1. Copyright © 2009 Wolters Kluwer Health | Lippincott Williams & Wilkins Chapter 2 Nursing Process

2. Copyright © 2009 Wolters Kluwer Health | Lippincott Williams & Wilkins Definition of the Nursing Process Organized sequence of problem-solving steps Used to identify and manage the health problems of clients Accepted standard for clinical practice: American Nurses Association (ANA) Framework for nursing care

3. Copyright © 2009 Wolters Kluwer Health | Lippincott Williams & Wilkins Characteristics of the Nursing Process Within the legal scope of nursing Based on knowledge Planned Client centered Goal directed Prioritized Dynamic

4. Copyright © 2009 Wolters Kluwer Health | Lippincott Williams & Wilkins Assessment –First step of nursing process oSystematic collection of facts or data  Types of data  Objective data: observable and measurable facts, referred to as signs of disorder Steps of the Nursing Process

5. Copyright © 2009 Wolters Kluwer Health | Lippincott Williams & Wilkins Steps of the Nursing Process (cont’d) Assessment (cont’d) –Types of data (cont’d) oSubjective data: information only client feels and can describe; called symptoms –Sources of data: primary source–client; secondary sources–client’s family, reports, or discussion with other health care professionals

6. Copyright © 2009 Wolters Kluwer Health | Lippincott Williams & Wilkins Question Is the following statement true or false? Objective data, consisting of information that only the client feels and can describe, are called symptoms. An example is pain.

7. Copyright © 2009 Wolters Kluwer Health | Lippincott Williams & Wilkins Answer False. Objective data are observable and measurable facts and are referred to as signs of a disorder. Subjective data consists of information that only the client feels and can describe, and are called symptoms

8. Copyright © 2009 Wolters Kluwer Health | Lippincott Williams & Wilkins Steps of the Nursing Process (cont’d) Assessment (cont’d) –Types of assessment oData base assessment  Initial information: client’s physical, emotional, social, and spiritual health  Obtained during admission interview and physical examination

9. Copyright © 2009 Wolters Kluwer Health | Lippincott Williams & Wilkins Steps of the Nursing Process (cont’d) Assessment (cont’d) –Types of assessment (cont’d) oFocus assessment  Information: details about specific problems; expands original data base  Repeated frequently or on a scheduled basis

10. Copyright © 2009 Wolters Kluwer Health | Lippincott Williams & Wilkins Question Which of the following is a primary source for information? a. Client’s family b. Client c. Medical records d. Test results

11. Copyright © 2009 Wolters Kluwer Health | Lippincott Williams & Wilkins Answer b. Client The primary source for information is the client. The client’s family, test results, and medical records are secondary sources of information.

12. Copyright © 2009 Wolters Kluwer Health | Lippincott Williams & Wilkins Steps of the Nursing Process (cont’d) Assessment (cont’d) –Organization oInvolves grouping related information oNurses: organize assessment data; cluster related data using knowledge and past experiences

13. Copyright © 2009 Wolters Kluwer Health | Lippincott Williams & Wilkins Steps of the Nursing Process (cont’d) Diagnosis –Second step of the nursing process oIdentification of health-related problems oNursing diagnosis  Health issue that can be prevented, reduced, resolved, or enhanced through independent nursing measures

14. Copyright © 2009 Wolters Kluwer Health | Lippincott Williams & Wilkins Steps of the Nursing Process (cont’d) Diagnosis (cont’d) –Nursing diagnosis (cont’d) –Categorized into 5 groups: actual; risk; possible; syndrome; wellness oThe NANDA list  Authoritative organization for developing and approving nursing diagnoses

15. Copyright © 2009 Wolters Kluwer Health | Lippincott Williams & Wilkins Diagnosis (cont’d) –Nursing diagnosis (cont’d) oDiagnostic statement  Contains 3 parts:  Name of health-related issue or problem identified in the NANDA list Steps of the Nursing Process (cont’d)

16. Copyright © 2009 Wolters Kluwer Health | Lippincott Williams & Wilkins Steps of the Nursing Process (cont’d) Diagnosis (cont’d) –Nursing diagnosis (cont’d) oDiagnostic statement (cont’d)  Etiology (its cause): phrase “related to”  Signs and symptoms: phrase “as manifested (or evidenced) by”

17. Copyright © 2009 Wolters Kluwer Health | Lippincott Williams & Wilkins Steps of the Nursing Process (cont’d) Diagnosis (cont’d) –Nursing diagnosis (cont’d) oDiagnostic statement (cont’d)  Potential diagnoses: “risk for”  Uncertainty: “possible”  Wellness diagnoses: “potential for enhanced”

18. Copyright © 2009 Wolters Kluwer Health | Lippincott Williams & Wilkins Diagnosis (cont’d) –Nursing diagnosis (cont’d) oDiagnostic statement (cont’d)  Potential nursing diagnoses: signs or symptoms not manifested  Possible nursing diagnoses: data incomplete Steps of the Nursing Process (cont’d)

19. Copyright © 2009 Wolters Kluwer Health | Lippincott Williams & Wilkins Diagnosis (cont’d) –Nursing diagnosis (cont’d) oDiagnostic statement (cont’d)  Syndrome diagnoses and wellness diagnoses are one-part statements; they are not linked with an etiology or signs and symptoms Steps of the Nursing Process (cont’d)

