1. Nursing Process

2. Nursing Process Specific to the nursing profession
A framework for critical thinking
It’s purpose is to:
“Diagnose and treat human responses to actual or potential health problems”

3. Nursing Process Organized framework to guide practice
Problem solving method - client focused
Systematic- sequential steps
Goal oriented- outcome criteria
Dynamic-always changing, flexible
Utilizes critical thinking processes
1. Lets the nurse dev. A plan of care for the client and gives the nurse direction
2. Helps determine the client’s problems and ways to help the client overcome these problems
3.Based on 5 specific steps which need to be completed in order
4. Based on goals to determine if client’s needs have been met. Designed on monitoring the outcomes of the process
5. Continually looked at, reviewed, and changed based on the client’s condition
6. Guides the nurse to assist the client with reaching their greatest level of health

4. Advantages of Nursing Process
Provides individualized care
Client is an active participant
Promotes continuity of care
Provides more effective communication among nurses and healthcare professionals
Develops a clear and efficient plan of care
Provides personal satisfaction as you see client achieve goals
Professional growth as you evaluate effectiveness of your interventions

5. 5 Steps in the Nursing Process
Assessment
Nursing Diagnosis
Planning
Implementing
Evaluating
Each step needs to be completed before we can progress further in the process

6. Assessment First step of the Nursing Process
Gather Information/Collect Data
Primary Source - Client / Family
Secondary Source - physical exam, nursing history, team members, lab reports, diagnostic tests…..
Subjective -from the client (symptom)
“I have a headache”
Objective - observable data (sign)
Blood Pressure 130/80
Form a data base on information collected about the client

7. Assessment
To elicit as many symptoms as possible, the nurse should use open-ended rather than yes/no questions.
Examples:
“Describe what you are feeling”
“How long have you been feeling this way?”
“When did the symptoms start?”
“Describe the symptoms”
This type of questions will encourage the client to give more information about his or her situation.
Listen carefully for cues and record relevant information.

8. Assessment-collecting data
Nursing Interview (history)
Health Assessment -Review of Systems
Physical Exam
Inspection
Palpation
Percussion
Auscultation
Methods of data collection
Nurse client interview-health history
Physical exam inspection
Palpation
Percussion
ausculation

9. Assessment-collecting data
Make sure information is complete & accurate
Validate prn
Interpret and analyze data Compare to “standard norms”
Organize and cluster data

10. Example ofAssessment
Obtain info from nursing assessment, history and physical (H&P) etc…...
Client diagnosed with hypertension
B/P 160/90
2 Gm Na diet and antihypertensive medications were prescribed
Client statement “ I really don’t watch my salt” “ It’s hard to do and I just don’t get it”
Based on this assessment we can see one factor effecting the client’s uncontrolled hypertension is lack of maintaining sodium intake restrictions. Which one of these is subjective and objective

11. Nursing Diagnosis Second step of the Nursing Process
Interpret & analyze clustered data
Identify client’s problems and strengths
Formulate Nursing Diagnosis (NANDA : North American Nursing Diagnosis Association)-Statement of how the client is RESPONDING to an actual or potential problem that requires nursing intervention
Nursing Dx is a problem statement of how the client is RESPONDING to a problem…it may be an actual or potential problem
Interpreted data is clustered inaccording to body systems, risk factors, family factors,emotional fectors etc.

12. Diagnosis Statement
A working of nursing diagnosis may have two or three parts.
The three-part system consists of the nursing diagnosis, the “related to” statement, and the defining characteristics.
PES system:
P (problem) - The nursing diagnosis, the label; a concise term or phrase that represent a pattern of related cues
E (etiology) – “Related to” phrase or etiology; related cause or contributor to the problem
S (symptoms) –Defining characteristics phrase; symptoms that the nurse identified in the assessment

13. Nsg Dx vs MD Dx Within the scope of medical practice
Within the scope of nursing practice
Identify responses to health and illness
Can change from day to day
Within the scope of medical practice
Focuses on curing pathology
Stays the same as long as the disease is present

14. Example of Nursing Dx Ineffective therapeutic regimen management
R/T difficulty maintaining lifestyle changes and lack of knowledge
AEB B/P= 160/90, dietary sodium restrictions not being observed, and client statements of “ I don’t watch my salt” “It’s hard to do and I just don’t get it”.
Based on our assessment of the client with hypertension who wasn’t following the prescribed low salt diet this is an example of a nsg dx.
First part is the clients problem taken from the NANDA list
Second part is a reason why the client has the problem
Third part is the evidence of the problem

15. Types of Nursing Diagnoses
Actual Imbalanced nutrition; less than body requirements RT chronic diarrhea, nausea, and pain AEB height 5’5” weight 105 lbs.
Risk Risk for falls RT altered gait and generalized weakness
Wellness Family coping: potential for growth RT unexpected birth of twins.

