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

2. 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)

3. 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

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

5. 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

6. 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

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

8. 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

9. 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

10. 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.

11. 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

12. 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

13. 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.

14. 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

15. 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

16. 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.

17. 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

18. 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.

19. 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

20. 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

21. 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.

22. 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

23. 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.

24. 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.

25. 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