The Nursing Process Overview

The Nursing Process

• A framework for organizing nursing practice
• Focuses on identifying patient health status, problems, and needs
• Involves creating plans, implementing interventions, and evaluating effectiveness

5 Steps of the Nursing Process

• Assessing: Gathering, validating, and communicating client data
• Diagnosing: Analyzing client data to identify strengths and problems
• Planning/Outcome Identification: Specifying client outcomes and related nursing interventions
• Implementing: Carrying out the plan of care
• Evaluating: Measuring the extent to which the client achieved outcomes

Characteristics of the Nursing Process

• Interpersonal
• Systematic
• Dynamic
• Multi-dimensional
• Based on knowledge and critical thinking
• Cyclical

Critical Thinking in Nursing Process

• Apply critical thinking to each step of the nursing process
• Five steps to develop critical thinking:
  • Purpose of thinking
  • Adequacy of knowledge
  • Potential for problems
  • Helpful resources
  • Critique of judgment/decisions

Nurse Skills for the Nursing Process

• Cognitive skills
• Technical skills
• Interpersonal skills
• Ethical/legal skills

Step 1: Assessment Phase

• A systematic data collection process
• Continuous collection, organization, validation, and documentation of data
• Purpose is to establish a database for the client to meet their nursing care needs

Types of Assessment

• Initial Assessment: Comprehensive assessment at admission (establishes baseline data)
• Focused Assessment: Ongoing assessment related to a specific pre-existing condition
• Emergency Assessment: Assessment during a physiological or psychological crisis
• Time-Lapsed Assessment: Scheduled assessment to compare current status to baseline data

Purpose of Nursing Assessment & Database

• Determine the client's health status
• Assess their ability to function
• Identify strengths and limitations
• Determine ability to cope with stressors
• Guide the planning and delivery of appropriate care
• Identify the need for referrals to other professionals

Information Included in the Database

• Nursing history and health history
• Physical examination findings
• Laboratory results
• Diagnostic test results
• Past medical records

Types of Data

• Objective Data: Observable and measurable data (signs)
  • Collected through physical assessment, laboratory results, and diagnostic testing
• Subjective Data: Information only the client feels and describes (symptoms)
  • Collected through interviewing and understanding the client's perspective
  • Includes feelings, perceptions, and concerns

Sources of Data

• Primary Source: Client
• Secondary Source: Family, significant others, patient medical records, healthcare professionals, other experts, test and diagnostic results

Data Collection

• Takes place in the assessment phase
• Gathered through observation, interview, physical assessment, and diagnostics

Phases of the Interview

• Preparatory Phase: Reviewing records and gathering available data
• Introductory Phase: Meeting the client, introductions, and explaining the purpose of the interview
• Working Phase: Conducting the actual interview
• Termination Phase: Concluding the interview

Interviewing Techniques

• Direct Approach: Closed-ended questions (yes or no)
• Non-Direct Approach: Open-ended questions

Validating Data

• Double-checking or verifying information

Techniques Used for Physical Assessment

• Inspect
• Palpate
• Percussion
• Auscultate

Step 2: Diagnosing Phase

• The North American Nursing Diagnosis Association (NANDA) defines nursing diagnoses as clinical judgments about individual, family, or community responses to actual or potential health problems

Nursing Diagnosis vs. Medical Diagnosis

• Medical Diagnosis: Focuses on identifying and describing a disease, illness, or injury. Purpose is to identify disease or pathology. Remains the same as long as the disease is present.
• Nursing Diagnosis: Focuses on behaviors, responses, and reactions to disease, injury, or other stressors. Holistic perspective considering biological, emotional, interpersonal, social, spiritual, and environmental factors. Dynamic and can change as the patient's response changes.

