8/11/2019 The Nursing Process2
http://slidepdf.com/reader/full/the-nursing-process2 1/91
Nursing process
Dr. Abdul-Monim BatihaAssistant ProfessorCritical Care NursingPhiladelphia university
8/11/2019 The Nursing Process2
http://slidepdf.com/reader/full/the-nursing-process2 2/91
Nursing Process
The nursing process is a deliberate, problem-solvingapproach to meeting the health care and nursingneeds of patients. It involves assessment (data
collection), nursing diagnosis, planning,implementation, and evaluation, with subsequentmodifications used as feedback mechanisms thatpromote the resolution of the nursing diagnoses. Theprocess as a whole is cyclical, the steps beinginterrelated, interdependent, and recurrent.
8/11/2019 The Nursing Process2
http://slidepdf.com/reader/full/the-nursing-process2 3/91
Copyright 2008 by Pearson Education, Inc.
The Nursing Process
8/11/2019 The Nursing Process2
http://slidepdf.com/reader/full/the-nursing-process2 4/91
Copyright 2008 by Pearson Education, Inc.
Assessing
Collecting data
Organizing data
Validating is the act of “double-checking” or verifying data to confirm that it is accurate andfactual.
Documenting data Goal
Establish a database about the client’s response to
health concerns or illness
8/11/2019 The Nursing Process2
http://slidepdf.com/reader/full/the-nursing-process2 5/91
Copyright 2008 by Pearson Education, Inc.
Diagnosing
Analyzing and synthesizing data
Goals
Identify client strengths Identify health problems that can be prevented or
resolved
Develop a list of nursing and collaborative problems
8/11/2019 The Nursing Process2
http://slidepdf.com/reader/full/the-nursing-process2 6/91
Copyright 2008 by Pearson Education, Inc.
Planning
Determining how to prevent, reduce, or resolveidentified priority client problems
Determining how to support client strengths
Determining how to implement nursing interventionsin an organized, individualized, and goal-directedmanner
Goals
Develop an individualized care plan that specifies clientgoals/desired outcomes
Related nursing interventions
8/11/2019 The Nursing Process2
http://slidepdf.com/reader/full/the-nursing-process2 7/91
Copyright 2008 by Pearson Education, Inc.
Implementing
Carrying out (or delegating) and documenting plannednursing interventions
Goals
Assist the client to meet desired goals/outcomes
Promote wellness
Prevent illness and disease
Restore health
Facilitate coping with altered functioning
8/11/2019 The Nursing Process2
http://slidepdf.com/reader/full/the-nursing-process2 8/91
Copyright 2008 by Pearson Education, Inc.
Evaluating
Measuring the degree to which goals/outcomeshave been achieved
Identifying factors that positively or negativelyinfluence goal achievement
Goal
Determine whether to continue, modify, orterminate the plan of care
8/11/2019 The Nursing Process2
http://slidepdf.com/reader/full/the-nursing-process2 9/91
Copyright 2008 by Pearson Education, Inc.
Characteristics of the
Nursing Process
Cyclic and dynamic nature
Client centeredness
Focus on problem-solving and decision-making Interpersonal and collaborative style
Universal applicability
Use of critical thinking
8/11/2019 The Nursing Process2
http://slidepdf.com/reader/full/the-nursing-process2 10/91
Copyright 2008 by Pearson Education, Inc.
Characteristics of the
Nursing Process
8/11/2019 The Nursing Process2
http://slidepdf.com/reader/full/the-nursing-process2 11/91
Types of Assessments
Initial Performed within a specified time period Establishes complete database
Problem-Focused Ongoing process integrated with care Determines status of a specific problem
Emergency Performed during physiologic or psychologic crises
Identifies life-threatening problems Identifies new or overlooked problems
Time-lapsed Occurs several months after initial
Compares current status to baseline
8/11/2019 The Nursing Process2
http://slidepdf.com/reader/full/the-nursing-process2 12/91
Initial assessment is performed within aspecified time after admission to a health careagency for the purpose of establishing a
complete database for problem identification,reference, and future comparison.
