Brief Overview of Nursing Process Gail Ladwig MSN, RN, CHTP Mosby items and derived items © 2011 by Mosby, Inc., an affiliate of Elsevier Inc.

2 Introduction  History: labeled “Nursing Process” in 1950  How nurses: Think Identify patient problems Determine patient outcomes Prioritize patient care Introduction

3 Mosby items and derived items © 2011 by Mosby, Inc., an affiliate of Elsevier Inc. Critical Thinking  Nurse uses critical thinking in all steps  Process includes client  Respect confidentiality; follow HIPAA laws HIPAA lawsHIPAA laws

4 Mosby items and derived items © 2011 by Mosby, Inc., an affiliate of Elsevier Inc. Steps of Nursing Process  Five-step process: based on the scientific process  The acronym ADPIE is a useful way to remember the steps of the nursing process 1. A = Assessment 2. D = (Nursing) Diagnosis 3. P = Plan 4. I = Implementation 5. E = Evaluation

5 Mosby items and derived items © 2011 by Mosby, Inc., an affiliate of Elsevier Inc. Step One: Assessment  Follow format used by facility/educational setting  Identify yourself, then gather necessary information  Perform a physical assessment  Obtain an accurate history  Review medical records and diagnostic tests  Collaborate with entire health care team and client's significant other if appropriate

6 Mosby items and derived items © 2011 by Mosby, Inc., an affiliate of Elsevier Inc. Step Two: Nursing Diagnosis  Two-part system  Nursing Dx (label from NANDA-I list)  “Related to” statement (what is contributing to the nursing diagnosis?)  Three-part system  P(roblem) (label from NANDA-I list)  E(tiology)/"related to" factor (what is contributing to the nursing diagnosis?)  S(ymptom) (signs and symptoms, or as NANDA-I describes them, defining characteristics, taken from assessment information)

7 Mosby items and derived items © 2011 by Mosby, Inc., an affiliate of Elsevier Inc. How to Make a Nursing Diagnosis  Look for common patterns in the assessment  Cluster or group common patterns  Verify defining characteristics  Identify possible nursing Dx  Use critical thinking skills to determine accurate Dx Ask: "Does client information match NANDA-I information?" Ask: "Does client information match NANDA-I information?" Ask: "Is it important to the client?" Ask: "Is it important to the client?"

8 Mosby items and derived items © 2011 by Mosby, Inc., an affiliate of Elsevier Inc. “Related to” Phrase or Etiology  Etiology  Relationship to nursing Dx  Types of nursing Dx  Independent nursing Dx  Collaborative nursing Dx

9 Mosby items and derived items © 2011 by Mosby, Inc., an affiliate of Elsevier Inc. Defining Characteristics Phrase  Signs and symptoms (s/s) identified in assessment  The phrase as evidenced by (AEB) may be used to connect the etiology (r/t) with the defining characteristics  Example  Activity intolerance r/t generalized weakness AEB c/o fatigue and SOB with activity

10 Mosby items and derived items © 2011 by Mosby, Inc., an affiliate of Elsevier Inc. Writing a Nursing Dx Statement  P — Choose the label  Nursing Dx  E — Write an r/t phrase  Etiology  S — Write the defining characteristics  Signs and symptoms

11 Mosby items and derived items © 2011 by Mosby, Inc., an affiliate of Elsevier Inc. Step Three: Planning  Prioritizing nursing Dx  Maslow’s hierarchy Maslow’s hierarchy Maslow’s hierarchy  Outcomes  Interventions based on evidence

12 Mosby items and derived items © 2011 by Mosby, Inc., an affiliate of Elsevier Inc. Outcomes  Developed as a result of priority nursing Dx  Influenced by nursing interventions  Measurable  Compared with baseline over time  Client involvement

13 Mosby items and derived items © 2011 by Mosby, Inc., an affiliate of Elsevier Inc. Outcomes (Continued)  Nursing outcomes classifications (NOC)  Definition  Uses five-point Likert-type rating scale  Assists in recording change after intervention  Increases client motivation to achieve outcomes  When writing an outcome statement, ask:  Is it client centered?  Is it measurable?  What is the time frame?  Is it relevant to the nursing diagnosis and client symptoms?

14 Mosby items and derived items © 2011 by Mosby, Inc., an affiliate of Elsevier Inc. Interventions  Clear interventions = Successful client outcomes  Evidence-based nursing = Effective interventions  Use interventions based on research  Best practices = Best care and outcomes

15 Mosby items and derived items © 2011 by Mosby, Inc., an affiliate of Elsevier Inc. Interventions (Continued)  Independent  Collaborative  Nursing intervention classification (NIC)  Comprehensive  Standardized  Covers all nursing specialties

16 Mosby items and derived items © 2011 by Mosby, Inc., an affiliate of Elsevier Inc. Putting It All Together  Write the care plan  Prioritize nursing Dx  Outcomes  Interventions  Document and share

17 Mosby items and derived items © 2011 by Mosby, Inc., an affiliate of Elsevier Inc. Step Four: Implementation  Initiation of care plan  Performing interventions  Assessing effectiveness  Documentation

18 Mosby items and derived items © 2011 by Mosby, Inc., an affiliate of Elsevier Inc. Step Five: Evaluation  Continuous process  Constant evaluation of outcomes  Attainable?  Correct nursing Dx?  Intervention changes needed?  Time frame appropriate?  Constant evaluation of evidence

19 Mosby items and derived items © 2011 by Mosby, Inc., an affiliate of Elsevier Inc. Summary  ADPIE  Do you remember all the steps?  Did it work?  What can you, should you change?  Can you do it again?  What did you learn? CONGRATULATIONS. YOU HAVE JUST COMPLETED THE NURSING PROCESS!