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Transition to Registered Nursing
West Coast University
Week 3
Nursing Process: Overview, Assessment and Nursing Diagnosis
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Objectives
• History of the Nursing Process and Nursing Diagnosis
• Discuss characteristics of Nursing Process and Nursing Diagnosis
• Describe Assessment • Formulate a Nursing Diagnosis
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History of Nursing Diagnosis
• 1950’s – Introduction only – mainly used in relationship to the care plan– only sporadically in the literature
• 1970’s– 1st National Conference for classification of Nursing Diagnosis and
formed the North American Nursing Diagnosis Association (NANDA)– ANA published standards of practice & a social policy statements
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History of Nursing Diagnosis
• 1970’s – continued– ANA published standards of practice & a social policy
statements• Defined nursing as diagnosis and treatment of human response
to actual or potential health problems
• 1990’s – 9th Conference of NANDA was held and Taxonomy II was
published
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Globalization of Nursing
• Nursing Diagnosis is recognized globally– Provides common language for nursing to talk to each other,
identifies problems, gives nursing greater accountability, and professional autonomy
– Captures nursing’s contributions to health, enables cross-country comparisons of nursing and promotes the development of nursing
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• Pre-1955: No clearly identifiable boundaries defined for nursing practice
• 1955: Term nursing process coined by Lydia Hall• 1973: ANA published Standards of Clinical
Nursing Practice
continues
Timeline
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Timeline
• 1973: Classification of nursing diagnoses began: North American Nursing Diagnosis Association (NANDA)
• 1980: ANA published A Social Policy Statement• 1982: NCLEX exams were revised
to include concepts• 1994: JCAHO initiated requirements for
accredited hospitals to use the nursing process • Current: Ongoing use of the five-step process• In 2006 NANDA had their 13 Conference
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Basic Characteristics of the Nursing Process
• Method of providing care• Purposeful, systematic, and orderly • Method of problem solving and decision making• Scientifically based—understanding of the
human body• Philosophically based—understanding of
philosophical views
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Nursing Process Characteristics
• Method for organization• Promotes wellness• Restores wellness• Maintains present state of health
continues
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Nursing Process Characteristics
• Promotes quality care• Promotes coordinated, ongoing care• Serves as a guide to avoid omissions or
inaccuracies• Provides a framework for nursing
continues
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Nursing Process Characteristics
• Client centered• Assists to plan according to client needs• Client participates• Promotes collaboration with other disciplines• Universally applicable
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Critical Thinking
• Purposeful thought process• Strategy used in search for meaning• Deliberate questions are asked
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Problem Solving
• Gather data• Identify problem• Interpret data• Plan to resolve• Implement plan• Evaluate results
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Decision Making
• Based on scientific theories• Results from nurse’s ability to think critically• Perceptual and intellectual skills used
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Benefits of the Nursing Process
• Improved quality of care• Continuity of care• Promotes client participation in care• Delivery of care is organized, continuous,
and systematic• Efficient use of time and resources• Expectations of client and standards of
care are met• Holds nurses accountable and responsible
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Five Steps of the Nursing Process
• Assessment• Diagnosis• Planning and outcome identification• Implementation• Evaluation
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Scope and Standards of Practice
I. Assessment: Nurse collects dataII. Diagnosis: Nurse analyzes data in
determining diagnosesIII. Outcome identification: Nurse identifies
expected outcomesIV. Planning: Nurse develops a plan of care V. Implementation: Nurse implements
interventions identified in planVI. Evaluation: Nurse evaluates client’s progress
From American Nurses Association. (1991). Standards of clinical nursing practice. Washington DC: Author.
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continues
Questions Critical Thinkers Ask...
• What actual problems were identified during assessment?
• What are possible causes?• Is client at risk for developing other problems?• What are the factors involved?• Did the client indicate a desire to function at a
higher level of wellness?
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Questions Critical Thinkers Ask...
• What are the client’s strengths?• What additional data might be needed to answer
these questions?• What are possible sources of data collection?• Is collaboration needed at this time?• What data are pertinent to collect before
contacting the physician?
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Characteristics of Assessment
• Systematic, ongoing, and continuous• Process of collecting data• Identification of problems• Data yield information regarding health status
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Baseline Data
• Initial data becomes foundation• Accurate data collection is critical• Used for comparison of future data
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Data Collection
• Interview, physical exam, diagnostic exams• Communicated and documented• Begins when client enters health care system• Continues as long as there is a need
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Validating & Clarifying Data
• Subjective Data: “I feel like my heart is racing”• Objective Data: Pulse 150 beats per minute,
regular, strong
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Sources of Data
• Client• Family or significant other• Nursing records• Medical records• Consultations• Health care team members• Diagnostic results• Relevant literature
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Promoting Data Collection
• Use communication techniques– paraphrasing– clarifying– focusing– summarizing– open-ended questions
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Nursing vs. Medical Diagnoses
Nursing Diagnosis • Determined by the nurse• Clinical judgment about the client• Human responses to disease or treatment• May change
Medical Diagnosis • Determined by physician• Indicates disease, illness• Doesn’t change
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Definition: Nursing Diagnosis
• A clinical judgment about individual, family, or community responses to actual or potential health problems/life processes. Nursing diagnosis provides the basis for selecting interventions to achieve outcomes for which the nursing is accountable
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Making a Nursing Diagnosis• Know diagnoses
– Collect valid & pertinent data, cluster data, differentiate nursing diagnosis from collaborative problems, prioritize
• Defining the characteristics– Major & Minor
• Related factors– Pathophysiological– Treatment– Situational– Maturational
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Actual ND
• Represents a problem that has been validated by the presence of major defining characteristics.