8/11/2019 The Nursing Process2
http://slidepdf.com/reader/full/the-nursing-process2 13/91
Problem-focused assessment is an ongoingprocess integrated with nursing care todetermine the status of a specific problem
identified in an earlier assessment.
8/11/2019 The Nursing Process2
http://slidepdf.com/reader/full/the-nursing-process2 14/91
Emergency assessment occurs during anyphysiologic or psychologic crisis of the client toidentify the life-threatening problems and to
identify new or overlooked problems.
8/11/2019 The Nursing Process2
http://slidepdf.com/reader/full/the-nursing-process2 15/91
Time-lapsed (expired)reassessment occursseveral months after the initial assessment tocompare the client’s current status to baseline
data previously obtained.
8/11/2019 The Nursing Process2
http://slidepdf.com/reader/full/the-nursing-process2 16/91
Assessment Activities
Collecting data
Organizing data
Validating data Documenting data
8/11/2019 The Nursing Process2
http://slidepdf.com/reader/full/the-nursing-process2 17/91
8/11/2019 The Nursing Process2
http://slidepdf.com/reader/full/the-nursing-process2 18/91
Collecting data is the process of gatheringinformation about a client’s health status.
8/11/2019 The Nursing Process2
http://slidepdf.com/reader/full/the-nursing-process2 19/91
Organizing data is categorizing datasystematically using a specified format.
Validating data is the act of “double-checking”
or verifying data to confirm that it is accurateand factual.
Documenting is accurately and factuallyrecording data.
8/11/2019 The Nursing Process2
http://slidepdf.com/reader/full/the-nursing-process2 20/91
Copyright 2008 by Pearson Education, Inc.
Subjective Data
Symptoms or covert data
Apparent only to the person affected
Can be described only by person affected Includes sensations, feelings, values,
beliefs, attitudes, and perception of
personal health status and life situations
8/11/2019 The Nursing Process2
http://slidepdf.com/reader/full/the-nursing-process2 21/91
Copyright 2008 by Pearson Education, Inc.
Objective Data
Signs or overt data
Detectable by an observer
Can be measured or tested against anaccepted standard
Can be seen, heard, felt, or smelled
Obtained through observation or physicalexamination
8/11/2019 The Nursing Process2
http://slidepdf.com/reader/full/the-nursing-process2 22/91
Copyright 2008 by Pearson Education, Inc.
Sources of Data
Primary Source
The client
Secondary Sources All other sources of data
Should be validated, if possible
8/11/2019 The Nursing Process2
http://slidepdf.com/reader/full/the-nursing-process2 23/91
Copyright 2008 by Pearson Education, Inc.
Methods of Data Collection
Observing
Gathering data using the senses
Used to obtain following types of data:
Skin color (vision)
Body or breath odors (smell)
Lung or heart sounds (hearing)
Skin temperature (touch)
8/11/2019 The Nursing Process2
http://slidepdf.com/reader/full/the-nursing-process2 24/91
Copyright 2008 by Pearson Education, Inc.
Methods of Data Collection
Interviewing
Planned communication or a conversation with apurpose
Used to:
Identify problems of mutual concern
Evaluate change
Teach Provide support
Provide counseling or therapy
8/11/2019 The Nursing Process2
http://slidepdf.com/reader/full/the-nursing-process2 25/91
Copyright 2008 by Pearson Education, Inc.
Methods of Data Collection
Examining (physical examination)
Systematic data-collection method
Uses observation and inspection, auscultation,
palpation, and percussion
Blood pressure
Pulses
Heart and lungs sounds Skin temperature and moisture
Muscle strength
8/11/2019 The Nursing Process2
http://slidepdf.com/reader/full/the-nursing-process2 26/91
Copyright 2008 by Pearson Education, Inc.
