Nursing Process: Steps, Development, Assistance

Nursing Process

• Systematic and rational planning and providing patient care method.
• It is organized in phases to facilitate evidence-informed and ethical nursing practice.

Nursing Process Development

• Ida Jean Orlando developed it in 1958
• Enables nurses to formulate effective and adaptable nursing care plans.
• It uses critical thinking, client-centered approaches, goal-oriented tasks, evidence-informed practice, and intuition.
• Holistic and scientific postulates provide the foundation for compassionate, quality-based care.

Nursing Process Assistance

• Critical thinking
• Guideline for data collection and care planning
• Work organization
• Client needs and care plan documentation

Nursing Process Misconceptions

• It is NOT a conceptual framework, theory, model of care, or a standard for the profession.

Five Steps of Nursing Process

• Assessment
• Diagnosis
• Planning
• Implementation
• Evaluation

Conceptual Framework (Theory)

• Person
• Health
• Environment
• Nursing

Conceptual Framework Considerations

• Assessment: What to look for, how to analyze data, follow up, and who to refer.
• Nursing Diagnosis: Diagnostic statements.
• Planning: Goals, deadlines, options for intervention, and the specific intervention.
• Implementation: How to implement and what to watch for.
• Evaluation: Comprehensiveness, effectiveness, efficiency, appropriateness, adequacy, and unintended consequences.

Steps of the Nursing Process in Detail

• Assessment: Collecting data regarding the client's health status or situation.
• Diagnosis: Analyzing data to determine key issues and clinical judgment represented as a nursing diagnosis.
• Planning: Prioritizing strategies and interventions in a client-centered plan with identified outcomes.
• Implementation: Executing the care plan and coordinating care.
• Evaluation: Reviewing outcomes to determine the effectiveness of interventions.

Nursing Care Plan

• Written, standardized, or computerized methods used to provide client care.
• Includes Nursing Diagnosis, Expected Outcomes, and Specific Nursing Interventions.
• Facilitates communication, continuity, and coordination of care.

Nursing Care Plan vs Nursing Process

• Nursing process requires assessing links between each step.
• Analyze similarities and differences between nursing process and care plans.
• Plan how to use the nursing care plan during clinical placements.

Assessment - Gathering Information

• Nurses gather info to understand the clients unique situation.
• Data is collected with a (NCP) or framework.
• The goal is to "solve the puzzle" and see a clear client's situation.

Data Sources

• Primary: Client
• Secondary: Family and significant others, health care team
• Tertiary: Medical records, literature, nurse's experience

Data Collection Methods

• Interview
• Nursing health history
• Physical examination

Holistic/Comprehensive Assessment

• Provides a detailed database including all areas of human functioning (physical, psychological, spiritual, socio-cultural).

Problem-Based Assessment

• It starts with an initial health problem, then the nature of the problem is assessed for cues.
• As it collects the data, it's categorized into cues, make inferences about the data, and identify emerging patterns.
• Patterns of information point to a conclusion about the current problem.

Data Validation

• The act of "double checking" or verifying it.
• Done prior to analysis.
• Compares data to the patient, textbook, nurses, and health care.

Data Analysis and Interpretation

• Data Clustering organizes data into meaningful clusters to help recognize significant cues/problems.
• Recognize patterns to signify current or potential problems.
• Uses inferential reasoning by attaching meaning to clinical data.
• Compares client data to normal values or norms.
• Looks for interrelationships and reasoned conclusions.

Diagnostic Phase

• Further analyzes and synthesizes info for conclusions.
• Identifies functional or problematic areas

Diagnostic Reasoning Definition

• Using assessment data about a client to logically explain a clinical judgment
• It involves the process of drawing conclusions from related evidence to form patterns

Moving From Assessment to Nursing Diagnosis

• Screening comes before potential which moves to in-depth then nursing diagnosis

Diagnosis

• Identifying strengths and needs are the basis for the plan of care.

Differentiating Diagnosis

• Differentiate between nursing, medical and collaborative problems with examples.