20. Copyright © 2009 Wolters Kluwer Health | Lippincott Williams & Wilkins Diagnosis (cont’d) –Nursing diagnosis (cont’d) oCollaborative problem  Physiologic complications require both nurse- and physician- prescribed interventions  Written using the abbreviation potential complication (PC) Steps of the Nursing Process (cont’d)

21. Copyright © 2009 Wolters Kluwer Health | Lippincott Williams & Wilkins Planning –Third step of the nursing process oSetting priorities  Determine which problems require most immediate attention oEstablishing goals  Goal: expected or desired outcome Steps of the Nursing Process (cont’d)

22. Copyright © 2009 Wolters Kluwer Health | Lippincott Williams & Wilkins Planning (cont’d) –Establishing goals (cont’d) oShort-term goals:  Outcomes achievable in a few days to 1 week  Characteristics: developed from; client-centered Steps of the Nursing Process (cont’d)

23. Copyright © 2009 Wolters Kluwer Health | Lippincott Williams & Wilkins Planning (cont’d) –Establishing goals (cont’d) oShort-term goals (cont’d)  Characteristics (cont’d)  Measurable  Realistic  Target date for accomplishment Steps of the Nursing Process (cont’d)

24. Copyright © 2009 Wolters Kluwer Health | Lippincott Williams & Wilkins Planning (cont’d) –Establishing goals (cont’d) oShort-term goals (cont’d)  Characteristics (cont’d)  Predicted time  Time line for evaluation Steps of the Nursing Process (cont’d)

25. Copyright © 2009 Wolters Kluwer Health | Lippincott Williams & Wilkins Planning (cont’d) –Establishing goals (cont’d) oLong-term goals  Desirable outcomes take weeks or months to accomplish oGoals for collaborative problems  Written for the nurse Steps of the Nursing Process (cont’d)

26. Copyright © 2009 Wolters Kluwer Health | Lippincott Williams & Wilkins Planning (cont’d) –Establishing goals (cont’d) oGoals for collaborative problems (cont’d)  Focus: what the nurse will monitor, report, record, or do to promote early detection and treatment Steps of the Nursing Process (cont’d)

27. Copyright © 2009 Wolters Kluwer Health | Lippincott Williams & Wilkins Planning (cont’d) –Selecting nursing intervention oPlanning measures: to accomplish identified goals involves critical thinking oPlanned interventions: must be safe; within legal scope of nursing practice; and compatible with medical orders Steps of the Nursing Process (cont’d)

28. Copyright © 2009 Wolters Kluwer Health | Lippincott Williams & Wilkins Planning (cont’d) –Documenting plan of care oPlan of care: written by hand; standardized form; computer generated; based on an agency’s written standards or clinical pathways oNursing order: performing nursing interventions; providing specific instructions Steps of the Nursing Process (cont’d)

29. Copyright © 2009 Wolters Kluwer Health | Lippincott Williams & Wilkins Planning (cont’d) –Documenting plan of care (cont’d) oStandardized care plan: preprinted; computer generated oAgency-specific standards for care and clinical pathways: indicate activities provided to ensure quality, consistent care Steps of the Nursing Process (cont’d)

30. Copyright © 2009 Wolters Kluwer Health | Lippincott Williams & Wilkins Planning (cont’d) –Communicating the plan of care oNurses share plan with nursing team members, client, and the client’s family oPermanent part of client’s medical record placed in client’s chart; nurses refer to it, review it, and revise it Steps of the Nursing Process (cont’d)

31. Copyright © 2009 Wolters Kluwer Health | Lippincott Williams & Wilkins Implementation –Fourth step in the nursing process: carrying out the plan of care –Implementation of: oMedical records: legal evidence oRecord: quantity and quality of client response Steps of the Nursing Process (cont’d)

32. Copyright © 2009 Wolters Kluwer Health | Lippincott Williams & Wilkins Evaluation –Fifth and final step of the nursing process: nurses determine whether client has reached the goal –Analyze client’s response Steps of the Nursing Process (cont’d)

33. Copyright © 2009 Wolters Kluwer Health | Lippincott Williams & Wilkins Question Is the following statement true or false? Evaluation is the fifth and final step in the nursing process.

34. Copyright © 2009 Wolters Kluwer Health | Lippincott Williams & Wilkins Answer True. Evaluation, the fifth and final step in the nursing process, is the way by which nurses determine whether a client has reached a goal. The other steps in the nursing process are assessment, diagnosis, planning, and implementation.

35. Copyright © 2009 Wolters Kluwer Health | Lippincott Williams & Wilkins Use of the Nursing Process Standard for clinical nursing practice Nurse practice act –Holds nurses accountable for demonstrating all the steps in the nursing process –To do less implies negligence

36. Copyright © 2009 Wolters Kluwer Health | Lippincott Williams & Wilkins Concept Mapping Method of organizing information in graphic or pictorial form Formats used: spider diagram, hierarchy, linear flow chart Uses: –Enables students to integrate previous knowledge with newly acquired information

37. Copyright © 2009 Wolters Kluwer Health | Lippincott Williams & Wilkins Concept Mapping (cont’d) Uses (cont’d): –Increases critical thinking and clinical reasoning skills –Enhances retention of knowledge –Correlates theoretical knowledge with nursing practice –Helps students recognize information –Promotes better time management

38. Copyright © 2009 Wolters Kluwer Health | Lippincott Williams & Wilkins Concept Map Diagram Samples