16. Case study:
A 73-year-old man has been admitted to the unit with a diagnosis of chronic obstructive pulmonary disease (COPD). He states that he has “difficulty breathing when walking short distances”. He also states that his “heart feels like it is racing” at the same time. He states that he is “tired all the time”, and while talking to you he is continually wringing his hands and looking out the window.

17. Step II: Nursing Diagnosis Part 1 (Problem)
Interpretation of information:
“difficulty breathing when walking short distances”= dyspnea
“heart feels like it is racing”= dysrythmia
“tired all the time”= fatigue
In Section II we can find the nursing diagnosis Activity intolerance listed with these symptoms.

18. Step II: Nursing Diagnosis
To validate that the diagnosis Activity intolerance is appropriate for the client, we have to read NANDA definition of the nursing diagnosis.
When reading, ask Does this definition describe the symptoms demonstrated by the client? If the appropriate nursing diagnosis has been selected, the definition should describe the condition that has been observed.

19. Activity intolerance NANDA Definition
Insufficient physiological or psychological energy to endure or complete required or desired daily activities.
Defining Characteristics
Verbal report of fatique or weakness; abnormal heart rate or blood pressure response to activity; exertional discomfort or dyspnea; electrocardiografic changes reflecting dysrhytmias or ischemia
Related factors (r/t)
Bed rest or immobility; generalized weakness,; sedentary lifestyle; imbalance between oxygen supply and demand

20. Part 2 (Etiology) “Reated to” Phrase
This phrase states what may be causing or contributing to the nursing diagnosis, commonly referred to as the etiology.
Ideally the etiologe, or cause, of the nursing diagnosis is something that can be treated by a nurse. When this is the case, the diagnosis is identified as an independent nursing diagnosis. If medical Intervention is also necessary, it might be identified as a collabarative diagnosis.
For each suggested nursing diagnosis, the nurse should refer to the statements listed under the heading “Related Factors”

21. Part 3 (Symptoms) Defining Characteristic phrase
It consist of the signs and symptoms that have been gathered during the assessment phase. Signs and symptoms are labeled as defining characteristics in Section III.
The use of identifying defining characteristics is similar to the process the physician uses when making a medical diagnosis

22. Writing a Nursing Diagnosis Statement
P - Activity intolerance E – “Related to” imbalance between oxygen supply and demand S – Verbal reports of fatique, exertional dyspnea (“difficulty breathing when walking”), and dysrythmia (“racing heart ”)

23. Collaborative Problems
Require both nursing interventions and medical interventions
EXAMPLE: Client admitted with medical dx of pneumonia
Collaborative problem = respiratory insufficiency
Nsg interventions: Raise HOB, Encourage C&DB
MD interventions: Antibiotics IV, O2 therapy

24. Planning Third step of the Nursing Process
This is when the nurse organizes a nursing care plan based on the nursing diagnoses.
Nurse and client formulate goals to help the client with their problems
Expected outcomes are identified
Interventions (nursing orders) are selected to aid the client reach these goals.
Now that we have a nsg dx we need a plan to help this client
Goals allow us to determine the specific outcome desired by the client
Short term- goal in which a specific time frame with date ie Able to identify 20 foods which are low in sodium within 2 days
Long term goal in which desired outcome is expected in a broader time frame ie Client be able to develop a daily meal plan based on 2 Gm Na restrictions by the end of the monthl
Cognitive goal - goal in which client gains new knowledge ie able to correctly identify foods high and low in sodium
Pyschomotor goal- goal in which client’s acquire a new skill ie client able to correctly monitor B/P using stethoscope and sphygmomanometer
Affective goal - goal in which the client’s values or attitudes change ie client able to accept the need for maintaining life time dietary changes to control B/P
Interventions are nursing orders that you are empowered to select based on your judgement of the client’s needs
Prioritize most important goals first

25. Planning – Begin by prioritizing client problems
Prioritize list of client’s nursing diagnoses using Maslow
Rank as high, intermediate or low
Client specific
Priorities can change
Pt. Have many dx…..need to prioritize

26. Planning Developing a goal and outcome statement
Goal and outcome statements are client focused.
Worded positively
Measurable, specific observable, time- limited, and realistic
Goal = broad statement
Expected outcome = objective criterion for measurement of goal
Utilize NOC as standard
EXAMPLE
Goal:
Client will achieve therapeutic management of disease process….
Outcome Statement:
AEB B/P readings of / and client statement of understanding importance of dietary sodium restrictions by day of discharge.
NOC = nursing outcome classification

