Fundamentals of Nursing - The Nursing Process
The Nursing Process
Primary Goals of Nursing
Determine client/family responses to health problems, wellness level, and need for assistance.
Provide physical and emotional care, teaching, guidance, and counseling.
Implement interventions for 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 the patient’s story:
Primary source: direct communication with the client and family.
Consideration: clients may be unable to verbally communicate their story, but their physical state can provide information.
The Nursing Process Defined
A way of thinking and acting based on the scientific method.
A tool to identify patient problems and an organized method to meet patients’ needs.
Components of the Nursing Process
Assessment (data collection)
Nursing diagnosis
Planning
Implementation
Evaluation
Critical Thinking and Clinical Judgment
Critical Thinking:
Create and evaluate ideas.
Analyze data.
Anticipate problems.
Use expansive thinking.
Reflect on experience.
Construct plans and determine desired outcomes.
Clinical Reasoning:
Reliable observations regarding health status and draw conclusions from data.
Clinical Judgment:
Outcome of clinical reasoning.
Conclusion/decision made by 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 your 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 the assessment data.
Identify potential health problems.
Problems identified during the process are specific nursing diagnoses.
Nursing diagnoses prioritized and entered into the nursing plan of care.
Nursing Diagnosis Details
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 in collaboration
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 Details
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
Example Goal Statements
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 performing 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 Actions
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 met
Continue current plan
Inactivate
When goals are not met:
revise the plan
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