Closed and Open-ended
Questions
Closed Question
Restrictive
Yes/no
Factual
Less effort and informationfrom client
“What medications did you
take?”
“Are you having pain now?”
Open-ended Question
Specify broad topic todiscuss
Invite longer answers Get more information
from client
Useful to change topics
and elicit attitudes “How have you been
feeling lately?”
8/11/2019 The Nursing Process2
http://slidepdf.com/reader/full/the-nursing-process2 27/91
Types of Nursing Diagnosis
Actual
Risk
Wellness
Possible
Syndrome
8/11/2019 The Nursing Process2
http://slidepdf.com/reader/full/the-nursing-process2 28/91
Actual Diagnosis
Problem present at the time of the assessment
Presence of associated signs and symptoms
(ineffective breathing pattern)
8/11/2019 The Nursing Process2
http://slidepdf.com/reader/full/the-nursing-process2 29/91
Risk Diagnosis
Problem does not exist
Presence of risk factors
8/11/2019 The Nursing Process2
http://slidepdf.com/reader/full/the-nursing-process2 30/91
Wellness Diagnosis
Readiness for enhancement
describes human responses to levels of wellness in an individual, family, or communitythat have a readiness enhancement.”
(readiness for enhanced spiritual well-being orreadiness for enhanced family coping)
8/11/2019 The Nursing Process2
http://slidepdf.com/reader/full/the-nursing-process2 31/91
Possible Diagnosis
Evidence about a health problem incomplete orunclear
Requires more data to either support or to refute it
(possible social isolation)
8/11/2019 The Nursing Process2
http://slidepdf.com/reader/full/the-nursing-process2 32/91
Syndrome Diagnosis
Associated with a cluster of other diagnoses
(risk for disuse syndrome)
8/11/2019 The Nursing Process2
http://slidepdf.com/reader/full/the-nursing-process2 33/91
8/11/2019 The Nursing Process2
http://slidepdf.com/reader/full/the-nursing-process2 34/91
8/11/2019 The Nursing Process2
http://slidepdf.com/reader/full/the-nursing-process2 35/91
Components of a Nursing
Diagnosis
Problem
Etiology
Defining characteristics
8/11/2019 The Nursing Process2
http://slidepdf.com/reader/full/the-nursing-process2 36/91
Problem Statement (Diagnostic
Label)
Describes the client’s health problem or response
8/11/2019 The Nursing Process2
http://slidepdf.com/reader/full/the-nursing-process2 37/91
Identifies one or more probable causes of the health
problem
8/11/2019 The Nursing Process2
http://slidepdf.com/reader/full/the-nursing-process2 38/91
Defining Characteristics
Cluster of signs and symptoms indicating thepresence of a particular diagnostic label (actualdiagnoses)
Factors that cause the client to be more vulnerable to the problem (risk diagnoses)
8/11/2019 The Nursing Process2
http://slidepdf.com/reader/full/the-nursing-process2 39/91
Steps in Diagnostic Process Analyzing data
Compare data against standards
Cluster cues
Identify gaps and inconsistencies
Identifying health problems, risks, and strengths
Formulating diagnostic statements
8/11/2019 The Nursing Process2
http://slidepdf.com/reader/full/the-nursing-process2 40/91
Formats for Writing Nursing Diagnoses
Basic two-part statement
Problem (P)
Etiology (E)
8/11/2019 The Nursing Process2
http://slidepdf.com/reader/full/the-nursing-process2 41/91
8/11/2019 The Nursing Process2
http://slidepdf.com/reader/full/the-nursing-process2 42/91
Basic three-part statement
Problem (P)
Etiology (E)
Signs and symptoms (S)
8/11/2019 The Nursing Process2
http://slidepdf.com/reader/full/the-nursing-process2 43/91
One-part statement
Wellness (readiness for enhanced)
Syndrome
8/11/2019 The Nursing Process2
http://slidepdf.com/reader/full/the-nursing-process2 44/91
Variations
Unknown etiology
Complex factors Possible
Secondary
Other additions for precisions
Th fi i i f h
8/11/2019 The Nursing Process2
http://slidepdf.com/reader/full/the-nursing-process2 45/91
There are five variations of the
basic formats:
Writing unknown etiology when the definingcharacteristics are present but the nurse does
not know the cause or contributing factors Using the phrase complex factors when there are
too many etiologic factors or when they are too
