Nursing Process

• Process


  A series of planned actions or operations directed towards a particular result or goal
• Nursing Process


  A systematic, rational method of planning and providing individualized nursing

  
• Nursing Process

  1. Assessment

  2. Diagnosis

  3. Planning and outcome identification

  4. Implementation

  5. Evaluation

  
• Assessment


  The first step in the nursing process, a systematic and continuous collection, validation, and communication of patient data

  
• Nursing Assessment


  The deliberate and systematic collection of information about a patient to determine his or her current and past health and functional status and his or her present and past coping patterns

  
• Nursing Assessment


  1. Collection of information from primary and secondary sources

  2. Interpretation and validation of data

  
• Types of Assessment


  • Initial Assessment
  • Problem-Focused Assessment
  • Emergency Assessment
  • Time-Lapsed Assessment
• Subjective Data


  Data from client's point of view, including sensations, feelings, values, beliefs, attitudes, and perception of personal health status and life situations
• Objective Data


  Observable and measurable data, obtained through both physical examination and the results of lab and diagnostic testing
• Sources of Data


  • Primary source (client)
  • Secondary source (family, health care providers, medical records)
• Data Collection


  • Systematic and continuous
  • Includes past history and current problem
  • Can be subjective or objective
  • From primary or secondary source
• Data Collection Methods


  • Observation
  • Interviewing
  • Physical Assessment
• Observation


  Gathering data using senses (vision, smell, hearing, touch)
• Interviewing


  A planned communication or conversation with a purpose, including preparatory phase, introduction, working phase, and termination
• Physical Examination


  Systematic data-collection method using observation and inspection, auscultation, palpation, and percussion
• Validating Data


  The act of double checking, comparing with another source, differentiating between cues and inferences
• Cue


  Information directly observed by the nurse
• Inference


  Nurse's judgment or interpretation of cues
• Organizing Data


  Putting the data together in order to identify areas of the client's problems and strengths, using frameworks like nursing models or non-nursing models
• Interpreting Data

  Recognizing patterns of response or behavior, distinguishing relevant from irrelevant, determining gaps, identifying cause and effect, identifying functional and dysfunctional patterns
• Documenting Data

  Recording client data in a factual manner, including subjective data in client's own words, deciding what to immediately report and what to just record
• Diagnosis


  The second step in the nursing process, a clinical judgment about individual, family, or community response to actual or potential health problems/life processes

  
• Medical Diagnosis


  A clinical judgment by the physician that identifies or determines a specific disease, condition, or pathological state
• Nursing Diagnosis


  A problem statement consisting of the diagnostic label plus etiology, focusing on unhealthy responses to health and illness
• Nursing diagnoses may change from day to day as the patient's responses change, whereas medical diagnoses remain the same as long as the disease is present
• Diagnosis


  1. Statement or conclusion regarding the nature of a phenomenon

  2. Diagnostic labels are the standardized NANDA names

  3. Nursing diagnosis is the problem statement consisting of the diagnostic label plus etiology
• Clients have both nursing and medical diagnoses


  Medical diagnoses identify disease process whereas Nursing diagnoses focus on unhealthy responses to health and illness
• Medical diagnosis remains the same as long as the disease is present


  Nursing diagnosis may change from day to day as the patient's responses change
• Nursing diagnosis


  A clinical judgment about individual, family, or community responses to actual and potential health problems or life processes that the nurse is licensed and competent to treat

  
• Collaborative problems


  • Using both independent and physician-prescribed interventions
  • Monitoring the clients condition and preventing development of the potential complication
  • Present when a particular disease or treatment is present
• Types of nursing diagnoses

  • Actual nursing diagnosis
  • Risk nursing diagnosis
  • Health Promotion diagnosis
  • Syndrome nursing diagnosis
• Actual nursing diagnosis


  • Indicates that problem exists
  • Problem presents at the time of the assessment
  • Presence of associated signs and symptoms
  • Validated by the major defining characteristics

  
• Risk nursing diagnosis


  • Indicates that specific risk factors are present
  • Problem does not exist yet
• Health Promotion diagnosis


  • Clients' preparedness to implement behaviors to improve their health condition
  • Diagnosis labels begin with the phrase Readiness for Enhanced
• Syndrome nursing diagnosis


  Assigned by a nurse's clinical judgment to describe a cluster of nursing diagnoses that have similar interventions
• Components of NANDA nursing diagnosis

  • Problem statement (diagnostic label)
  • Etiology (related factors and risk factors)
  • Defining Characteristics (Cluster of signs and symptoms)
• Two-part nursing diagnosis (PE format)


  • Part one - problem statement or diagnostic label
  • Part two - etiology or the related cause or contributor to the problem
• Three-part nursing diagnosis (PES format)

  • Part one - diagnostic label / Problem
  • Part two - etiology
  • Part three - defining characteristics, or signs and symptoms, subjective and objective data, or clinical manifestations
• One-part statement


  Used for Health promotion (readiness for enhanced) and Syndrome Diagnosis
• Variations of basic format

  • Unknown etiology
  • Complex factors
  • Possible
  • Secondary
  • Other additions for precision like location