Nursing Process - Analysis, Planning, Implementation, and Evaluation

Identify components of a nursing analysis or patient problem statement and a goal statement.
Summarize the meaning of interventions, implementation, and evaluation when prioritizing nursing care.

Using critical thinking skills.
Interpretation of data, lab results, radiological results, subjective and objective data.
Identification of specific patient problems, risks, strengths, and formulating the patient problem statement.
Difference between a medical diagnosis and a nursing diagnosis or a nursing problem.
- Medical diagnosis: Labels the illness, identifies the cause, and describes the disease process; it is never used in the nursing problem statement.
- Nursing problem: Defines the patient's response to the illness or problem, based on actual or potential health problems.
Interventions are learned through education and experience.

A judgment or conclusion resulting from assessment and data collection.
Involves comparing data and identifying cues or deviations from the normal.
Clustering cues to generate hypotheses, then identify gaps and inconsistencies.
Requires knowledge of pathophysiology which is the study of physical and biological abnormalities in the body that occur because of a condition or disease.
Pathophysiology: Considered the foundation of nursing practice.
- Helps outline a nurse's main responsibilities, such as:
  - Assisting in the treatment of acute and chronic illnesses.
  - Managing medications.
  - Assisting with diagnostic tests.
  - Managing general healthcare and disease prevention for patients and their families.
Nurses use pathophysiology to understand the progression of disease in order to identify the disease and implement treatment options for their patients.
Nurses use the information that they find to identify the next course of the disease so that they can provide their patient with the appropriate care they need.

Nursing problem.
Related factors or etiology (cause of the problem).
Defining characteristics.
Problem related to what, as evidenced by what?
Two types of patient problems:
- Actual: Condition is currently present, based on signs and symptoms (priority need).
- Potential: Problem may develop (risk factors present); no signs/symptoms yet.

Five steps to formulate a nursing analysis:
1. Highlight or underline the relevant symptoms.
2. Make a short list of the symptoms.
3. Cluster similar symptoms.
4. Analyze or interpret the symptoms.
5. State a patient problem that aligns with related factors and defining characteristics.
Most critical problems receive the highest priority.
Using Maslow's hierarchy of needs, physical needs are addressed first; safety is also a priority.
Maslow's Hierarchy of Needs: Physiological needs (breathing) come first.

Step three of the nursing process: planning.
Determine the appropriate way to solve or decrease the effect of the problem.
Begins with the first patient contact.
Patients should participate actively whenever possible (patient-centered care).
Three types of planning: Immediate, ongoing, and discharge or long-term.
Steps involved in planning:
- Setting priorities
- Identifying your goals
- Planning your nursing interventions

Priority one: ABCs + V (airway, breathing, cardiac/circulation, vital signs, lab values).
Priority two: Classic changes in mental status, untreated medical problems, pain, urinary elimination problems.
Priority three: Health problems that don't fit into the first two (activity, rest, family coping, lack of knowledge).

What do you hope to achieve or accomplish with your patient?
Must be specific, realistic, measurable, and patient-centered.
Designed to remedy, solve, or decrease the problem.
Statement providing a description of specific and measurable behavior that the patient will be able to show in a given time frame.
Two types of goals:
- Long-term: Takes weeks or months (rehab or long-term care).
- Short-term: Achievable within 7-10 days or before discharge.
Developed from a problem, client/patient-centered, and measurable.
Avoid vague terms like "increase" or "improve."
Measurable and realistic, considering the patient's capabilities.
Accomplished by a targeted date.

Subject (the patient)
Verb (a desired behavior or action) - measurable action verbs (define, describe, list, ambulate).
Condition (when, what, where, how)
Time frame (dates and times)

Example: The patient will be able to ambulate with a walker 100 feet by 1/23/24 at 0700.

Patient will ambulate 25 feet with a walker by 1/31/24 at 0700.
Patient will drink 2500 milliliters of fluid daily by 1/15/24 at 1700.
Client will ambulate 50 feet with a walker and assistance of one by 1/31/24 at 1300.

Activities chosen by the nurse to lead to the accomplishment of the patient goal/outcome.
Patient-centered: The patient is involved and makes decisions about their own care.
Individualized to the patient.
Independently carried out by the nurse; do not require a provider order.
Developed to eliminate or reduce the cause of the problem.
Clearly state your nursing action, keep patient safety in mind, and ensure it agrees with other therapies.
Must be specific for the patient to do, based on nursing knowledge, within the legal scope of practice, and must help achieve the goal that is set for the patient.
Must include a rationale or scientific reasoning.
Example: Turn and reposition every 2 hours; continuous pressure on body areas compresses tissue and obstructs blood flow, and keeping the client turned will decrease continuous pressure to one area.

The nursing process is a cyclical critical thinking process.
The nursing process is a dynamic, continuous, client-centered, problem-solving decision-making framework.
The nursing process provides a framework for applying knowledge, experience, judgment, and skills to a plan of care.
The nursing process promotes professionalism in nursing while differentiating the practice of nursing from other healthcare professionals.