complex to state in a brief phrase
8/11/2019 The Nursing Process2
http://slidepdf.com/reader/full/the-nursing-process2 46/91
Using the word possible to describe either theproblem or the etiology when the nurse believesmore data are needed about the client’s problem
or the etiology
8/11/2019 The Nursing Process2
http://slidepdf.com/reader/full/the-nursing-process2 47/91
Using secondary to divide the etiology into twoparts, thereby making the statement moredescriptive and useful (the part following
secondary to is often a pathophysiologic or diseaseprocess or a medical diagnosis)
Adding a second part to the general response or
NANDA label to make it more precise
8/11/2019 The Nursing Process2
http://slidepdf.com/reader/full/the-nursing-process2 48/91
The following are guidelines for
writing nursing diagnosis statements:
Write statements in terms of a problem insteadof a need.
Word the statement so that it is legally advisable.
Use nonjudgmental statements.
Be sure both elements of the statement do notsay the say thing.
8/11/2019 The Nursing Process2
http://slidepdf.com/reader/full/the-nursing-process2 49/91
8/11/2019 The Nursing Process2
http://slidepdf.com/reader/full/the-nursing-process2 50/91
Be sure cause and effect are stated correctly.
Word diagnosis specifically and precisely.
Use nursing terminology rather than medicalterminology to describe the client’s response.
Using nursing terminology rather than medicalterminology to describe the probable cause ofthe client’s response.
8/11/2019 The Nursing Process2
http://slidepdf.com/reader/full/the-nursing-process2 51/91
. To improve diagnostic reasoning and avoiddiagnostic reasoning errors, the nurse should dothe following: verify diagnoses by talking with
the client and family, build a good knowledgebase and acquire clinical experience, have a working knowledge of what is normal, consult
resources, base diagnoses on patterns (that is,behavior over time) rather than an isolatedincident, and improve critical-thinking skills.
8/11/2019 The Nursing Process2
http://slidepdf.com/reader/full/the-nursing-process2 52/91
Advantages of a Taxonomy of Nursing
Diagnoses
Development of a standardized nursing language Nursing minimum data set
Id if i i i h i h
8/11/2019 The Nursing Process2
http://slidepdf.com/reader/full/the-nursing-process2 53/91
Identify activities that occur in the
planning process.
Activities in the Planning Process
Prioritizing problems/diagnoses
Formulating client goals/desired outcomes
Selecting nursing interventions
Writing individualized nursing interventions
Id tif ti l id li f
8/11/2019 The Nursing Process2
http://slidepdf.com/reader/full/the-nursing-process2 54/91
Identify essential guidelines for
writing nursing care plans.
Guidelines for Writing Nursing
Care Plans Date and sign the plan
Use category headings
Use standardized/approved terminology and symbols Be specific
8/11/2019 The Nursing Process2
http://slidepdf.com/reader/full/the-nursing-process2 55/91
Refer to other sources
Individualize the plan to the client
Incorporate prevention and health maintenance
Include discharge and home care plans
8/11/2019 The Nursing Process2
http://slidepdf.com/reader/full/the-nursing-process2 56/91
Identify factors that the nurse must
consider when setting priorities. Setting Priorities
Establishing a preferential sequence foraddressing nursing diagnoses and interventions
High priority (life-threatening)
Medium priority (health-threatening)
Low priority (developmental needs)
8/11/2019 The Nursing Process2
http://slidepdf.com/reader/full/the-nursing-process2 57/91
Factors to Consider When Setting
8/11/2019 The Nursing Process2
http://slidepdf.com/reader/full/the-nursing-process2 58/91
Factors to Consider When Setting
Priorities Client’s health values and beliefs
Client’s priorities
Resources available to the nurse and client
Urgency of the health problem
Medical treatment plan
8/11/2019 The Nursing Process2
http://slidepdf.com/reader/full/the-nursing-process2 59/91
Describe the relationship of
goals/desired outcomes to thenursing diagnoses.