Examples of Nursing Diagnoses vs. Medical Diagnoses

• Ineffective Breathing Patterns -> Chronic Obstructive Pulmonary Disease (COPD)
• Activity Intolerance -> Cerebrovascular Accident (CVA)
• Pain -> Appendectomy
• Body Image Disturbance -> Amputation
• Risk for Altered Body Temperature -> Strep Throat

Diagnosis Phase Steps

• Interpret data/cues (analyze data)
• Cluster cues (organize data)
• Confer with approved list from NANDA (identify health problems, risks, strengths)
• Formulate diagnosis statements (write it)

Types of Nursing Diagnoses

• Actual Diagnosis: Describes a problem response that exists at the time of assessment. Identified by signs and symptoms (cues).
• Risk Diagnosis: Describes a problem response likely to happen in a vulnerable client if the nurse does not intervene.
• Possible Diagnosis: Describes a situation where evidence about a health problem may be incomplete or unclear.
• Wellness Diagnosis: Describes the transition of an individual, family, or community from one level of wellness to a higher level. No identified health problem.

Components of a Nursing Diagnosis: PES

• Problem: Identifies what is unhealthy about the client.
• Etiology: Identifies factors maintaining the unhealthy state.
• Sign & Symptoms: Identifies subjective and objective data that signal the existence of a problem.

Step 3: Planning/Outcome Identification Phase

• Nurses work with the client and family to prioritize problems, formulate goals, select evidence-based interventions, and write nursing orders.
• Communicate the plan of nursing care.

Elements of Comprehensive Planning

• Initial Planning: Developed by the nurse performing the initial nursing history and physical examination.
• Ongoing Planning: Carried out by any nurse interacting with the client to keep the plan up-to-date.
• Discharge Planning: Information or teaching needed before discharge. Planning begins when the client is admitted.

Goal Prioritization Using Maslow's Hierarchy of Needs

• Highest priority at the base, progressing to medium and low priority.

Types of Goals

• Short-Term: Goals achieved within a few hours or days.
• Long-Term: Goals achieved over a longer period, weeks to months, or more.

Categories of Outcomes

• Cognitive: Describes increases in client knowledge or intellectual behaviors.
• Psychomotor: Describes the patient's achievement of new skills.
• Affective: Describes changes in client values, beliefs, and attitudes.

Standardized Classifications: NANDA, NIC, NOC

• NANDA: North American Nursing Diagnosis Association
• NIC: Nursing Interventions Classification: Standardized classification of interventions that describe direct or indirect care activities by nurses. Includes a label, a definition, and a list of nursing activities.
• NOC: Nursing Outcomes Classification: Standardized system to describe client outcomes that respond to nursing interventions.

Five Steps in Writing Outcomes

• Subject
• Verb
• Conditions or Modifiers
• Performance Criteria
• Timing

Three Types of Nursing Interventions

• Independent (Nurse Initiated): Actions performed without a physician's order.
• Collaborative (Interdependent): Actions performed jointly with other members of the healthcare team.
• Dependent (Physician Initiated): Actions performed under orders written by a physician.

Step 4: Implementation Phase

• Carry out previously planned nursing actions (interventions).

Process of the Implementation Phase

• Reassess the client as needed.
• Determine the need for assistance.
• Organize resources and care delivery (equipment, personnel, environment).
• Implement or delegate nursing interventions.
• Supervise any delegated care.
• Document all nursing activities and interventions provided.

Step 5: Evaluation Phase

• Determines if expected outcomes have been met, partially met, or not met.
• Review evaluative criteria and standards.
• Collect data to determine if criteria and standards were met.
• Interpret and summarize findings.
• Document judgment.

Evaluating Outcomes

• Cognitive Outcomes: Ask the patient to repeat or explain information, or apply new knowledge.
• Psychomotor Outcomes: Ask the patient to demonstrate a new skill.
• Affective Outcomes: Observe behaviors.
• Physiologic Outcomes: Collect and compare data.

Quality Assurance (QA)

• Focuses on the organization and is influenced by external factors (Joint Commission, state mandates, etc.).
• Goal is to evaluate:
  • Structure: Physical environment, standards, policies and procedures, equipment.
  • Process: Nature and sequence of activities, criteria, and acceptable levels of performance.
  • Outcomes: Measurable changes in client health status or the end results of nursing care.

Methods of Assuring Quality

• Quality by Inspection: Finding deficient workers and removing them.

This quiz explores the nursing process, a fundamental framework that organizes nursing practice. It focuses on the five steps: assessing, diagnosing, planning, implementing, and evaluating patient care. Participants will also learn about the importance of critical thinking in each step of the process.