Unit 2 pt 1 Nursing process

Nursing Process Overview

• Nursing Process Overview

  • NUR111 - Fall 2025

  • Key Phases of the Nursing Process:

  • Assessment

  • Diagnosis

  • Planning

  • Implementation

  • Evaluation

  • Cycle of the Nursing Process:

  • Collect data

  • Formulate nursing diagnosis

  • Write care plan to meet goals

  • Carry out plan

  • Collect objective data to determine achievement of goals

  • Revise plan as needed

Assessment

• Definition of Assessment

  • Collect, validate, organize, and record data

  • Involves a systematic and ongoing process

  • Stages of Assessment:

  • Collecting data

  • Categorizing data

  • Recording data

• Differences between Medical and Nursing Assessments

  • Medical Assessments: Focus on disease and pathology

  • Nursing Assessments: Concentrate on the client’s responses to illness

• Uses of Assessment Data

  • Used by other disciplines for collaboration

  • Planning for nursing care

  • Ensuring clients receive proper care from qualified individuals at needed times

• Delegation of Assessments

  • Only a professional nurse may perform the assessment phase of the nursing process

• Resources for Delegation

  • State nurse practice acts

  • Agency policies and procedures

  • Accrediting agencies

  • American Nurses Association (ANA)

Types of Data in Nursing Assessment

• Subjective and Objective Data

  • Subjective Data: What the patient says

  • Objective Data: What can be observed or measured

• Sources of Data

  • Primary: Obtained directly from the client

  • Secondary: Obtained secondhand through records or other individuals

• Examples of Subjective and Objective Data

  • Subjective: "My throat hurts when I swallow."

  • Objective: "White patches noted at the back of the throat, and tonsillar area reddened and swollen."

Nursing Assessment Skills

• Key Nursing Skills:

  • Observation

  • Physical assessment

  • Interviewing

• Techniques in Nursing Assessment

  • Inspection

  • Palpation

  • Percussion

  • Auscultation

• Types of Assessments

  • Initial

  • Ongoing

  • Comprehensive

  • Focused

  • Special needs assessments

Special Needs Assessments

• Categories of Special Needs Assessments:

  • Nutritional assessment

  • Pain assessment

  • Cultural assessment

  • Spiritual health assessment

  • Psychosocial assessment

  • Wellness assessment

  • Family assessment

  • Community assessment

  • Functional ability assessment

Nursing Interview Techniques

• Directive and Nondirective Interviews

  • Directive Interviewing:

  • Nurse controls topics and uses mostly closed questions

  • Obtains factual, easily categorized information, typically in emergencies

  • Nondirective Interviewing:

  • Patient controls subject matter; nurse clarifies, summarizes, and questions

  • Utilizes mostly open-ended questions, promotes communication, facilitates thought, and builds rapport

• Principles for Interview Preparation

  • Knowledge of purpose and usage of data

  • Review the client’s chart

  • Prepare goals and opening questions

  • Schedule uninterrupted time

  • Have necessary forms and equipment ready

  • Compose oneself prior to the interview

Validation of Data

• When to Validate Data

  • When subjective and objective data do not agree

  • When client statements differ at different times

  • When data are far outside the normal range

  • When factors interfere with accurate measurement

Documenting Data

• Guidelines

  • Document data as soon as possible

  • Write neatly, legibly, and in black ink

  • Document electronically using proper spelling and grammar

  • Avoid acronyms unless necessary

  • Use patient’s own words when feasible

  • Document concrete, specific information, and focus on cues not inferences

Example of Vital Signs Documentation

Organizing Data

• Nursing Models for Organization

  • Gordon’s Functional Health Patterns

  • NANDA-International Nursing Diagnosis Taxonomy II

  • International Classification for Nursing Practice (ICNP®)

  • Roy Adaptation Model

  • Orem’s Self-Care Model

  • Non-nursing models (e.g., Maslow’s Hierarchy of Needs)

Tools for Recording Assessment Data

• Examples of Tools

  • Graphic flow sheet

  • Intake & output (I & O) sheets

  • Nursing admission assessments

  • Nursing discharge summary

  • Special-purpose forms

  • Electronic documentation systems

Reflection on Assessment

• Questions to Consider

  • Are the data complete, accurate, and validated?

