nursing process 2023-24
Nursing Process
Definition of Nursing
Nursing is the protection, promotion, and optimization of health and abilities.
It involves the prevention of illness and injury, alleviation of suffering, and advocacy in the care of individuals, families, communities, and populations.
Purpose of Nursing Process
Think like a nurse
Organized and systematic way of thinking about nursing care
Establish plans to meet patient needs
Standard of care for assessing patients and creating plans of action
Effective communication among nurses
Delivery of high-quality evidence-based care
Systematic approach to patient care
Legal protection for nurses
Steps of Nursing Process
Assessment (Systematic data collection)
Collecting data through interview, observation, and examination
Types of assessment: comprehensive, focused, ongoing, emergency, time-lapsed
Sources of data: patient, family members, friends, health team members, health record
Types of data: current, historical, objective, subjective
Methods of data collection: observation, interview, laboratory, physical examination, health history
Diagnosis (Identify patient strengths and problems)
Nursing diagnoses are the basis for nursing care plans
Different from medical diagnosis
Collaborative problems require both medical and nursing interventions
Planning (Specify desired patient goals and develop a plan of individualized care)
Implementation (Interventions to meet expected outcomes)
Evaluation (Evaluate the effectiveness of the plan of care)
Formats for Writing Nursing Diagnoses
Problem statement
Etiology (related factors)
Defining characteristics
Examples of Nursing Diagnoses
Deficient fluid volume: Diarrhea, dry skin, dryness of the mouth
Ineffective airway clearance: Pneumonia
Disturbed body image: Amputation
Risk for unstable blood glucose: Type 2 Diabetes Mellitus
Impaired urinary elimination: Post-op Prostatectomy
Self-care deficit: Dressing Cerebrovascular Accident
Collaborative Problems
Require both medical and nursing interventions
Nursing aspect focused on monitoring the client's condition and preventing potential complications
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Components of a NANDA-I Nursing Diagnostic Statement
Qualifiers + Focus
"related to (rt) Etiology / Related Factors
Defining Characteristics / "as evidenced by" (a.e.b.)
Problem / Diagnostic Label
Risk Factors
Example
Qualifier: Acute Pain
Focus: Etiology / Related Factor
Defining Characteristics / Diagnostic Label
Risk Factors
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Qualifier
Focus of the Diagnosis
Deficient Fluid volume
Imbalanced Nutrition: Less Than Body Requirements
Impaired Gas Exchange
Ineffective Breathing pattern
Risk for Injury
Structure of nursing diagnosis label
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The NANDA-International system of nursing diagnosis provides four categories.
A- Actual diagnosis: a statement about a health problem that the patient has.
B- Risk diagnosis: a statement about health problems that a patient doesn't have yet, but is at a higher than normal risk of developing in the near future. (risk for)
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Nursing Diagnosis Actual or Potential problems identified
Actual: actual evidence of signs/symptoms of diagnosis exist. (Altered skin integrity, Fluid Volume Deficit)
Potential/Risk for Diagnosis: client’s database contains risk factors of diagnosis, but no true evidence (Risk for altered skin integrity or Fluid Volume Deficit)
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NANDA NURSING DIAGNOSIS Last updated August 2009, "=new diagnosis 2009-2011
Activity/Rest-ability to engage in necessary/desired activities of life (work and leisure) and to obtain adequate sleep/rest
Post trauma syndrome, risk for
Nutrition: imbalanced, more than body requirements
Autonomic dysreflexia, risk for
Communication, impaired verbal
Powerlessness, risk for
Self mutilation, risk for
Divisional activity, deficit
Nutrition, readiness for enhanced
Skin integrity, impaired
Fatigue
Relocation stress syndrome
Confusion, acute
Insomnia
Swallowing, impaired
Sudden infant death syndrome, risk for
Mobility: bed, impaired
Dentition, impaired
Mobility: physical, impaired
Gastro Environmental interpretation
Mobility: wheelchair, impaired
Infant behavior, disorganized
Sleep deprivation
