nursing process

Nursing process

is a systematic, rational method of planning and providing individualized nursing care.

Critical thinking

is an essential skill needed for the identification of client problems and the implementation of interventions to promote effective care outcomes

Problem solving

is a mental activity in which a problem is identified that represents an unsteady state. It requires the nurse to obtain information that clarifies the nature of the problem and suggests possible solutions.

Decision making

is involved in every phase of the nursing process. Nurses can be highly creative in determining when and how to use data to make decisions. This facilitates the individualization of the nurse’s plan of care.

Cyclic and dynamic

Continuously changing

• regularly repeated event or sequence of events (a cycle)

• Data from each phase provide input into the next phase. Findings from the evaluation phase feed back into assessment

Client centered

Focus is client’s problems

• The nurse collects data to determine the client’s habits, routines, and needs. Enabling the nurse to incorporate client routines into the care plan

Adaptation of Problem Solving and Systems Theory

Parallel to but separate from medical model (used by physicians)

Interpersonal and collaborative

requires the nurse to communicate directly and consistently with clients and families to meet their needs.

Universal applicability

used as a framework of nursing care in ALL types of healthcare settings, with clients of ALL age groups

Critical thinking

reasonable reflective thinking that is focused on deciding what to believe or do

Clinical reasoning

utilize clinical reasoning throughout the delivery of nursing care. The nurse determines whether the outcome of care was appropriate.

Assessing

is the systematic and continuous collection, organization, validation, and documentation of data (information)

PURPOSE: To establish a database about the client’s response to health concerns or illness and the ability to manage health care need

Initial assessment

Performed within specified time after admission to a health care agency

Purpose: to establish a complete database for problem identification, reference, and future comparison

Problem-focused assessment

Ongoing process integrated with nursing care

Purpose: to determine the status of a specific problem identified in an earlier assessment

Emergency assessment

During any physiological or psychological crisis of the client

Purpose: to identify life-threatening problems and to identify new or overlooked problems

Time-lapsed reassessment/assessment

Several months after initial assessment

Purpose: to compare the client’s current status to baseline data previously obtained

Subjective data

COVERT DATA

• can be described or verified only by that individual

• Itching, pain, and feelings of worry

• Feelings, values, beliefs, attitudes

Objective data

OVERT DATA

• can be observed or can be measured

• Discoloration of the skin, blood pressure

Database

Contains all the information about a client

Nursing Diagnosis

is a clinical judgment concerning a human response to health conditions/life processes, or a vulnerability for that response, by an individual, family, group, or community

PURPOSE: To identify client strengths and health problems that can be prevented or resolved by collaborative and independent nursing interventions. To develop a list of nursing and collaborative problem

Medical Diagnosis

• focuses on illness, injury or disease process

• Focuses on curing Pathology

• Stays the same as long as the disease is present

Nursing Diagnosis

• focuses on the responses to actual or potential health problems or life processes

• Identify responses to health and illness

• Can change from day to day

Actual nursing diagnosis

Is a client problem that is present at the time of the nursing assessment

Example: ineffective breathing

Risk nursing diagnosis

is a clinical judgment that a problem does not exist, but the presence of risk factors indicates that a problem is likely to develop unless nurses intervene.

For example, all people admitted to a hospital have some possibility of acquiring an infection; however, a client with compromised immune system is at higher risk than others.

*Therefore, the nurse would appropriately use the label Risk for Infection to describe the client’s health status

Health promotion diagnosis

relates to clients’ preparedness to implement behaviors to improve their health condition. These diagnosis labels begin with the phrase Readiness for Enhanced, as

Example: Readiness for Enhanced Nutrition.

Syndrome diagnosis

is assigned by a nurse’s clinical judgment to describe a cluster of nursing diagnoses that have similar interventions (Herdman & Kamitsuru, 2014, p. 23). Is used when a cluster of assessment findings or nursing diagnosis occur together, showing a specific clinical pattern.

Examples: Post-trauma syndrome/ Rape Trauma Syndrome

Problem

The _____ statement, or diagnostic label. It describes the client’s health status clearly and concisely in a few words.

• The purpose of the diagnostic label is to direct the formation of client goals and desired outcomes. It may also suggest some nursing interventions.

Etiology

component of a nursing diagnosis identifies one or more probable causes of the health problem, gives direction to the required nursing therapy, and enables the nurse to individualize the client’s care

Defining characteristics

are the cluster of signs and symptoms that indicate the presence of a particular diagnostic label. For actual nursing diagnoses, the defining characteristics are the client’s signs and symptoms

Qualifiers

are words that have been added to some NANDA labels to give additional meaning to the diagnostic

Ex:

Deficient fluid volume or

Ineffective breathing

Planning

the process of designing nursing activities required to prevent, reduce, or eliminate a client’s health problems.

— is an intentional, systematic phase of the nursing process that involves decision-making and problem-solving.

Initial planning

• the nurse who performs the admission assessment usually develops the initial comprehensive plan of care

• Should be initiated as soon as possible after the initial assessment

Ongoing Planning

• occurs at the beginning of a shift as the nurse plans the care to be given that day

Discharge planning

• the process if anticipating and planning for needs after discharge, is a crucial part of a comprehensive healthcare plan and should be addressed in each client’s care plan

Implementing

Is the action phase in which the nurse performs the nursing interventions

Independent interventions

are those activities that nurses are licensed to initiate on the basis of their knowledge and skills

Ex: Physical care, emotional support and comfort, teaching, environmental management, and referrals to healthcare professionals

Dependent interventions

are activities carried out under the orders of a licensed physician

Ex: Medications, intravenous therapy, diagnostic tests, treatments, diet, and activity

Collaborative interventions

are actions the nurse carries out in collaboration with other health team members (physical therapists, social workers, dietitians)

Documenting Nursing Activities

the nurse completes the implementing phase by recording the interventions and client res

Evaluating

5th phase of the nursing process

— conclusions drawn whether the nursing interventions should be terminated, continued, or changed