Goals/Desired Outcomes and Nursing
Diagnosis Goals derived from diagnostic label
Diagnostic label contains the unhealthy response
(problem) Goal/desired outcome demonstrates resolution
of the unhealthy response (problem)
8/11/2019 The Nursing Process2
http://slidepdf.com/reader/full/the-nursing-process2 60/91
Identify guidelines for writing goals/desired
outcomes.
Components of Goal/Desired Outcome
Statements
Subject
Verb
Condition or modifier
Criterion of desired performance
8/11/2019 The Nursing Process2
http://slidepdf.com/reader/full/the-nursing-process2 61/91
Guidelines for Writing
8/11/2019 The Nursing Process2
http://slidepdf.com/reader/full/the-nursing-process2 62/91
Guidelines for Writing
Goal/Outcome Statements Write in terms of the client responses
Must be realistic
Ensure compatibility with the therapies ofother professionals
Derive from only one nursing diagnosis
Use observable, measurable terms
8/11/2019 The Nursing Process2
http://slidepdf.com/reader/full/the-nursing-process2 63/91
Describe the process of selecting
and choosing nursing interventions. Nursing Interventions and Activities
Actions nurse performs to achieve goals/desiredoutcomes
Focus on eliminating or reducing etiology ofnursing diagnosis
Treat signs/symptoms and definingcharacteristics
8/11/2019 The Nursing Process2
http://slidepdf.com/reader/full/the-nursing-process2 64/91
Types of Nursing Interventions
Direct
Indirect
Independent interventions
Dependent interventions
Collaborative interventions
8/11/2019 The Nursing Process2
http://slidepdf.com/reader/full/the-nursing-process2 65/91
Direct care is an intervention performedthrough interaction with the client.
Indirect care is an intervention performed away
from but on behalf of the client such asinterdisciplinary collaboration or management ofthe care environment.
8/11/2019 The Nursing Process2
http://slidepdf.com/reader/full/the-nursing-process2 66/91
independent interventions, those activitiesthat nurses are licensed to initiate on the basis of
their knowledge and skills; dependent interventions, activities carried out
under the primary care provider’s orders or
supervision, or according to specified routines; collaborative interventions, actions the nurse
carries out in collaboration with other health
team members. The nurse must chooseinterventions that are most likely to achieve thegoal/desired outcome.
Criteria for Choosing Appropriate
8/11/2019 The Nursing Process2
http://slidepdf.com/reader/full/the-nursing-process2 67/91
Criteria for Choosing Appropriate
Intervention
Safe and appropriate for the client’s age, health, and
condition
Achievable with the resources available Congruent with the client’s values, beliefs, and culture
Congruent with other therapies
Based on nursing knowledge and experience orknowledge from relevant sciences
Within established standards of care
8/11/2019 The Nursing Process2
http://slidepdf.com/reader/full/the-nursing-process2 68/91
Discuss the five activities of the
implementing phase.
Five Activities of the Implementing Phase
Reassessing the client
Determining the nurse’s need for assistance
Implementing nursing interventions
Supervising delegated care
Explain how evaluating relates to other
8/11/2019 The Nursing Process2
http://slidepdf.com/reader/full/the-nursing-process2 69/91
Explain how evaluating relates to other
phases of the nursing process.
