Nursing Process

Nursing Fundamentals

Introduction: Nursing Process

• Communication tool• Organization tool

Overview of the Nursing Process

• Purpose is to provide client care that is:– Individualized– Holistic

Holistic Health

• Treat the Whole person– Mental – Spiritual– Social– Physical

Overview of the Nursing Process

• Process:• Purpose:

– Individualized– Holistic– Effective– Efficient

• Nursing CARE

Overview of the Nursing Process

• Consists of 5 steps

–AD-PIE

Nursing Process

• Used throughout the life span

• Used in every care setting

Small group questions:

1. What are the names of each of the steps?2. What is the purpose of the nursing process?

Assessment

• Step #1• Involves

– Collecting data– Validating the data– Organizing the data– Interpreting the data– Documenting the data

Assessment• Types of assessment:

1. Comprehensive2. Focused3. Ongoing

Assessment

• Comprehensive assessment– Baseline– Physical &

psychosocial

Assessment

• Focused Assessment–Limited in scope–Screening for a

specific problem–Short stay

Assessment

• Ongoing –Follow-up–Monitoring

changes

Assessment• Types of data

– Subjective• Data from the client’s

viewpoint– Interview

– Objective• Observable & measurable

– Physical assessment– Labs– Tests

iClicker

John is being admitted to the psychiatric facility, after being transferred from the acute hospital with a diagnosis of schizophrenia and multiple sclerosis. What type of assessment should be performed on John?A.ComprehensiveB.FocusedC.Ongoing

Small group questions:

1. Baby Jane a 2 month infant goes into the doctor for her initial immunization and well baby check-up. What type of assessment should the nurse perform?A. ComprehensiveB. Focused C. Ongoing

Which one of the following is objective data?

A. NauseaB. PainC. DizzinessD. Unsteady gaitE. Anxiety

Which one of the following is subjective data?

A. VomitingB. Warm, moist skinC. Head acheD. Bruise on the right armE. Temperature 99.3 o F

Diagnosis

• Step 2 in the nursing process

Nursing diagnosis:

• “A clinical judgment…• about an individual, family or

community…• responses to actual or potential health

problems”• Forms the basis for nursing

interventions

Medical vs. Nursing diagnosis

Medical diagnosis Nursing diagnosis

Identifies conditions the MD is licensed & qualified to treat

Identifies situations the nurse is licensed & qualified to treat

Medical vs. Nursing diagnosis

Medical diagnosis Nursing diagnosis

Identifies conditions the MD is licensed & qualified to treat

Identifies situations the nurse is licensed & qualified to treat

Focuses on illness, injury or disease processes

Focuses on the clients responses to actual or potential health / life problems

Medical vs. Nursing diagnosis

Medical diagnosis Nursing diagnosis

Remains constant until a cure is effected

Changes as the clients response and/or the health problem changes

Medical vs. Nursing diagnosis

Medical diagnosis Nursing diagnosis

Remains constant until a cure is effected

Changes as the clients response and/or the health problem changes

i.e. Breast cancer i.e. Knowledge deficit

Powerlessness

Grieving, anticipatory

Body image disturbance

Individual coping, ineffective

DiangosisNursing diagnosis Medical diagnosis

Breathing patterns, ineffective

Chronic obstructive pulmonary disease

Activity intolerance Cerebrovascular accident

Pain Appendectomy

Body image disturbance Amputation

Body temperature, risk for altered

Strep throat

Planning & Outcome identification

• Step 3

Planning & Outcome identification

–Types of planning• Initial•Ongoing•Discharge

Planning & Outcome identification

• Outcome identification = Goals– Short term

• Hrs - days (< week)– Long term

• Wks. – mons.

Planning & Outcome identification

• Interventions– Independent interventions

• No MD order needed

– Interdependent interventions• With interdisciplinary team member

– Dependent interventions• MD order required

The nursing care plan includes “administer digoxin per MD order”.

What type of intervention is this?A. DependentB. InterdependentC. Independent

Prioritizing Nrs Dx

• Maslow’s hierarchy of needs

Maslow’s Hierarchy of Needs

Maslow’s Hierarchy of Needs

• Physiological:– Breathing, food, water, sleep, homeostasis,

excretion– ABC’s

Maslow’s Hierarchy of Needs

• Safety– Security of body, employment, resources,

morality, family, health or property

• Physiological

Maslow’s Hierarchy of Needs

• Love/Belonging– Friendship, family, sexual intimacy

• Safety• Physiological:

Maslow’s Hierarchy of Needs

• Esteem– Self esteem, confidence, achievement, respect of

others, respect by others

• Love/Belonging• Safety• Physiological

Maslow’s Hierarchy of Needs

• Self-Actualization– Creativity, spontaneity, problem solving, lack of

prejudice, acceptance of facts

• Esteem• Love/Belonging• Safety• Physiological:

Which of the following client issues should receive the highest priority?

A. John’s best friend just stormed out of the room mad.

B. Todd feels like not one respects his workC. Mary feels scared she is going to dieD. Anna feels like she is lacking in creativity

Which of the following client issues should receive the highest priority?

A. George is climbing out of bed and he can’t walkB. Paul is having a difficulty breathingC. Susan is crying hysterically because she just found

out the person who was driving in the car with her, died in the car accident.

D. Jane has severe hip pain due to post-op hip surgery

Implementation

• 4th step:– Execution of the care

plan

–DO IT–DO IT RIGHT–DO IT RIGHT

NOW!

• Direct• Assist• Supervise• Delegate• Teach• Monitor

Implementation

• 5 Rights of Implementation1) Right patient2) Right medication3) Right route4) Right dose / amount5) Right time

Evaluation

• 5th step– Have the clients goals

have been met, partially met or not met.

Small group questions:

1. What is the purpose of the nursing process and where is it used?

2. Name & describe the steps of the nursing process

3. Explain the difference between objective and subjective data.

4. Define holistic and explain how it relates to nursing.

Role of the LVN & Psych Tech• Use the nrs process• Contribute to Dx & nrs

care plan• Provide info• Implement• The RN has ultimate

responsibility

Critical Thinking & the Nursing Process

• Critical thinking• Thinking like a nurse

Critical Thinking

• Inquisitive• Open-minded• Flexible• Fairminded