Timby/Smith: Introductory Medical-Surgical Nursing, 11/e Chapter 3:The Nursing Process

Nursing Process Systematic method to plan and implement care to achieve desired outcomes Problem-solving techniques and scientific process Framework for nursing care in all healthcare settings Nurse practice acts include nursing process in nursing definition. Organized structure of nursing curricula Basis for National Council Licensure Examination (NCLEX)

Steps of Nursing Process Five steps Assessment—collects data Diagnosis (analysis)—defines problems/needs Planning—establishes outcomes to achieve goals Implementation—plans into action Evaluation—responses to care

Nursing Process—(cont.) Systematic method to plan and implement care to achieve desired outcomes

Nursing Process—(cont.) Assessment Purpose: collect information Determines abnormal function and risk factors as well as client strengths Obtains data about client’s health and illness Client database Medical and nursing history, physical examination, and diagnostic studies

Nursing Process—(cont.) Nursing diagnosis Purpose: analyzes data and defines health problems LPN/LVN reports information. Actual and potential health problems RNs examine and analyze data to formulate nursing diagnoses. NANDA—classification system for problems and diagnoses

Nursing Diagnostic Statement Nursing diagnosis—(cont.) Three parts Name/label of the problem Cause of the problem Signs and symptoms

Nursing Diagnosis Four types Actual—identify existing problems Example: Urinary Retention or Anxiety Health promotion—client’s motivation and behavior Example: Ineffective Health Maintenance Risk—potential problems Example: Risk for Impaired Skin Integrity Syndrome—specific diagnoses Example: Disuse Syndrome

Question Your patient has a diagnosis of rheumatoid arthritis. While making the patient’s plan of care, which nursing diagnosis would be most applicable to this patient? A) Self-Care Deficit related to fatigue and joint stiffness B) Urinary Retention related to narcotic pain medication C) Risk for Depression related to inactivity D) Fluid Volume Deficit related to nausea

Answer A) Self-Care Deficit related to fatigue and joint stiffness Rationale: Actual nursing diagnoses identify existing problems and are derived from data gathered by assessing the client.

Nursing Process—(cont.) Planning Purpose: setting priorities, defining desired outcomes (goals), determining interventions, and recording plan of care Encourage client and family participation. Establishing priorities Maslow’s hierarchy of needs Five levels: physiologic, safety and security, love and belonging, esteem and self-esteem needs, self-actualization

Question Maslow proposed five levels of need and grouped them according to motivation. Which client need is of primary importance? A) Breathing easy B) Being safe from falling C) Liking the nurse D) Recognizing surroundings

Answer A) Breathing easy Rationale: The first-level needs, sometimes called baseline survival needs, have the highest priority. These activities, such as eating, breathing, and drinking, sustain life.

Nursing Process—(cont.) Nursing expected outcomes Outcomes: specific, realistic, and measurable Client-centered outcomes; developed with client and family and healthcare providers Derived from nursing diagnosis Achievable with client’s available resources Time estimate for achievement; short- or long-term Direction for continuity of care

Question A patient comes to the emergency department complaining of severe chest pain. The nurse asks the patient questions and takes vital signs. Which step of the nursing process is the nurse demonstrating? A) Assessing B) Diagnosing C) Planning D) Implementing

Answer A) Assessing Rationale: Assessing is the step in which nurses assess the patient to determine the need for nursing care. When assessing, the nurse systematically collects patient data.

Nursing Process—(cont.) Interventions Purpose: actions for achieving outcomes Written as nursing orders Specific and compatible with medical orders Documentation functions Communicates care Shows trends in client status Creates legal document Supplies validation for reimbursement

Nursing Process—(cont.) Evaluation Purpose: assessment and review of care and client’s response to care Compare actual outcome to expected outcome. Conclusions: outcomes are met or not met Outcome achieved; problem solved; nursing orders discontinued Outcome is not met; plan of care continued or revised.

Nursing Process—(cont.) Evaluation—(cont.) Outcome is not achieved; plan requires reevaluation Reasons Unrealistic expectations Incorrect diagnosis of problem Development of additional problems Ineffective nursing measure Premature target date

Question What phase of the nursing process is the nurse in when he determines a medication is effective and documents this in the medication record? A) Analysis B) Evaluation C) Assessment D) Data Collection

Answer B) Evaluation Rationale: Evaluation allows the nurse to determine the patient’s response to the nursing interventions and the extent to which the goal has been achieved.

Nursing Process and Critical Thinking Intentional, contemplative, and outcome-directed thinking Guided by standards, based on nursing process, identifies key problems, applies logic, calls for strategies, and constant reevaluation Makes nurses efficient and effective Scientific problem solving in a systematic, client- centered, outcome-based thinking

Question Which of the following is a true statement about critical thinking in nursing? A) It involves purposeful, outcome-directed thinking. B) It shows outcomes for client care. C) It makes judgments based on assessment data. D) It provides justification for actions.

Answer A) It involves purposeful, outcome-directed thinking. Rationale: Critical thinking assists nurses to identify client problems and develop and implement plans of care with a logical, purposeful, and outcome-based method.

Nursing Process and Critical Thinking—(cont.) Concept care mapping Links important ideas Organizes data Considers all client’s problems as a whole Steps of nursing process Shows interrelationships Dependent on assessment skills