Nursing Process — Evaluating
Depends on the effectiveness of phases thatprecede
Assessing and nursing diagnosis must beaccurate
Goals/desired outcomes must be statedbehaviorally to be useful for evaluating
8/11/2019 The Nursing Process2
http://slidepdf.com/reader/full/the-nursing-process2 70/91
Without implementing phase, there would benothing to evaluate
8/11/2019 The Nursing Process2
http://slidepdf.com/reader/full/the-nursing-process2 71/91
Evaluating and assessing phases overlap
1. Evaluating is a planned, ongoing, purposefulactivity in which clients and health care
professionals determine the client’s progresstoward achievement of goals/ outcomes and theeffectiveness of the nursing care plan. Successful
evaluation depends on the effectiveness of thesteps that precede it.
8/11/2019 The Nursing Process2
http://slidepdf.com/reader/full/the-nursing-process2 72/91
Assessment data must be accurate and completeso the nurse can formulate appropriate nursingdiagnoses and goals/desired outcomes. The
goals/desired outcomes must be statedconcretely in behavioral terms to be useful forevaluating client responses. Without the
implementing phase in which the plan is put intoaction, there would be nothing to evaluate. Theevaluating and assessing phases overlap.
8/11/2019 The Nursing Process2
http://slidepdf.com/reader/full/the-nursing-process2 73/91
During the assessment phase the nurse collectsdata for the purpose of making diagnoses.During the evaluation step the nurse collects
data for the purpose of comparing the data topreselected goals and judging the effectivenessof the nursing care. The act of assessing (data
collection) is the same. The differences lie in when the data are collected and how the data areused.
Components of the Evaluation
8/11/2019 The Nursing Process2
http://slidepdf.com/reader/full/the-nursing-process2 74/91
Components of the Evaluation
Process Collecting data related to the desired outcomes
( nursing outcomes classifications NOC indicators)
Comparing the data with outcomes
Relating nursing activities to outcomes
Drawing conclusions about problem status
Continuing, modifying, or terminating thenursing care plan
8/11/2019 The Nursing Process2
http://slidepdf.com/reader/full/the-nursing-process2 75/91
8/11/2019 The Nursing Process2
http://slidepdf.com/reader/full/the-nursing-process2 76/91
8/11/2019 The Nursing Process2
http://slidepdf.com/reader/full/the-nursing-process2 77/91
8/11/2019 The Nursing Process2
http://slidepdf.com/reader/full/the-nursing-process2 78/91
8/11/2019 The Nursing Process2
http://slidepdf.com/reader/full/the-nursing-process2 79/91
8/11/2019 The Nursing Process2
http://slidepdf.com/reader/full/the-nursing-process2 80/91
8/11/2019 The Nursing Process2
http://slidepdf.com/reader/full/the-nursing-process2 81/91
8/11/2019 The Nursing Process2
http://slidepdf.com/reader/full/the-nursing-process2 82/91
8/11/2019 The Nursing Process2
http://slidepdf.com/reader/full/the-nursing-process2 83/91
8/11/2019 The Nursing Process2
http://slidepdf.com/reader/full/the-nursing-process2 84/91
8/11/2019 The Nursing Process2
http://slidepdf.com/reader/full/the-nursing-process2 85/91
8/11/2019 The Nursing Process2
http://slidepdf.com/reader/full/the-nursing-process2 86/91
8/11/2019 The Nursing Process2
http://slidepdf.com/reader/full/the-nursing-process2 87/91
8/11/2019 The Nursing Process2
http://slidepdf.com/reader/full/the-nursing-process2 88/91
8/11/2019 The Nursing Process2
http://slidepdf.com/reader/full/the-nursing-process2 89/91
8/11/2019 The Nursing Process2
http://slidepdf.com/reader/full/the-nursing-process2 90/91
8/11/2019 The Nursing Process2
http://slidepdf.com/reader/full/the-nursing-process2 91/91
Top Related