Nursing Process

• Steps to the Nursing Process: Assessment, Diagnosis, Planning, Implement, Evaluation
• Nursing process is a systematic way to provide care to patients
• Critical Thinking in Assessment:

  • Sources of data: Patient (interview, observation, physical examination), Family and significant others, Health care team, Medical records, Scientific literature, Database, EMR
  • Methods for collecting patient data: Subjective data (include patient feelings, perceptions, & reported symptoms), Objective data (What the nurse see, hear, touch, Behavior observation, clinical signs, diagnostic & lab results)
• Types of assessments:

  • Patient-centered interview (conducted during a nursing history)
  • Periodic assessments (conducted during ongoing contact with patients)
  • Each type of assessment is either comprehensive or problem focused
• Critical Thinking/Clinical Judgment in Assessment:

  • Nurses use judgement and critical thinking when interpreting their patient’s story
  • Essential for safe, efficient, and skillful nursing intervention
  • Help to ensure optimal patient outcomes
• Collecting Assessment Data:

  • Nurses must have some knowledge to recognize cues for diseases
  • Talk to the patient for the best source of data collection
  • Subjective data: verbal descriptions, feelings, what the patient states
  • Objective data: clinical signs, what you see, hear, touch
• The Patient-Centered Interview:

  • Different ways to communicate with patients: Observation, Open-ended questions, Direct closed-ended questions, Leading questions, Back channeling, Probing
• Diagnosis:

  • A clear label or term that is familiar to all health care providers involved in a patient’s care is necessary to understand a patient’s needs
  • Medical diagnoses: disease condition (Ex: respiratory failure, heart failure, COPD)
  • Nursing diagnoses: term that describes a patient’s response or vulnerability to health condition (Ex: Ineffective airway clearance, Impaired Gas Exchange, impaired mobility)
• Formulating a Nursing Diagnosis Statement:

  • Identify the correct diagnostic label or diagnosis with associated defining characteristics, risk factors and related factor
  • A related factor allows you to individualize a nursing diagnosis for a specific patient
• Components of Planning Patient Care:

  • Knowledge, Environment, Experience, Standards, Attitudes
• Critical Thinking in Planning:

  • Set a Goal: a broad statement that describes the desired change in a patient’s condition, perceptions, or behavior
  • Expected outcome: an expected conclusion to a health problem, measurable change that must be achieved to reach a goal
• Establishing Priorities:

  • Plan care arranged by priorities: High, intermediate, low based on the ABCs (airway, breathing circulation)
  • Consider each patient’s unique situation
  • Avoid classifying only physiological nursing diagnoses as high priority
• Nursing goal must be patient-centered and use SMART acronym:

  • Specific, Measurable, Attainable, Realistic, Timed
• Nurse-initiated:

  • Independent actions that a nurse initiates, autonomous actions by the nurse
  • Health care provider initiated: Dependent actions that require an order from a physician or other health care professional
  • Collaborative: Interdependent actions that require combined knowledge, skill, and expertise of multiple health care professionals
• Evaluation:

  • Compare clinical data, patient behavior measures, and patient self-report measures collected before implementation with the evaluation findings gathered after administering nursing care
  • Evaluate whether the results of care match the expected outcomes and goals set for a patient
• Nurses implement care to meet patient goals

  • Priorities help nurses to anticipate and sequence nursing interventions