Self-esteem, chronic low
Infant behavior, organized, readiness for enhanced
Trauma, risk for
Self-esteem, risk for situational low
Growth and development
Mobility: bed, impaired
*Resilience, impaired individual
Confusion, chronic
Suffocation, risk for
Mobility: physical, impaired
*Resilience, readiness for enhanced
Gastro Environmental interpretation
Suicide, risk for
Mobility: wheelchair, impaired
*Resilience, risk for compromised
*Jaundice, neonatal
Syndrome, impaired
Surgical recovery, delayed
Sedentary lifestyle
Self concept, readiness for enhanced
Liver function, impaired, risk for
Infant behavior, disorganized
Thermoregulation, ineffective
Sleep, readiness for enhanced
Self concept, readiness for enhanced
Oral mucous membrane, impaired
Confusion, acute, risk for
Sudden infant death syndrome, risk for
Mobility: bed, impaired
*Resilience, impaired individual
Confusion, chronic
Suffocation, risk for
Mobility: physical, impaired
*Resilience, readiness for enhanced
Gastro Environmental interpretation
Suicide, risk for
Mobility: wheelchair, impaired
*Resilience, risk for compromised
*Jaundice, neonatal
Syndrome, impaired
Surgical recovery, delayed
Sedentary lifestyle
Self concept, readiness for enhanced
Liver function, impaired, risk for
Infant behavior, disorganized
Thermoregulation, ineffective
Sleep, readiness for enhanced
Self concept, readiness for enhanced
Oral mucous membrane, impaired
Confusion, acute, risk for
Sudden infant death syndrome, risk for
Mobility: bed, impaired
*Resilience, impaired individual
Confusion, chronic
Suffocation, risk for
Mobility: physical, impaired
*Resilience, readiness for enhanced
Gastro Environmental interpretation
Suicide, risk for
Mobility: wheelchair, impaired
*Resilience, risk for compromised
*Jaundice, neonatal
Syndrome, impaired
Surgical recovery, delayed
Sedentary lifestyle
Self concept, readiness for enhanced
Liver function, impaired, risk for
Infant behavior, disorganized
Thermoregulation, ineffective
Sleep, readiness for enhanced
Self concept, readiness for enhanced
Oral mucous membrane, impaired
Confusion, acute, risk for
Sudden infant death syndrome, risk for
Mobility: bed, impaired
*Resilience, impaired individual
Confusion, chronic
Suffocation, risk for
Mobility: physical, impaired
*Resilience, readiness for enhanced
Gastro Environmental interpretation
Suicide, risk for
Mobility: wheelchair, impaired
*Resilience, risk for compromised
*Jaundice, neonatal
Syndrome, impaired
Surgical recovery, delayed
Sedentary lifestyle
Self concept, readiness for enhanced
Liver function, impaired, risk for
Infant behavior, disorganized
Thermoregulation, ineffective
Sleep, readiness for enhanced
Self concept, readiness for enhanced
Oral mucous membrane, impaired
Confusion, acute, risk for
Sudden infant death syndrome, risk for
Mobility: bed, impaired
*Resilience, impaired individual
Confusion, chronic
Suffocation, risk for
Mobility: physical, impaired
*Resilience, readiness for enhanced
Gastro Environmental interpretation
Suicide, risk for
Mobility: wheelchair, impaired
*Resilience, risk for compromised
*Jaundice, neonatal
Syndrome, impaired
Surgical recovery, delayed
Sedentary lifestyle
Self concept, readiness for enhanced
Liver function, impaired, risk for
Infant behavior, disorganized
Thermoregulation, ineffective
Sleep, readiness for enhanced
Self concept, readiness for enhanced
Oral mucous membrane, impaired
Confusion, acute, risk for
Sudden infant death syndrome, risk for
Mobility: bed, impaired
*Resilience, impaired individual
Confusion, chronic
Suffocation, risk for
Mobility: physical, impaired
*Resilience, readiness for enhanced
Gastro Environmental interpretation
Suicide, risk for
Mobility: wheelchair, impaired
*Resilience, risk for compromised
*Jaundice, neonatal
Syndrome, impaired
Surgical recovery, delayed
Sedentary lifestyle
Self concept, readiness for enhanced
Liver function, impaired, risk for
Infant behavior, disorganized
Thermoregulation, ineffective
Sleep, readiness for enhanced
Self concept, readiness for enhanced
Oral mucous membrane, impaired
Confusion, acute, risk for
Sudden infant death syndrome, risk for
Mobility: bed, impaired
*Resilience, impaired individual
Confusion, chronic
Suffocation, risk for
Mobility: physical, impaired
*Resilience, readiness for enhanced
Gastro Environmental interpretation
Suicide, risk for
Mobility: wheelchair, impaired
