The Nursing Process

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The Nursing Process

• NUR 403 Foundations of Nursing Practice
• SP 10

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The Nursing Process is ...

• A systematic, rationale method of planning and
  providing individualized nursing care. Its
  purpose is to identify clients health status,
  actual or potential healthcare problems or needs,
  to establish plans to meet those needs and to
  deliver specific nursing interventions to meet
  those needs.
• (Kozier, 2004)

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The Nursing Process is ...

• The set of activities that professional nurses
  perform to determine the needs of the patient and
  make a judgment to provide the care that is
  needed.

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Your legal and professional accountability and
the nursing of process

• CA BRN Standards of Competent Performance RN
  shall be considered to be competent when he/ she
  consistently demonstrates the ability to transfer
  scientific knowledgein applying the nursing
  process

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Standards of Competent Performance (Board of
Registered Nursing)

• Formulates nursing diagnosis, through observation
  and interpretation of information.
• Formulates a care plan in collaboration with the
  client.
• Performs skills essential to the nursing actions
  to be taken.
• Delegates tasks to subordinates
• Evaluates the effectiveness of the care plan
• Acts as the clients advocate.

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American Nurses Association Standards of Practice

• The collection of data is systematic
• Derive nursing diagnosis from data
• Plan nursing care including goals
• Plan includes priorities and nursing approaches
• Nursing actions provide for client participation
  in health promotion, maintenance, and restoration
• Evaluation of progress or lack of progress

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Problem-Solving Priority Setting

• Priority Setting
• Determine client health values beliefs
• Establish priorities from highest to lowest
• Determine urgency or the problem
• Problem-Solving
• Once problem is identified, collect data
• Analyze the data identify an action-plan
• Implement the plan, observing initial responses
• Evaluate the results

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Steps of the Nursing Process

• Assessment
• Diagnosis
• Planning
• Implementation
• Evaluation

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The Nursing Process
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The Nursing Process
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Assessment Phase
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Assessment Data

• Subjective Data- The client states . . .
• Objective Data- Vital signs- Physical
  assessments- Previous documentation

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Examples of Data

• Temp of 102 degree
• I feel tired
• WBC 24,000/mm3
• I need help to walk
• B/P 180/96
• My leg hurts
• Redness and swelling in R ankle

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Diagnosis Phase
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A Nursing Diagnosis is ...

• A description of the clients response to a
  disease state, process, condition or situation.
  It is a clinical judgment about an individual,
  family or community responses to actual/potential
  health problems/life processes. Nursing
  diagnoses provide the basis for selection of
  nursing interventions to achieve desired client
  outcomes.
• (NANDA, 1990)

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Comparing Nursing Medical Diagnoses

• Nursing Diagnosis
• Describes a response to a disease process,
  condition or situation
• Oriented to individual changes as client
  changes
• Compliments medical diagnoses
• Teaches client re self-care

• Medical Diagnosis
• Describes a specific disease process
• Oriented to pathology remains constant
• Well defined classification system
• Teaches clients about treatments

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Advantages Disadvantages of Nursing Diagnoses

• Advantages
• Provides a common language for nurses
• Outcome-oriented
• Efficient, Organized , Systematic, and Goal
  Directed
• Disadvantages
• Inconsistently used
• Not always formally recognized (by MDs.)
• Some problems dont fit diagnostic statements as
  outlined by NANDA

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Two Types of Nursing Diagnoses

• Actual Problems
• Altered Nutrition, less than body requirements
  related to poor oral intake as evidenced by
  weight loss of 12 lbs. in two weeks.
• Potential Problems
• High risk for infection (Potential for) related
  to decreased primary defenses.

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Components of a Nursing Diagnosis

• Actual Problem (3 Part Statement)
• Diagnostic Label/Statement (Problem Statement)
  Activity Intolerance Impaired Physical
  Mobility(identifies unhealthy responses, what
  needs change)
• Etiology (Contributing Factors) related to
  _______________(identifies factors causing
  undesirable response)
• Defining Characteristics (Manifestations) as
  evidenced by __________ (what you see)

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Components of a Nursing Diagnosis

• Potential Problems (2 Part Statement)
• Diagnostic Label/Statement
• Etiology (Contributing Factors)

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Planning Phase
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Planning Phase Goals Outcomes

• Goals are broad statements about the effects of
  nursing interventions on the client (overall,
  non-measurable statements)
• Outcomes are specific, measurable criteria used
  to evaluate whether goals have been met based on
  specific nursing interventions

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Outcome Statements (Criteria)

• Outcomes are derived from the diagnosis
• Outcomes are measurable/behavioral
• Outcomes are realistic compared to the clients
  self-care abilities
• Outcomes have a time-frame for completion
• Outcomes provide direction for care

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Planning Phase Interventions

• Interventions should be developed which are
  consistent with the established plan of care
• Interventions should be implemented in a safe,
  appropriate manner based on sound nursing theory
  and judgment

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Planning Phase Interventions

• Interventions should always be documented in the
  medical record
• Interventions should be realistic for client,
  based on abilities and resources

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Types of Nursing Interventions

• Independent
• Able to be implemented without a physicians
  order
• Dependent
• Must have or obtain physicians order to
• implement this intervention
• Collaborative
• Combination of dependent/independent
• nursing intervention

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Types of Nursing Functions

• Independent functions that are within scope of
  nursing practice.
• Assessment - history and physical
• Nursing diagnosis, which require nursing
  interventions
• Nursing actions
• Referrals to other health members
• Evaluation of patients responses

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Types of Nursing Functions

• Interdependent activities that are carried out
  in conjunction with other health team members.
• RN works with a dietician to help a diabetic
  patient control blood sugar.
• RN works with PT to help improve patients
  ambulation.