27. Planning- Types of goals
Short term goals
Long term goals
Cognitive goals
Psychomotor goals
Affective goals

28. Goals are patient-centered and SMART
Specific Measurable Attainable Relevant Time Bound

29. Goals PT. will walk 50 ft. Pt. will eat 75% of meals
Pt. will be OOB 2-4 Hrs.
Pt. will maintain HR <100
To will state pain level is acceptable 6 (0-10)

30. Planning-select interventions
Interventions are selected and written.
The nurse uses clinical judgment and professional knowledge to select appropriate interventions that will aid the client in reaching their goal.
Interventions should be examined for feasibility and acceptability to the client
Interventions should be written clearly and specifically.
Be specific clearly state what teaching is needed, materials to be used etc
Utilize research and evidence based practice protocols

31. Interventions – 3 types
Independent ( Nurse initiated )- any action the nurse can initiate without direct supervision
Dependent ( Physician initiated )-nursing actions requiring MD orders
Collaborative- nursing actions performed jointly with other health care team members

32. Implemention The fourth step in the Nursing Process
This is the “Doing” step
Carrying out nursing interventions (orders) selected during the planning step
This includes monitoring, teaching, further assessing, reviewing NCP, incorporating physicians orders and monitoring cost effectiveness of interventions
Utilize NIC as standard
NIC = nursing intervention classification

33. Implementing- “Doing”
Teach potential complications of hypertension to instill importance of maintaining Na restrictions
Assess for cultural factors affecting dietary regime
Monitor VS q4h
Maintain prescribed diet (2 Gm Na)
Teach client amount of sodium restriction, foods high in sodium, use of nutrition labels, food preparation and sodium substitutes
Teaching may be given to client as well as family members…state this in the nursing interventions
Specific handouts, dietary consults etc all would be included

34. Implementing – “Doing”
Teach the client- hypertension can’t be cured but it can be controlled.
Remind the client to continue medication even though no S/S are present.
Teach client importance of life style changes: (weight reduction, smoking cessation, increasing activity)
Stress the importance of ongoing follow-up care even though the patient feels well.

35. Evaluation- To determine effectiveness of NCP
Final step of the Nursing Process but also done concurrently throughout client care
A comparison of client behavior and/or response to the established outcome criteria
Continuous review of the nursing care plan
Examines if nursing interventions are working
Determines changes needed to help client reach stated goals.
Is the goal met and problem resolved?
Is goal not yet reached but progress being made and care ongoing?
Is goal not met and revisions needed to the care plan?

36. Evaluation Outcome criteria met? Problem resolved!
Outcome criteria not fully met? Continue plan of care- ongoing.
Outcome criteria unobtainable- review each previous step of NCP and determine if modification of the NCP is needed.
Were the nsg interventions appropriate/effective?

37. Evaluation Factors that impede goal attainment: Incomplete database
Unrealistic client outcomes
Nonspecific nsg interventions
Inadequate time for clients to achieve outcomes.

38. Checkpoint Identify which stage of the nursing process
is being described below:
The nurse writes nursing interventions
A goal is agreed upon
The nurse performs a physical assessment
A revision is made to the NCP
The nurse administers antibiotic medication
A statement is written that outlines the clients response to a potential health problem
Planning
Assessment
Implementation
Diagnosis

39. S and O Data Quiz RR 22/min, even unlabored
“I can only walk 3 blocks before my legs start to hurt”
Pain rated 3 on a scale of 0-10
Skin pink, warm and dry
Urine output 300mL/8 hr
“My wife doesn’t come to visit very often”
Dressing clean, dry and intact.

40. NCLEX Time
The nurse records the following subjective data in the client’s medical record:
A.Breath sounds clear to auscultation
B.Amber urine in sufficient quantities
C.Pain intensity 8 out of 10
D.Skin warm and dry

41. NCLEX Time
When interviewing a client, the nurse uses the following open-ended style sentence:
A.Do you have any concerns right now?
B.Is your family worried about you being in the hospital?
C.How many times do you get up to go to the bathroom at night?
D.What do you mean when you say, “I don’t feel quite right?”

42. NCLEX Time
In order for an actual nursing diagnosis to be valid it must have one or more supporting:
A.Laboratory results
B.Diagnostic data
C.Defining characteristics
D.Medical diagnoses

43. NCLEX Time
Nursing diagnoses are aimed at identifying client problems that are treatable by _______.
A.The physician
B.The nurse
C.Invasive techniques
D.Complementary strategies