Nursing Process

Dr . Mohamed idriss
 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”
 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
 Scientific Method of problem
solving
• ID problem
• Collect data
• Form hypothesis
• Plan of action
• Hypothesis testing
• Interpret results
• Evaluate findings
 Advantages of Nursing Process
• Provides individualized • Develops a clear and
care efficient plan of care
• Client is an active • Provides personal
participant satisfaction as you see
• Promotes continuity of client achieve goals
care • Professional growth as
• Provides more effective you evaluate
communication among effectiveness of your
nurses and healthcare interventions
professionals
5 Steps in the Nursing Process
• Assessment
• Nursing
Diagnosis
• Planning
• Implementing
• Evaluating
 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
 Assessment-collecting
data
• Nursing Interview (history)
• Health Assessment -Review of Systems
• Physical Exam
• Inspection
• Palpation
• Percussion
• Auscultation
 Assessment-collecting
data
• Make sure information is complete &
accurate
• Validate prn
• Interpret and analyze data
Compare to “standard norms”
• Organize and cluster data
 Example of Assessment
• 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”
 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
 Nsg Dx vs MD Dx
• Within the scope of • Within the scope of
nursing practice medical practice
• Identify responses to • Focuses on curing
health and illness pathology
• Can change from day • Stays the same as long
to day as the disease is
present
 Formulating a Nursing Diagnosis
• Composed of 3 parts:
• Problem statement- the client’s response to a problem
• Etiology- what’s causing/contributing to the client’s
problem
• Defining Characteristics- what’s the evidence of the
problem
 Nursing Diagnosis
• Problem( Diagnostic Label)-based on your assessment of
client…(gathered information), pick a problem from the
NANDA list...
• Etiology- determine what the problem is caused by or
related to (R/T)...
• Defining characteristics- then state as evidenced by
(AEB) the specific facts the problem is based on...
 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”.
 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.
 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
 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.
 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
 Planning
Developing a goal and outcome statement
EXAMPLE
• Goal:
• Goal and outcome Client will achieve
statements are client therapeutic management of
focused. disease process….
• Worded positively • Outcome Statement:
• Measurable, specific AEB B/P readings of
observable, time-limited, 110-120 / 70-80 and client
and realistic statement of understanding
• Goal = broad statement importance of dietary sodium
restrictions by day of
• Expected outcome = discharge.
objective criterion for
measurement of goal
• Utilize NOC as standard
 Planning- Types of goals
• Short term goals
• Long term goals
• Cognitive goals
• Psychomotor goals
• Affective goals
 Goals are patient-centered and
SMART
Specific
Measurable
Attainable
Relevant
Time Bound
Pt will walk 50 ft.
Pt will eat 75% of meal
Pt will be OOB 2-4hrs
Pt will maintain HR<100
Pt will state pain level is acceptable 6 (0-10)
•
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.
 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
 Implementation
• 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
 Implementing- “Doing”
• Teach potential
• Monitor VS q4h complications of
• Maintain prescribed diet hypertension to instill
(2 Gm Na) importance of
maintaining Na
• Teach client amount of restrictions
sodium restriction, foods
high in sodium, use of • Assess for cultural
nutrition labels, food factors affecting dietary
preparation and sodium regime
substitutes
 Implementing – “Doing”
• Teach client importance
• Teach the client- of life style changes:
hypertension can’t (weight reduction,
be cured but it can smoking cessation,
be controlled. increasing activity)
• Remind the client to • Stress the importance of
continue medication ongoing follow-up care
even though no S/S even though the patient
are present. feels well.
 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.
 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?
 Evaluation

Factors that impede goal attainment:

• Incomplete database
• Unrealistic client outcomes
• Nonspecific nsg interventions
• Inadequate time for clients to achieve outcomes.
 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
 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.
 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
 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?”
 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
 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