  • Did I record data and not conclusions?

  • Did I follow up on special needs assessments if indicated?

  • Consider the client interview and physical assessment results

Importance of Nursing Assessments

• Early identification of complications through:

  • Identifying the most likely or worst possible complications with corresponding signs and symptoms

  • Emphasizing proactiveness over reactivity in nursing care

Nursing Diagnosis

• Definition

  • A nursing diagnosis is a statement regarding a health problem or concern identified by the nurse that can be prevented or treated independently.

  • Written in terms of human responses to health problems or life processes as defined by NANDA-I.

  • NANDA-I Definition:

  • “A clinical judgment about individual, family, or community experiences/responses to actual or potential health problems/life processes.”

• Types of Collaborative Problems

  • Physiological complications due to diseases, medical treatments, or diagnostic studies

  • Clients with specific diseases are at risk for the same complications, which should be monitored continuously

Diagnostic Reasoning Process

• Critical Thinking Steps

  • Analyze and interpret data

  • Draw conclusions based on assessment information

  • Verify problems with the client

  • Prioritize identified problems

  • Record relevant diagnostic statements

Analyzing Data

• Key Steps in Analysis

  • Identify significant data and cluster cues

  • Identify gaps and inconsistencies in the data

  • Draw conclusions regarding the health status

  • Formulate inferences and deduce problem etiologies

  • Verify problems identified with the patient if possible

Prioritizing Problems

• Ranking Problems by Importance:

  • High Priority: Life-threatening issues

  • Medium Priority: Not immediately threatening but may lead to deterioration

  • Low Priority: Require minimal intervention

Maslow’s Hierarchy of Needs

• Components of a Needs Hierarchy:

  • Physiological: Basic needs for life (food, air, water)

  • Safety and Security: Emotional and physical safety

  • Love and Belonging: Relationships and affection

  • Self-Esteem: Pride and recognition

  • Cognitive: Knowledge and understanding

  • Aesthetic: Appreciation for beauty and order

  • Self-Actualization: Achieving individual potential

Problem Identification Example

• Labeling each problem:

  • Pain (High Priority)

  • Falls Risk (High Priority)

  • Chronic Low Self-Esteem Disturbance (Low Priority)

• Ranking Example:

  • 1: Risk for Falls

  • 2: Pain

  • 3: Nutrition Deficit

  • 4: Chronic Low Self-Esteem

Standardized Nursing Language

• Definition and Purpose

  • Standardized terms are designed for clarity and uniformed understanding among nursing professionals

  • Supports communication regarding nursing knowledge, actions, and practices

Classification Systems

• Examples of Classification Systems used in Nursing:

  • NANDA International (NANDA-I)

  • Clinical Care Classification (CCC)

  • Omaha System

  • Perioperative Nursing Data Set (PNDS)

  • International Classification for Nursing Practice (ICNP)

Writing Quality Statements

• Guidelines for Nursing Diagnoses

  • Choose a standard label accurately, considering definitions

  • Include problem and etiology details

  • Ensure etiology does not simply restate the problem

  • Avoid using medical diagnoses as etiological factors

Formulating Problem Statements

• Example Definitions

  • Actual Problem:

  • "Constipation related to decreased fiber intake as evidenced by no bowel movement in 5 days."

  • Risk for Problem:

  • "Risk for Constipation related to physical inactivity for age and gender."

Identifying Problems Framework

• Key Concepts for Problem Identification:

  • Health, Wellness, and Illness

  • Infection control

  • Spirituality and cultural diversities

  • Fluid and electrolyte balance

  • Mobility and safety

  • Self-esteem and psychosocial factors

  • And many others related to the patient’s well-being

Nursing Diagnosis and Patient Outcomes

• Relationship Understanding

  • Problems indicate desired outcomes (goals)

  • Etiology provides insight for interventions

Planning Process Overview

• Core Components

  • Selection and creation of standardized care plans

  • Individualization of plans based on patient needs

  • Establishing desired outcomes and goals

• Types of Planning

  • Initial Planning: Begins at first contact and written as soon as possible

  • Ongoing Planning: Adjustments made based on evaluations

  • Discharge Planning: Begins on initial assessment and considers continuity and self-care for the patient post-discharge

