Nursing Process

a systematic problem solving approach toward providing individualized nursing care.

North American Nursing Diagnosis Association International

1-framework for care to indiv, families, & communities 2-orderly & systematic 3-interdependent 4-provides specific care for the indiv, fam, & comm 5- client centered 6-appropriate for use throughout lifespan 7-used in ALL settings

ADPIE A=assessment D=diagnosis P=planning I=implementation E=evaluation

1- initial (or admission assessment) 2- focused assessment 3- emergency assesment

past medical hx - family hx - reason for admission - current meds - previous hospitalizations & surgeries - psychosocial assessment - nutrition - complete physical assessment

Collects data about a problem that has already been identified. This type of assessment determines whether the problem still exists, or any changes.

‐ What are your symptoms? ‐ When did they start? ‐ What activity were you doing ? ‐ What makes it better or worse? ‐ What are you doing to relieve the symptom?

Performed to identify a life‐threatening problem (choking, stab wound, heart attack).

Information verbalized or stated by the client.

‐ Observable and measurable information. ‐ Remember to include your senses: smell, hearing, touch and sight.

An objective finding perceived by the examiner ex. (fever, rash, etc.)

Subjective findings verbalized or stated by the client ex. ("I have a headache" " I feel sick in my stomach.")

objective

subjective

primary & 2ndary

‐Information obtained from the patient (only)

‐ Family members ‐ Significant others ‐ Past & current health records, laboratory tests,diagnostic procedures, consultations from other healthcare professionals.

VALIDATE ‐Confirm and verify the information. ‐ Keep it free from errors, bias, or misinterpretation.

collected, validated, then clustered

defining characteristics which are specific assessment findings that support a nursing diagnosis.

critical thinking is used to analyze and synthesize the information that is collected. The data is then put into specific clusters that describe a specific client problem.

subjective & objective, primary & secondary, people, healthcare professionals, medical chart, test & lab results etc

As you cluster data, you begin to consider various diagnoses that may relate to the client. You must remember that if certain defining characteristics do not exist for a specific diagnosis, then you must not use the diagnosis.

1. Complete thorough assessment of the patient. 2.Highlight or underline relevant symptoms (defining characteristics). 3. Make a list of symptoms. 4. Cluster and interpret the symptoms. 5. Analyze and interpret the symptoms. 6. Select a nursing diagnosis based on the definition found in the nursing diagnosis manual by Doenges, Moorhouse and Murr. 7. Remember to prioritize the identified problems.

A medical diagnosis describes a disease process. A nursing diagnosis describes an individual, family or group response to an actual or potential problem.

‐Identification of a disease condition based on specific findings such as diagnostic tests and procedures. ‐ Remains the same as long as the disease is present.

‐ Clinical judgment in response to actual or potential health problems. ‐ Provides a basis for providing nursing care through various interventions to achieve outcomes. ‐ Changes possibly from day to day as the patient's response changes.

1. Actual diagnosis 2. Risk diagnosis 3. Health promotion diagnosis 4. Wellness diagnosis

Represents a problem that has been validated by the presence of defining characteristics (signs and symptoms).

Is defined by NANDA‐I , "describes human responses to health conditions/life processes that may develop in a vulnerable individual, family, or community. It is supported by risk factors that contribute to increased vulnerability" (NANDA, 2007). Ex. infection after surgery

Clinical judgment of a person, family, or community desire to enhance their well being and readiness to implement health behaviors of a higher level. Ex. nutrition

Describes the human responses to levels of wellness in an individual, family or community that have readiness to enhance well being. Ex.Coping, readiness of enhanced related to successful cancer treatment.

A nursing diagnosis consists of 3 parts or what is referred to PES format: P= Problem E =Etiology S =Signs and Symptoms

to identify the health status or problem of the individual using the approved NANDA - I list. Ex.Pain, acute

the cause ; Identifies the physiologic, psychological, sociologic, spiritual, or environmental factors assumed to be the cause of the problem or a contributing factor.

"related to" ; The etiology cannot be related to a medical diagnosis.

Identified as subjective and/or objective data that supports the problem. ‐ Identified by the nurse from the clustering of significant data including assessment findings.

"as evidenced by"

consist of a problem and the etiology only - there are NO signs & sypmtoms because it hasn't happened yet

develop a plan of care.This is accomplished by developing client centered goals and expected outcomes. - use critical thinking to develop nursing interventions to resolve the client's problem and achieve the goals.

1-Maslow 2- Pt preference what does the pt think is important 3-Anticipation or future problems

Maslow's Hierarchy of Needs a. physiological needs b. safety needs c. love and belonging needs d. self‐esteem needs e. self‐actualization needs

1 -airway 2- urinary 3- sexual 4- skin integrity

1-gas exchange 2-hypothermia 3-knowledge defecit 4- infection

1-pain 2-mobility 3- social isolation 4-self esteem

" a broad statement that describes the desired change in a client's condition or behavior."

include expected outcomes or measurable criteria to evaluate the achievement of the goal.

an objective behavior or response you expect the client to achieve in a short period of time usually less than one week.

An objective behavior or response you expect the client to achieve in a longer period of time possibly over several days, weeks, or months.

An outcome is a measurable change in the client's status that you expect to occur related to the implemented care.

1-client centered 2-singular 3-observable 4-measurable 5-time limited 6-mutual 7-realistic

Are actions or treatments based on knowledge or judgment that the nurse performs to meet the patient outcomes.

1-independent ex. positioning 2-dependent ex. med admin 3-collaborative or interdependent ex. OT

1-Failure to be precise or fully indicate the nursing action. 2-Failure to indicate frequency 3-Failure to indicate quantity 4-Failure to indicate method

is the reason for choosing the particular intervention based on supportive evidence from textbooks, journals, and/or online nursing references (so we know why we are doing the task we are doing)

This step begins after the care plan has been developed by the nurse. This is the step of the nursing process where the nurse performs the interventions as a means of achieving the goals.

direct (performed through interaction with the client) or indirect (without the client but on their behalf)

1-reassessing 2-review/revise existing nursing dx & care plan 3-organizing resources & delivery of care 4-Anticipating/preventing any complications 5-Implementing interventions

1-cognitive 2-personal 3-psychomotor

critical thinking ; good decisions

communication ; therapeutic interactions

proper performance and knowledge of skills

Evaluation is the final stage of the nursing process. You as the nurse determine if the patient has achieved the expected outcomes not if the nursing interventions were completed.

1. Identifying criteria and standards. 2. Collecting data to determine if the criteria or standards are met. 3. Interpreting and summarizing findings. 4. Documenting findings and any clinical judgment. 5. Terminating, continuing or revising the care plan.