RN Process
Nursing Process Overview
The nursing process is a systematic approach used by nurses to ensure effective care and includes five main components:
Assessment
Diagnosis
Planning
Implementation
Evaluation
Planning Outcomes
Nursing Process and Planning
Formal Planning:
Defined as a conscious, deliberate activity involving decision-making, critical thinking, and creativity.
Engages the patient and family in discussing the plan to achieve specific outcomes.
Informal Planning:
Takes place concurrently with other phases of the nursing process.
Example: During a routine procedure, a patient might disclose issues affecting their health, prompting the nurse to adjust the care plan.
Types of Planning
Initial Planning:
Initiated during the first meeting with the patient, often with incomplete data.
Ongoing Planning:
Involves continuous evaluations and adjustments based on the patient’s status.
Discharge Planning:
Needs to start at admission, considering various factors, including:
Expected discharge date.
Patient's physical condition and function.
Emotional state.
Financial situation.
Availability of caregivers.
Environmental needs.
Community services.
Continuity of care to maintain current function.
Policies, Procedures, and Protocols
Policies & Procedures:
Handle recurring situations like blood transfusions, catheter removal, and central line care.
Protocols:
Set guidelines for specific situations or conditions, including nursing interventions for scenarios like hypoglycemia or chest pain.
Nursing Care Plans
Basic Needs and Activities of Daily Living (ADLs):
Include medical treatment and nursing diagnoses or collaborative concerns regarding:
Social discharge needs.
Teaching needs.
Standardized Care Plans
May be printed or computerized:
Can contain medical orders, especially in collaborative care settings.
Organized by nursing diagnoses.
Triggered by documentation in the patient's chart.
Utilized to save time, ensure consistency of care, and prevent oversight.
Creating a Care Plan
Steps to create a care plan:
Make a working problem list.
Determine manageable problems with standardized care plans or critical pathways.
Individualize the standardized plan as necessary.
Transcribe medical orders into appropriate documents.
Document ADLs and basic care needs in the patient care summary (Kardex or EMR).
Develop individualized care plans for problems not covered by standardized documents.
Prioritization
Essential to set correct priorities while creating a care plan:
Consider the patient’s priorities and potential biases.
Evaluate the course of medical treatment.
Be aware of patient’s resource availability.
Patient Goals/Outcomes
Expected outcomes are crucial as they:
Guide nursing interventions.
Provide patients with clear targets.
Serve as the foundation for the evaluation phase.
Components of a goal statement:
Subjective statement.
Action verb.
Performance criteria.
Target time (short-term or long-term).
Special conditions if needed.
Client Outcomes
Must include:
An outcome label indicating the broad expected result.
Indicators to evaluate patient responses.
A measurement scale may be included for specific outcomes.
Interventions in Nursing
Nursing Interventions:
Actions based on clinical judgment aimed at achieving client outcomes:
Direct Care Interventions: Direct actions towards the patient.
Indirect Care Interventions: Supportive measures that do not involve the patient directly.
Types of Interventions
Independent Interventions:
Conducted by nurses autonomously without MD prescriptions.
Dependent Interventions:
Prescribed by a physician or APRN, such as medication administration and treatments.
Interdependent Interventions:
Carried out in collaboration with other health care team members.
Choosing Interventions
Reference resources include:
ANA standards, nursing theories, nursing research, and evidence-based practice.
Consider diagnosis and expected changes, as well as patient or family capabilities within their limits.
Relationship of Problem Status to Intervention Type
Different problem statuses require varied interventions:
Actual Nursing Diagnosis:
To detect changes in status (improvement, condition exacerbation).
Potential (Risk) Nursing Diagnosis:
To prevent complications.
Wellness Diagnosis:
Assess to maintain wellness.
Interventions Flow from Desired Outcomes
Example goals and interventions:
Goal 1: Will have a bowel movement within 12 hours after receiving stool softener and laxative.
Goal 2: Will have daily soft, formed bowel movements during hospital stay.
Interventions include administering prescribed medications and educating on dietary changes.
Reflection Prior to Intervention
Reflect on:
Did anything get overlooked?
What might the intervention cause?
Personal confidence in completing the intervention.
Knowledge and skill adequacy.
Correctness of ordered interventions.
Nursing Orders
Key components of nursing orders:
Date of writing and revision.
Subject statement of what the nurse will do.
Action verbs indicating the actions taken.
Specific times and limits for when actions will occur.
Example: "Nurse will reposition patient q2hrs."
Rationales for each intervention must be documented in care plans.
Delegation
Definition: The RN may transfer responsibility for tasks to nursing assistive personnel while retaining accountability for outcomes.
Governed by ANA and Nurse Practice Act standards for delegation.
5 Rights of Delegation
Right Task
Right Circumstance
Right Person
Right Direction/Communication
Right Supervision/Evaluation
Evaluation in the Nursing Process
Evaluation is a planned, ongoing, and systematic process to determine:
Whether the goals were met and if the treatment was effective.
If care should be modified, continued, or terminated.
Types of Evaluation
Ongoing Evaluation: After each patient interaction.
Intermittent Evaluation: Conducted at specific intervals.
Terminal Evaluation: At discharge.
Outcome Evaluation: Assessing any changes in patient’s status.
Steps of Evaluation
Review outcomes.
Collect reassessment data.
Judge goal achievement.
Record evaluative statements.
Evaluate collaborative problems.
Relate outcomes to interventions.
Draw conclusions about problem status and plan next actions.
Example of Evaluation Statement
Nursing Diagnosis: Urinary retention related to neurologic impairment secondary to diabetes.
Evaluation statement: The patient had no bladder distention; however, there was a post-void residual of 100 mL. Short-term goal partially met; continue with goals and care plan, long-term goals not met.
Terminology:
Nurse-initiated/independent interventions: Nurses use evidence and scientific rationale to take autonomous actions to benefit clients. They base these actions on identified problems and health care needs, and make sure they are within their scope of practice. Nurses perform or delegate the interventions and are accountable for them. An example is repositioning a client at least every 2 hr to prevent skin breakdown.
Collaborative interventions: These involve cooperation with other healthcare professionals to ensure comprehensive care, such as coordinating with physical therapy to enhance mobility and prevent complications.
Provider-initiated/dependent interventions: Interventions nurses initiate as a result of a provider’s prescription (written, standing, or verbal) or the facility’s protocol (blood administration procedures).
Sources of Data:
Primary Source:
- Subjective: What the pt states
- Objective: What the RN observes, physical assessments, vital signs, diagnostic tests, and any clinical findings.
Secondary Source:
- Subjective: What other RN’s say or what the PT told them
- Objective: data the RN collected from other sources ex. pt friends/family, medical records, literature review, caregivers, HC professionals
Other Info:
The nursing care plan (NCP) is the end product of the planning step. Nurses organize the NCP for quick identification of problems, outcomes, and interventions to implement.