Importance of Care Plans

• Functions of Care Plans

  • Central source of information for nursing staff

  • Ensures completeness of care and continuity

  • Guides assessments and documentation

  • Meets accreditation standards

Types of Care Plans

• Variants in Care Plans Include

  • Preprinted, standardized plans

  • Nursing care plans derived from standardized nursing interventions

  • Integrated plans of care (IPOCs) and computerized plans

  • Student care plans for learning purposes

Developing Nursing Care Plans

• Step-by-Step Process

  • Create a problem list

  • Identify standardized plans applicable to problems

  • Adapt as necessary to develop individualized care plans

Planning Client Objectives

• Goals and Outcomes in Nursing

  • Goals: Desired changes in client health status

  • Nursing-sensitive outcomes influenced by nursing interventions

Short-Term vs Long-Term Goals

• Definitions

  • Short-Term Goals: Achievable within hours to days

  • Long-Term Goals: Targets set for weeks or months

Components of Nursing Outcomes Classification

• Key Elements

  • Outcome label

  • Associated indicators

  • Measurement scale

Planning Interventions

• Overview Steps:

  • Review diagnoses and outcomes

  • Select standardized interventions

  • Customize for patient needs

Standardized Intervention Language

• Key Languages Includes:

  • Nursing Interventions Classification (NIC)

  • Clinical Care Classification (CCC)

  • The OMAHA System

Writing Nursing Orders

• Key Components of a Nursing Order

  • Date of order

  • Subject of order

  • Action verb indicating the task

  • Terms defining time and limits of action

  • Signature of the nurse

Safe and Effective Nursing Care

• Core Principles

  • Provide patient-centered, goal-directed care

  • Ensure mutual goal-setting with client collaboration

  • Embrace the patient’s individual values and preferences

  • Implement evidence-based, holistic approaches to care

Implementation Phase

• Core Actions in Implementation

  • Execute care plans

  • Delegate tasks appropriately while maintaining accountability

  • Document and assess outcomes of delivered interventions

Delegation and Supervision

• Understanding Delegation

  • Transferring responsibility while retaining accountability

  • Essential to supervise and cannot delegate actions requiring independent nursing judgment

• Five Rights of Delegation:

  • Right task

  • Right circumstance

  • Right person

  • Right direction/examples

  • Right supervision

Documentation Procedures

• Final Implementation Step

  • Captures nursing actions and client responses in documentation

  • Important for continuous evaluation and communication among healthcare providers

Evaluating the Nursing Process

• Evaluation Overview

  • Involves assessing the effectiveness of interventions and determining client outcomes

  • Types of Evaluation:

  • Process: Review nursing actions

  • Outcomes: Assess client condition post-intervention

  • Structure: Evaluate care system design involving the interprofessional team

Evaluating Frequency and Timing

• Evaluation Methods Include:

  • Continuous evaluation during implementation

  • Immediate post-intervention assessment

  • Scheduled evaluations for ongoing care adjustments

  • Terminal evaluations prior to discharge

Client Progress Evaluation

• Key Actions in Evaluating Progress

  • Review outcomes and collect reassessment data

  • Judge goal achievement levels and record evaluative statements

  • Reassess collaborative challenges

Revising the Care Plan

• Signs for Revision

  • Align outcomes with interventions and evaluate current status

  • Revise plans based on evaluative outcomes

Checklist for Care Plan Evaluation

• Steps in the Evaluation Procedure include:

  • Review assessment data

  • Review nursing diagnosis

  • Review planned outcomes

  • Review planned interventions

  • Review implementation outcomes

Reflective Thinking in Evaluation

• Engaging in Self-Reflection

  • Analyze assumptions and behaviors during evaluations

  • Foster critical thinking by questioning evaluations

Quality Improvement in Healthcare

• Goals of Quality Improvement (QI)

  • To assess and enhance the quality of care delivered in a healthcare setting

  • Consider evaluation methodologies for structures, outcomes, and care processes

Nursing Strategies for Safe and Effective Care

• Responsibilities of Nurses

  • Provide evidence-based care that is patient-centered

  • Implement fair practices with inclusivity

  • Focus on patient satisfaction and compliance with both legal and accreditation standards