*Resilience, risk for compromised
*Jaundice, neonatal
Syndrome, impaired
Surgical recovery, delayed
Sedentary lifestyle
Self concept, readiness for enhanced
Liver function, impaired, risk for
Infant behavior, disorganized
Thermoregulation, ineffective
Sleep, readiness for enhanced
Self concept, readiness for enhanced
Oral mucous membrane, impaired
Confusion, acute, risk for
Sudden infant death syndrome, risk for
Mobility: bed, impaired
*Resilience, impaired individual
Confusion, chronic
Suffocation, risk for
Mobility: physical, impaired
*Resilience, readiness for enhanced
Gastro Environmental interpretation
Suicide, risk for
Mobility: wheelchair, impaired
*Resilience, risk for compromised
*Jaundice, neonatal
Syndrome, impaired
Surgical recovery, delayed
Sedentary lifestyle
Self concept, readiness for enhanced
Liver function, impaired, risk for
Infant behavior, disorganized
Thermoregulation, ineffective
Sleep, readiness for enhanced
Self concept, readiness for enhanced
Oral mucous membrane, impaired
Confusion, acute, risk for
Sudden infant death syndrome, risk for
Mobility: bed, impaired
*Resilience, impaired individual
Confusion, chronic
Suffocation, risk for
Mobility: physical, impaired
*Resil
Nursing Process
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Nursing diagnoses provide the basis for selection of nursing interventions to achieve outcomes for which the nurse is accountable.
Nursing diagnosis is a standardized statement about the health of a patient for the purpose of providing nursing care.
Nursing diagnoses are developed during the course of performing the nursing assessments.
A clinical judgment about individual, family, or community responses to actual and potential health problems/life processes.
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Planning
Prioritization
Maslow's hierarchy
Specify outcomes
Realistic, measurable
Identify goals
Identify nursing/independent interventions
Document plan of care
Communicate plan of care
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Establishing Priorities
Maslow hierarchy of human needs
Patient preference
Anticipation of future problems
Critical thinking and reasoning
Priorities (very important) (pain, anxiety)
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Establishing Priorities
High priority
A life-threatening situation (bleeding, difficulty in breathing)
Something that needs immediate attention (preparing for a test)
Medium priority
Problems that could result in unhealthy consequences like physical or emotional impairments but not life-threatening
Fatigue, stress incontinence
Low priority
Problems that can be resolved easily with minimum interventions
Deficient knowledge regarding smoking cessation programs
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Writing goals/outcomes
Identifying outcome from nursing diagnoses
At least one outcome/goal
Involve patient and family
Cognitive, psychomotor and affective outcomes
Clinical, functional and quality of life outcomes
Culturally appropriate
Short term
Hours to days (less than a week)
Long term
Weeks to months
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Guidelines for writing goals (outcomes)
Specific
Measurable
Attainable (Achievable)
Realistic
Timed
Example: leaving the hospital 2 days after surgery without complication
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Outcome-Criteria
Subject – Who or some part of the patient
Verb - what actions the person will perform
Condition – under what circumstances person perform the action
Criteria – how well is the person to perform
Specific time – when is the person expected to perform
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Planning involves making plans to carry out the necessary interventions to achieve those goals.
Setting goals to improve the outcomes for the patient are a primary focus of the nursing process.
Based on the nursing diagnoses, what are the expectations for this patient? This is not about nursing goals. This is about improving the quality of life for the patient.
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Characteristics of the nursing care plan
It focuses on actions which are designed to solve or minimize the existing problem.
It is a product of a systematic process.
It relates to the future.
It is based upon identifiable health and nursing problems.
Its focus is holistic.
