Nursing Process NUR101 Fall 2008 Lecture #6 and #7

Nursing Process
Fall 2008
Lecture #6 and #7
K. Burger, MSEd, MSN, RN, CNE
PPT By: Sharon Niggemeier RN MSN
Revised KBurger 8/06
Revised JBorrero 09/08
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
 Client is an active
 Promotes continuity of
 Provides more effective
communication among
nurses and healthcare
 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
5 Steps in the Nursing Process
 Assessment
 Nursing
 Planning
 Implementing
 Evaluating
 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
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
Assessment-collecting data
 Make sure information is complete &
 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
 Within the scope of  Within the scope of
nursing practice
medical practice
 Identify responses  Focuses on curing
to health and illness
 Can change from
 Stays the same as
day to day
long 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
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
 Wellness
Family coping: potential for growth RT
unexpected birth of twins.
Collaborative Problems
 Require both nursing interventions and medical
EXAMPLE: Client admitted with medical dx of
Collaborative problem = respiratory insufficiency
Nsg interventions: Raise HOB, Encourage C&DB
MD interventions: Antibiotics IV, O2 therapy
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
 Rank as high,
intermediate or low
 Client specific
 Priorities can change
Developing a goal and outcome statement
 Goal and outcome
statements are client
 Worded positively
 Measurable, specific
observable, time-limited,
and realistic
 Goal = broad statement
 Expected outcome =
objective criterion for
measurement of goal
 Utilize NOC as standard
 Goal:
Client will achieve
therapeutic management
of disease process….
 Outcome Statement:
AEB B/P readings of
110-120 / 70-80 and client
statement of
understanding importance
of dietary sodium
restrictions by day of
Planning- Types of goals
 Short term goals
 Long term goals
 Cognitive goals
 Psychomotor goals
 Affective goals
Goals are patient-centered and
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
Interventions – 3 types
 Independent ( Nurse initiated )- any
action the nurse can initiate without direct
 Dependent ( Physician initiated )-nursing
actions requiring MD orders
 Collaborative- nursing actions performed
jointly with other health care team members
 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”
 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
 Teach potential
complications of
hypertension to instill
importance of
maintaining Na
 Assess for cultural
factors affecting
dietary regime
Implementing – “Doing”
 Teach the clienthypertension can’t be
cured but it can be
 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.
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.
 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
Factors that impede goal attainment:
Incomplete database
Unrealistic client outcomes
Nonspecific nsg interventions
Inadequate time for clients to achieve
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
 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.
 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
 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
 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?”
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
Nursing diagnoses are aimed at identifying
client problems that are treatable by
 A.The physician
 B.The nurse
 C.Invasive techniques
 D.Complementary strategies