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