Fundamentals of Nursing: The Nursing Process

The Nursing Process

Primary Goals of Nursing

  • Determine client/family responses to health problems, wellness levels, and needs for assistance.
  • Provide physical and emotional care, teaching, guidance, and counseling.
  • Implement interventions aimed at prevention, client needs, and health goals.

The Patient’s Story

  • The "patient's story" includes objective and subjective information about the client.
  • Sources for obtaining patient’s story:
    • Primary source: direct communication with the client and their family.
    • Physical state: even if unable to communicate verbally, the client's physical state can tell their story.

The Nursing Process

  • A way of thinking and acting based on the scientific method.
  • Used to identify patient problems and to meet patient needs in an organized way.

Components of the Nursing Process

  • Assessment (data collection)
  • Nursing diagnosis
  • Planning
  • Implementation
  • Evaluation

Critical Thinking and Clinical Judgment

  • Critical Thinking:
    • Creating and evaluating ideas.
    • Analyzing data.
    • Anticipating problems.
    • Using expansive thinking.
    • Reflecting on experience.
    • Constructing plans and determining desired outcomes.
  • Clinical Reasoning:
    • Reliable observations regarding health status and drawing conclusions from data
  • Clinical Judgement:
    • The outcome of clinical reasoning.
    • A conclusion/decision made using clinical reasoning skills.

Priority Setting and Work Organization

  • Priority Setting (Prioritizing):
    • Placing nursing diagnoses/interventions in order of importance.
    • High priority.
    • Medium priority.
    • Low priority.

Assessment

  • Collecting, organizing, documenting, and validating a patient’s health data.
  • Data gathered from:
    • Client (physical assessment and interview).
    • Family.
    • Physician.
    • Medical record.

Analysis of Assessment Data

  • Abnormal data drives nursing diagnoses.
  • Identify abnormal data.
  • Related data are grouped or clustered.
  • Identify missing data.
  • Inferences are made regarding the patient’s problems.

Nursing Diagnosis

  • Sorting and analyzing assessment data.
  • Identifying potential health problems.
  • Problems identified are specific nursing diagnoses.
  • Nursing diagnoses are prioritized and entered into the nursing plan of care.

Nursing Diagnosis

  • A nursing diagnosis statement indicates:
    • Client’s actual health status or the risk of a problem developing.
    • The causative or related factors.
    • Specific defining characteristics (signs and symptoms).
    • NANDA-I nursing diagnoses.

Nursing Diagnosis Format

  • Complete Statement:
    • PROBLEM: Nursing Diagnosis.
    • RELATED TO: Etiology (cause).
    • AS EVIDENCED BY: Defining characteristics (signs/symptoms).
    • Example: Constipation R/T medication use AEB infrequent passage of stool and hard, dry stool.

2-Part Format for POTENTIAL Problem

  • Since it’s a POTENTIAL problem, there is no AEB (signs/symptoms).
    • Risk for (problem).
    • RELATED TO ETIOLOGY.
    • EXAMPLE: RISK FOR INFECTION R/T BREAK IN SKIN INTEGRITY.

Etiologic Factors

  • Causes of the problem.
  • Signs:
    • Abnormalities that can be verified by repeat examination and are objective data.
  • Symptoms:
    • Data the patient has said are occurring that cannot be verified by examination; symptoms are subjective data.

Prioritization of Problems

  • Problems ranked according to their importance.
  • Physiologic needs for basic survival take precedence.
  • After physiologic needs are met, safety problems take priority.

Planning

  • Nurse and the client collaborate.
  • Set priorities and goals to eliminate, diminish, or control identified problems.
  • Goals should be stated with specific outcomes.
  • Choose specific interventions to enable the client to meet the specific outcomes listed in the plan of care.

Planning

  • Sets measurable short-term and long-term goals.
  • MUST be realistic and attainable for the patient.
  • Goals/outcomes – what we want to achieve through nursing intervention.

Format of a Goal Statement

  • Subject:
    • Patient
  • Action Verb:
    • Will demonstrate, describe, apply
  • Time:
    • By discharge, within 24 hours

Goal Statements - Examples

  • Will ambulate to the nurses’ station, using cane, unassisted by 2/15/16.
  • Will describe system for taking medication by 2/15/16.
  • Will verbalize pain level of less than 3 (on a 0-10 pain scale) 30-60 minutes after each pain management intervention.

Planning - Interventions

  • Alleviate problems
  • Achieve expected outcomes
  • Give medications and perform ordered treatments
  • Individualize to the patient's needs

Implementation

  • Carrying out nursing interventions prioritized during the planning process.
  • Some interventions may be delegated or carried out by other members of the health care team.

Implementation

  • Independent nursing actions
  • Dependent nursing actions
  • Interdependent nursing actions
  • Nursing interventions (nursing orders) are carried out

Implementation in Long-Term Care

  • Delegation to nursing assistants
  • Exercise interventions performed by nursing assistants, physical therapy aides, or restorative aides
  • Medications
    • May be administered by LVNs/LPNs or nursing assistants with certification in medication administration
  • Nurse performs any invasive or sterile procedure

Documentation of the Nursing Process

  • Medications administered, dressings changed, vital signs measured, position changes
  • Intervention/procedures not documented are considered not performed
  • Each intervention must be documented in the patient’s chart

Evaluation

  • Assessing the patient to evaluate his or her response to the nursing interventions
  • Evaluate progress toward goal
  • Patient/family opinions considered
  • Continual process
  • Determines if nursing plan of care needs to be changed

Revising the Care Plan

  • When goals are not met
  • When goals are met
    • Continue current plan
    • Inactivate

Responsibility for the Nursing Care Plan

  • If patient admitted to long-term care facility when RN is not available, LPN/LVN may assemble a preliminary nursing care plan that an RN will review and validate as needed the next day
  • RN may construct the initial nursing care plan

Constructing a Care Plan

  • Collect patient data
  • Analyze data for potential problems
  • Choose appropriate nursing diagnoses
  • Rank the diagnoses in order of priority
  • Write goals and expected outcomes
  • Select appropriate nursing interventions
  • Implement nursing interventions
  • Evaluate outcomes