Fundamental Nursing Skills and Concepts Chapter 2

Definition of the Nursing Process An organized sequence of problem-solving steps used to identify and to manage the health problems of clients It is accepted for clinical practice established by the American Nurses Association

Characteristics of the Nursing Process Within the legal scope of nursing Based on knowledge-requiring critical thinking Planned-organized and systematic Client-centered Goal-directed Prioritized Dynamic

Steps of the Nursing Process Assessment Diagnosis Planning Implementation Evaluation

Assessment Systematic collection of facts or data

Types of Data Objective data-observable and measurable facts (Signs) Subjective data-information that only the client feels and can describe (Symptoms)

Sources of Data Primary source: Client Secondary source: Client’s family, reports, test results, information in current and past medical records, and discussions with other health care workers

Types of Assessments Data base assessment Focus assessment

Organization of Data Grouping of related information Organization of assessment data into small groups to be analyzed

Nursing Diagnosis Health issue that can be prevented, reduced, resolved, or enhanced through independent nursing measures Nursing Diagnosis Caregories: Actual Risk Possible Syndrome Wellness

Diagnostic Statements Name of the health-related issue or problem as identified in the NANDA list Etiology (its cause) Signs and Symptoms The name of the nursing diagnosis is linked to the etiology with the phrase “related to,” and the signs and symptoms are identified with the phrase “as manifested (or evidenced) by”

Collaborative Problems Physiologic complications whose treatment requires both nurse- and physician-prescribed interventions. They are an interdependent domain of nursing practice

Collaborative Problems-Nurse’s Responsibility Correlating medical diagnoses or medical treatment measures with the risk for unique complications Documenting the complications for which clients are at risk Making pertinent assessments to detect complications Reporting trends that suggest development of complications Managing the emerging problem with nurse- and physician-prescribed measures Evaluating the outcomes

Planning The process of prioritizing nursing diagnoses and collaborative problems, identifying measurable goals or outcomes, selecting appropriate interventions, and documenting the plan of care. The nurse consults with the client while developing and revising the plan.

Setting Priorities Determine problems that require immediate action Maslow’s Hierarchy of Human Needs

Short-Term Goals Outcomes achievable in a few days or 1 week Developed form the problem portion of the diagnostic statement Client-centered Measurable Realistic Accompanied by a target date

Long-Term Goals Desirable outcomes that take weeks or months to accomplish for client’s with chronic health problems

Goals for Collaborative Problems Goals for collaborative problems are written from a nursing rather than from a client perspective. The focus on what the nurse will monitor, report, record, or do to promote early detection and treatment.

Selecting Nursing Interventions Planning the measures that the client and nurse will use to accomplish identified goals involves critical thinking. Nursing interventions are directed at eliminating the etiologies. The nurse selects strategies based on the knowledge that certain nursing actions produce desired effects. Nursing interventions must be safe, within the legal scope of nursing practice, and compatible with medical orders.

Nursing Orders Directions for a client’s care Identifying what, when, where, and how for performing nursing interventions Nursing orders are signed to be accountable

Communicating The Plan The nurse shares the plan of care with nursing team members, the client, and client’s family. The plan is a permanent part of the record.

Implementation Carrying out the plan of care The nurse implements medical orders and nursing orders Implementation involves the client and one or more health care team The information in the chart shows a correlation between the plan and the care that has been provided. Nurses are accountable for carrying out nursing orders and physician orders.

Evaluation The way nurses determine whether a client has reached a goal. It is the analysis of the client’s response, evaluation helps to determine the effectiveness of nursing care.