Basic Nursing: Foundations of

Skills & Concepts Chapter 9

NURSING PROCESS

The Nursing Process

A systematic method of providing care to clients.

The 5-Step Nursing Process

Assessment. Diagnosis. Planning and outcome identification. Implementation. Evaluation.

Assessment or Data Collection

The first step in the nursing process involves the following:

Collecting data. Validating data. Organizing data. Interpreting data. Documenting data

Purpose of Assessment

To establish a database concerning a client’s physical, psychosocial, and emotional health.

To identify health-promoting behaviors as well as actual and/or potential health problems.

Types of Assessment

Comprehensive - Provides baseline data including complete health history and current needs assessment.

Focused - Limited in scope in order to focus on a particular need or concern or potential risk.

Ongoing - Includes systematic monitoring and observation related to specific problems.

Sources of Data

Primary Source: The client.

Secondary Source: The client’s family members, other health care providers, and medical records.

Types of Data

Subjective: Data from client’s (and sometimes family’s) point of view. Includes feelings, perceptions, and concerns. Collected by the interview.

Objective: Also called signs. Observable and measurable data obtained through physical examination and laboratory and diagnostic testing.

Validating Data

Validation prevents omissions, misunderstandings, and incorrect inferences and conclusions.

Organizing Data

Collected information must be organized to be useful.

Data Clustering is a useful tool to identify issues.

Interpreting Data

Three critical components: Distinguishing between relevant and

irrelevant data Determining whether and where there

are gaps in the data Identifying patterns of cause and effect

Documenting Data

Assessment data must be recorded and reported.

Accurate and complete recording of assessment data is essential for communicating information to health care team.

Diagnosis

A medical diagnosis is a clinical judgment by the physician that determines a specific disease, condition or pathological state.

A nursing diagnosis is a clinical judgment about individual, family, or community responses to actual or potential health problems/life processes.

Nursing Diagnosis Questions

Are there problems here? If so, what are the specific problems? What are some possible causes? Is there a situation involving risk factors? What are the risk factors? What are the client’s strengths? What data are available to answer these questions? Is more data needed? If so, what are the possible sources of further data?

Nursing Diagnosis is a Two-Part Statement

A problem statement or diagnostic label that describes the client’s response to an actual or potential health problem or wellness condition.

And the etiology - the related cause or contributor to the problem.

Nursing Diagnosis is a Three-Part Statement

Includes first two parts of Two-Part Statement: the diagnostic label and the etiology.

Also includes defining characteristics, the collected data, also known as signs and symptoms, subjective and objective data, and clinical manifestations.

Types of Nursing Diagnosis

Actual nursing diagnosis: A problem exists; it is composed of the diagnostic label, related factors, and signs and symptoms.

Risk nursing diagnosis: A problem does not yet exist, but special risk factors are present.

Wellness nursing diagnosis: Indicates client’s desire to attain higher level of wellness in some area of function.

Planning and Outcome Identification

Planning combines with outcome identification to comprise the third step of the nursing process.

Three Phases of Planning

Initial Planning: developing a preliminary plan of care by the nurse who performs the admission assessment.

Ongoing Planning: continuous updating of client’s plan of care.

Discharge Planning: Involves critical anticipation and planning for client’s needs after discharge.

Tasks Involved with Planning

Prioritizing list of nursing diagnoses.

Identifying and writing client-centered long- and short-term goals and outcomes.

Developing specific nursing interventions.

Recording entire nursing plan in client’s record.

Intervention

A nursing intervention is an action performed by the nurse that helps the client achieve the results specified by the goals and expected outcomes.

Categories of Nursing Interventions

Independent: Actions initiated by nurse that do not require direction or an order from another health care professional

Interdependent: Actions implemented in collaborative manner by nurse in conjunction with other health care professionals

Dependent: Actions that require an order from a physician or other health care professional.

Types of Nursing Interventions

Specific order - written by physician or nurse especially for an individual client.

Standing order - A standardized intervention written, approved and signed by a physician that is kept on file to be used in predictable situations or in circumstances requiring immediate attention.

Protocol - A series of standing orders or procedures.

Types of Nursing Interventions Specific order: written by physician or nurse

especially for an individual client Standing order: A standardized intervention

written, approved and signed by a physician that is kept on file to be used in predictable situations or in circumstances requiring immediate attention.

Protocol: A series of standing orders or procedures

The Nursing Care Plan

A written guide that organizes data about a client’s care into a formal statement of the strategies that will be implemented to help the client achieve optimal health.

Implementation

This fourth step of the nursing process involves the execution of the nursing care plan derived during the Planning phase.

Evaluation

This fifth step of the nursing process, determining whether client goals have been met, partially met, or not met.

Nursing Audit

The process of collecting and analyzing data to evaluate the effectiveness of nursing interventions.

The Nursing Process is Critical Thinking

Critical thinking, problem-solving, and decision-making are important in the use of the nursing process.

These skills can be learned!