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Nursing Functions

• Dependent activities performed based on the
  physicians orders
• Administration of medication
• Carrying out specific treatments

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Independent? Interdependent? Dependent?Patient
has a B/P of 160/100, the RN

• Retakes the B/P ask the pt what he was doing.
• Asks the pt. how he is feeling, notes changes
• Checks B/P with the previous B/P readings.
• Checks the MDs order for any related orders.
• Gives treatments ordered by the MD.
• Monitors effects of medication.
• Teaches the pt. relaxation techniques.

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Focus of Patient CareMedicine and Nursing

• Patient reports, It feels like my chest is being
  crushed
• Observations show facial grimace, SOB (shortness
  of breath), and diaphoresis (perspiring)

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Focus of Patient Care

• Goal of Medicine cure, treat disease, heal
  physiologic being

• Goal of Nursing works with the whole person

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Focus of Patient Care

• Medical interpretation of pain diminished blood
  flow from coronary arteries to myocardium
• Probable Diagnosis Myocardial Infarction

• Nursing interpretation Pain in the chest
• Probable Nursing Diagnosis chest pain related
  to cardiac disease

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Focus of Patient Care

• Medical Plan dependent functions
• Bedrest
• Vital Signs q 15 min.
• Morphine 2mg IV prn
• NTG 1/200 gr SL prn
• EKG, O2 at 2L/min

• Nursing Plan independent functions
• Monitor EKG and dysrhythmia
• Assess chest pain
• Employ comfort measures, allow rest
• Alleviate anxiety

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Implementation Phase
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Implementation Skills (3)

• Require cognitive skills (problem-solving,
  creative critical thinking skills)
• Require interpersonal skills (verbal/non-verbal
  communication,teaching, caring etc.)
• Require technical skills (hands-on psychomotor
  skills, tasks, procedures)

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Evaluation Phase
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The Nursing Process

• STEP 5
• Evaluation
• determining the clients progress
• monitoring the clients response

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Evaluation Process

• Compare the actual to expected outcomes- Did my
  client achieve their outcomes?
• - If not, determine why outcomes were unmet -
  Were the outcomes realistic? Correct problem?
  Enough time to achieve outcomes?
• If you determine the outcomes to be appropriate,
  assess the interventions
• -Were the interventions appropriate? Were they
  completed? Does the client require other nursing
  interventions?
• If everything looks good, continue with plan of
  care, observing for improvement

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Purposes of a Written Care Plan

• Provides direction individualizes client care
• Provides for continuity of care
• Provides direction for follow-up documentation
• Provides assistance in assigning staff
• Provides information for reimbursement

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Mrs. Ida Hubert, 67 y.o.

• Admitted to the unit with diagnosis of lung
  cancer with bone metastases 3 days ago
• Meds morphine 180 mg daily Tylenol 650 mg
  Oxycodone 10 mg q6h p.r.n.
• Morning report Mrs. Huber had been restless all
  night

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What assessments would you want to make in your
preparation for her care?

• Chart review Has been taking narcotics for 2
  months spends most of her days in bed

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Assessment of Mrs. Hubert

• Patient interview
• Alert and responsive
• Couldnt sleep or rest just couldnt get into a
  comfortable position. Had trouble describing her
  discomfort.
• Reported decreased appetite, ate 3 small
  meals/day, one 8 oz can of supplement. Said she
  is drinking very little fluids

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Assessment of Mrs. Hubert

• Measurements
• V.S. were stable
• Had active bowel sounds, abdomen non-tender to
  palpation, but noted a firm area in LLQ.
• Said she had not had a BM since admission (3 days
  ago).
• What nursing diagnosis might be appropriate for
  Mrs. Hubert?

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Critical Thinking What is it?

• Critical thinking is making decisions based on
  reason, reflection, knowledge and instinct
  derived from experience. Critical thinking helps
  nurses make patient-care decisions by helping
  them to think creatively, and explore new ideas
  and alternative ways of solving problems.
• (Catalano, 1996)

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The Critical Thinking Process

• Identify the problem
• Identifying the underlying beliefs (patient,
  personal and other healthcare providers)
• Find support for the beliefs (accurate, timely,
  consistent literature/research)
• Evaluate the situation for possible solutions and
  weigh the solutions against the beliefs and
  values
• Present a course of action

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Comparison of SOAP Nursing Process Steps
Assessment
Subjective
Diagnosis
Objective
Plan
Assessment
Implementation
Plan
Evaluation