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Implementation
Carry out the plan of care (Action phase)
Nurse assumes responsibility
"Ongoing" assessment
Make revisions when necessary
All interventions should be patient-focused and outcome-directed!
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The nurse selects interventions based on:
Characteristics of the nursing diagnosis.
Expected outcomes.
Research base, or nursing knowledge/or interventions.
Feasibility of the intervention.
Acceptability to the patient.
Competencies of the nurse.
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All members of the health care team should be informed of the patient's status and nursing diagnosis, the goals and the plans.
They are also responsible to report back to the nurse all significant findings and to document their observations and interventions as well as the patient's response and outcomes.
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Types of Interventions
Nurse-initiated interventions (Independent nursing interventions)
No order needed
Elevate edematous legs
Physician-initiated interventions (Dependent nursing interventions)
Require an order
Administering of medications
Collaborative interventions (Interdependent nursing interventions)
In collaboration with other health care team members
Assist client with physical therapy exercises
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Example: Developing specific nursing interventions
Nursing interventions
Rationales
Position the patient in proper alignment and reposition 2 hourly
Prevent the development of complications associated with immobility
Provide assistive devices as required
Increase functional level
Teach ROM exercises
Increase circulation to leg and increase mobility
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Nursing Interventions
Rationales
Encourage the patient to take in fluid 2000 to 3000 mL/day, if not contraindicated medically
Sufficient fluid is needed to keep the fecal mass soft.
Assist patient to take at least 20 g of dietary fiber (e.g., raw fruits, fresh vegetable, whole grains) per day.
Fiber adds bulk to the stool and makes defecation easier because it passes through the intestine essentially unchanged.
Urge patient for some physical activity and exercise.
Movement promotes peristalsis.
Abdominal exercises strengthen abdominal muscles that facilitate defecation.
Provide Suppositories, or stool softeners
These laxatives soften stool and lubricate intestinal mucosa.
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Evaluation
Allows nurse to determine patient's response to interventions
Have outcomes been met? (Met, partially met, not met)
Identify the factors contributing to the success or failure
Document
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What the nurse can do after evaluation?
Terminate plan
Modify plan of care
Continue plan of care
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The Nursing Process
Outcome(s)
care
NURSING ASSESSMENT
DIAGNOSIS
PLANNING
EVALUATION
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Benefits of Using the Nursing Process
Promotes quality patient care.
Decreases omissions and duplications.
Provides a guide for all staff involved to provide consistent and responsive care.
Encourages collaborative management of a patient's health care problems.
Improves patient safety.
Improves patient satisfaction.
Saves time, energy, and frustration by creating a care plan or path to follow.
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The Whole Patient: The nursing process involves looking at the whole patient at all times. It personalizes the patient. It also forces the health care team to observe and interact with the patient, and not just the task they are performing such as a dressing change, or a bed bath.
Systematic. Ordered sequence of activities.
Dynamic. There is great interaction among each step.
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The process provides a roadmap that ensures good nursing care and improves patient outcomes.
Outcome-oriented. It determines which outcome is most important.
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The nursing process is an ongoing event.
Evaluation involves not only analyzing the success of the goals and interventions but examining the need for adjustments and changes as well.
Evaluation leads back to assessment and the whole process begins again.
The evaluation incorporates all input from the entire health care team, including the patient.
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Characteristics of the Nursing Process
Systematic
Dynamic
Interpersonal
Outcome-oriented
Universally applicable
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Historical Perspective:
1955-Lydia Hall first referred to nursing as a "process" in a journal article. Ms. Hall identified three steps of the nursing process: observation, administration of care, and validation.
1967-Yura and Walsh published the first comprehensive Book "Nursing Process" (assessment, planning, intervention, and evaluation).
1973- American Nurses Association congress published the first standards of practice to guide nursing performance.
1974- after the first meeting of the group now called the North American Nursing Diagnosis Association (NANDA). Nursing diagnosis was added as a separate step in the nursing process.
1958, Ida Jean Orlando started the nursing process.
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Taylor, Lllis, Lynn & LeMone., (2019). Fundamentals of Nursing, The Art and Science of Nursing Care. 9th Ed. Lipp