• Has four parts– Label
– Definition
– Defining characteristics
– Related factors
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Risk ND
• Clinical judgment that an individual, family or community is vulnerable to develop the problem than others in the same or similar situation
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Possible ND
• Describes a suspected problem requiring additional data. This is where data is not complete or an evaluation has not been completed
• Not a NANDA ND because it is not classified, yet viable for the clinical nurse for further clarification of a problem
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Syndrome ND
• Clustering of predictable actual or high-risk NDs related to events or situations
• Complex clinical situation, use with care and stated as a one-part statement
• There should be a clustering of other NDs
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Wellness ND
• Clinical judgment about an individual, family or community transition from a specific level of wellness to a higher level
• Stated as a one-part
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Collaborative Problems
• Physiologic complications that nurses monitor to detect onset or changes in status. Nurses manage collaborative problems with PCP-prescribed (dependent nursing functions) and Nursing-prescribed (independent nursing functions) to minimize complications
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Cultural, Ethical & Spiritual ND
• Cultural Needs– Where is the cultural component?– Belief system, knowledge, food, environment, powerlessness
• Ethical Issues– What do you do with issues that are illegal, or different from your
belief system?
• Spiritual Concerns– Does, or how does the patient utilize spirituality in there health care?
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Components of a Nursing Diagnosis
• Stated as one, two or three parts
Type of Diagnosis Parts needed
Actual 3 – Label, Factors, S/S
Risk 2 – Label, Factors
Possible 2 – Label, Factors
Syndrome 1 – Label
Wellness 1 – Label
Collaborative Need the stem: Potential Complications (PC)
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Formulating Nursing Diagnosis
Diagnostic Label(Stem)
Contributing Factors(Etiology – RT)
Signs & Symptoms(AEB)
Related to
As evidenced by/secondary to
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Example of Actual Nursing Diagnoses
• Hyperthermia– Client’s temperature is 104.6°F.
• Impaired Gas Exchange– Client’s oxygen saturation in arterial blood is 92%.
continues
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Example of Actual Nursing Diagnoses
• Pain– Client states pain level “8” on scale of one to ten.
• Anxiety– Client states he is experiencing anxiety.
• Self-care deficit– Client is unable to perform ADLs.
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Etiology
• Related to (R/T) or related factor• Involved in development of problem• Becomes focus for interventions• Cause component• Gives direction to problem statement
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Defining Characteristics
• As evidenced by (AEB)• Clinical evidence• How response is manifested
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Scenario One:
The nurse is caring for a client who was involved in a motor vehicle accident and sustained superficial skin trauma. The client’s epidermal layer of skin on the right knee, forearm, and hand is excoriated, reddened, and bleeding as the result of sliding across a cement pavement.
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Answer:
• Impaired Skin Integrity• R/T: mechanical factors, shearing forces • AEB: disruption of skin surface, destruction of
skin, layers, traumatized skin excoriated, reddened, bleeding
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Scenario Two
The client you are caring for has been medically diagnosed with a right cerebral vascular accident (stroke). He experiences partial paralysis on the left side of his body. He is unable to turn over while in bed without assistance and has demonstrated decreased muscle strength and control in the left extremities.
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Answer:
• Impaired Physical Mobility • R/T: neuromuscular impairment• AEB: inability to purposefully move within the
environment, decreased muscle strength, control, left-sided partial paralysis
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Components of Risk Nursing Diagnoses
• Potential problem• Risk factor• No evidence• Problem does not exist
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Risk Nursing Diagnoses Examples
• Cancer patient, Risk for Infection– Risk Factors (R/T): inadequate secondary defenses,
immunosuppression
• Client with surgical incision, Risk for Infection– Risk Factors (R/T): inadequate primary defenses,
invasive procedure
continues
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Risk Nursing Diagnoses Examples
• Client who is semi-conscious, vomiting, Risk for Aspiration – Risk Factors (R/T): reduced level of
consciousness, vomiting
• Neonate unable to maintain his body temperature, parent does not keep the child covered, Risk for Hypothermia – Risk Factors (R/T): extremes of age,
inadequate clothing
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