Nursing Diagnosis Definition

• It’s a clinical judgment about individual, family, or community responses to actual and potential health problems, is within the nursing domain; provides basis for nursing interventions to achieve accountable outcomes.

Medical Diagnosis Definition

• The identification of a disease condition relying on client specific evaluation which include physical signs, symptoms, client history, and diagnostic results.

Collaborative Problems Definition

• These are actual or potential physiological complications to monitor for onset of change and managed between health care team members.

Differentiating Nursing Diagnosis from Collaborative Problems

• First must know if nurse can legally order primary interventions to achieve a goal, if yes then its nursing diagnosis and they may prescribe and execute.
• If the nurse can't do that, then its medical and nursing interventions that need to achieve the client's goal, which leads to collaborative problems and then prescribing implementations.

Diagnostic Process

• Steps: Data clustering (cues), inferential reasoning, identifying problems/needs, and formulating a diagnostic statement.
• Data clusters have defining characteristics that help confirm a diagnosis. (clinical criteria or findings)

Analyzing Clustered Cues

• Compare to accepted norms.
• Identify defining characteristics in the data.
• Consider the problem in the 'bigger picture' to customize nursing diagnosis.

NANDA

• North American Nursing Diagnosis Association, International
• Taxonomy of nursing diagnosis.
• Each diagnosis has two-parts
  • Diagnostic label
  • Statement of related factors (etiology).
    • This can be actual, risk, health promotion, or wellness diagnoses.

Types of Nursing Diagnosis

• Actual
• Risk
• Health promotion
• Wellness

Types of Nursing Diagnosis In Detail

• Actual: A response to existing health conditions or life processes in an individual, family, or community, evidenced by related cues (signs/symptoms).
• Risk (potential): A possible health or life process response in a vulnerable individual, family, or community. Involves physiological, psychological, and environmental factors that increase likelihood of condition development
• Health Promotion: A clinical judgment of a person's, family's or community's motivation and desire to well-being and human potential, as expressed in their readiness to enhance specific health behaviors.
• Wellness: Describes wellness can be enhanced. A judgment with enhanced from a specific level to a higher one.

Nursing Diagnostic Statement

• Two-part format: Diagnostic LABEL related to RELATED FACTORS (Etiology)

Diagnostic Statement Examples

• Ex. Deficient Knowledge related to lack of exposure to instruction.
• Ex. Risk for Infection related to surgical incision.
• Ex. Constipation related to prolonged laxative use.
• "Related to" should be used rather than "because of".

Nursing Diagnosis statement definitions

• Label
  • Describes patient response
  • Will include descriptors to strengthen meaning (impaired, decreased)
• Related Factors
  • Etiology of patients response
  • Nursing actions to address

Key Points for Nursing Diagnosis Creation

• Identify client response (not a medical diagnosis)
• Use NANDA or clear language
• Find a treatable etiology
• Focus on client problems
• Do NOT include judgmental/legally questionable statements
• Refer to one problem

Example: Problems, Etiology, and Diagnostics

• Problem: Decreased Physical Functioning
• Etiology: Limited Physical Activity and Nutrition
• Nurses need thinking skills to identify causes of the problems.

Example Activity Intolerance

• Relates the factors inactivity secondary to sedentary lifestyle, lack of motivation, increased assisted device metabolic demands and increased stress levels.

Sources of Data Errors

• In Data Collection
• Errors in interpretation and analysis of data
• Clustering Errors
• Diagnostic Statements Errors

Compare/Contrast NCSBN & Clinical Thinking

• NCSBN Recognizes cues
• NP focus is on client using general and specific critical thinking competencies, use research and evidence based chose interventions base them on client needs to high, intermediate an low priorities.

Diagnostic Reasoning Components

• Attend to initial cues
• Formulate diagnostic hypothesis
• Gather data
• Evaluate

NCSBN Clinical Judgement

• It has layers of environmental factor as well as levels

NCSBN Layers

• 1. Recognize Cues - what matters most
• 2. Analyze cutes - what client conditions are consistent
• 3. Prioritize Hypothesis by urgency
• 4. Generate Solutions
• 5. Implement highest priority
• 6. Evaluate Outcomes