning (cont) Therapeutic regimen management, Ineffective Therapeutic regimen management, Ineffective family Therapeutic regimen management, Readiness for enhanced

Nursing Planning and Outcomes Identification

Includes the formulation of guidelines that establish the proposed course of nursing action in order to solve the nursing diagnosis and develop the clients plan of care

Nursing Planning: Phases

Initial development of a preliminary plan of care to be performed by the nurse Addresses acute problems while correlates nursing care to hasten resolution of the problems On-going continuous updating of the plan of care of the client Generate revisions and/or individualize the clients plan of care Discharge critical anticipation and preparation for the clients needs after discharge

Nursing Planning: Steps

Prioritization of the list of nursing diagnoses Identification and writing of the clientcentered, long-term and short-term goals and outcomes Development of specific nursing interventions Documentation of the entire nursing care plan in the clients record

Nursing Planning: Prioritization

Maslows hierarchy of needs 3-level method Level 1 priority Immediate, ABCs, vital signs Level 2 priority - Immediate, but only after initiating treatment for Level 1; mental status change, acute pain, acute urinary elimination problems, untreated medical problems requiring immediate attention, abnormal laboratory/diagnostic values, risks for infection, safety, security Level 3 priority - Health problems not classified under Level 1 or 2

Nursing Planning: Outcomes Identification

Goals aim, intent or end Broad statements that describe the intended or desired changes in the clients condition or behavior. Outline the desired resolution of the nursing diagnosis over a longer period of time (weeks to months) and is often formulated with reference to the diagnostic label of the diagnostic statement. NDx: Decreased cardiac output r/t alteration in afterload Goal: Maintain adequate cardiac output

Nursing Planning: Outcomes Identification

Objectives short-term goals More specific statements than goals Time frame is shorter NDx: Decreased cardiac output r/t alteration in afterload Goal: Maintain adequate cardiac output Obj: Reduce afterload Reduce effects of medications to reduce afterload

Nursing Planning: Outcomes Identification

Expected Outcomes detailed, specific statement that describes the methods through which the goal will be achieved. Client will show BP within normal limits within 2-3 days Client will show normal VS and hemodynamic parameters within 2-3 days Client will show no signs of pulmonary involvement Client will show no signs of adverse effects of medications

Nursing Planning: Categories of Interventions

Independent initiated by the nurse Does not require direction or a physicians order or from another healthcare professional Can include ADLs, health education, health promotion, and counseling Dependent require an order from a physician or any other healthcare professional Requires specific nursing knowledge and responsibilities Not for non-licensed nurses (LPNs, LVNs, NAs, RNs)

Nursing Planning: Categories of Interventions

Interdependent carried out by the nurse in collaboration with other healthcare professionals Client care conferences with an interdisciplinary team Example: Nurses assist in rehabilitation by the PT

Nursing Planning: Nursing Care Plan

Student-oriented provides great depth for learning the process of planning care; includes a scientific rationale for each intervention Standardized pre-planned; works well if patient conditions are predictable Institutional documents that are part of a patients medical record Computerized systematized care planning

Nursing Implementation
Includes the actual execution of the nursing care plan which was developed during the planning stage Performance of nursing interventions that have been planned to meet client goals Delegation of some aspects of nursing interventions to staff members Assignment of a specific nursing task to an assistive personnel who is capable of competently performing the task

Nursing Implementation: Required Skills

Assessment skills initial, prior, and continuous assessment to evaluate response to interventions Psychomotor skills safe and effective performance of interventions Interpersonal skills maintain NPR and enhance holistic care Cognitive skills critical thinking

Nursing Implementation: Types of Interventions

Independent, dependent, and interdependent Specific orders order written for specific patient; not used by any other patient Standing order standardized interventions; written, approved, and signed by MD and kept on file Protocol series of standing orders or procedures used under certain specific conditions (ex. Patient prep for diagnostics or surgery)

Nursing Evaluation
Can signal the beginning of another cycle of the nursing process. Includes the determination of whether the goals set for and with the client have been met completely, partially, or not at all

Nursing Evaluation: Reasons for Unmet Goals

Incomplete initial assessment data Inappropriate nursing diagnoses Unrealistic goals and expected outcomes Too optimistic time frame Inappropriate or mismatch between goals and nursing interventions Ineffective implementation of the care plan or the plan was not fully executed

Nursing Evaluation and the Nursing Process

Assessment Phase Are data relevant to client needs? Are data obtained by appropriate methods? Are data collected from multiple and varied sources? Is data collection performed in a systematic and organized manner? Is data collection thorough and complete?

Nursing Evaluation and the Nursing Process

Diagnosis Phase Are the diagnoses based on the collected data? Is each nursing diagnosis complete? Are the nursing diagnoses clientcentered and relevant? Are the nursing diagnoses comprehensive? Are the nursing diagnoses used to guide planning and implementation of client care?

Nursing Evaluation and the Nursing Process

Planning and Outcome Identification Phase Are the nursing diagnoses prioritized? Are the expected outcomes relevant to the nursing diagnoses? Are the outcomes realistic and attainable? Are the resources used efficiently? Are the care plans documented? Is the care plan revised according to clients needs?

Nursing Evaluation and the Nursing Process

Implementation Phase Is the plan of care followed by all healthcare team members? Are the necessary resources available? Do the nursing actions assist the client in meeting the expected outcomes? Were the client expected outcomes achieved? Does documentation reflect the clients status including his/her responses to the nursing interventions?

Nursing Evaluation: Audit

Provides an overall picture of how well the client care was delivered by all members of the healthcare team. Examine records in order to identify and evaluate data that pertains to Safety measures Treatment interventions and client responses to these interventions Pre-established outcomes as basis for interventions Discharge planning Client teaching Adequacy of staffing patterns