FUNDA (NURSING PROCESS)

• Nursing process


  The cornerstone of the nursing profession, essential for the clinical application of knowledge and theory in nursing practice
• Evolution of the nursing process

  1. 3-step process

  2. 4-step process (APIE)

  3. 5-step process (ADPIE)

  4. 6-step process (ADOPIE) - Assessment, Diagnosis, Outcome Identification, Planning, Implementation and Evaluation
• Nursing process


  Synonymous with the problem-solving approach for discovering the healthcare and nursing care needs of clients, enabled nursing to build its own scientific body of knowledge and elevated nursing from a vocation into a profession
• This Block will help you acquire the necessary knowledge, skill and attitude for applying the nursing process, towards quality, comprehensive, ethical and humanistic care of clients
• Lydia Hall


  Originated the term Nursing Process in 1955, introduced three-steps: note observation, administration of care, validation
• Dorothy Johnson


  Introduced three steps of nursing process: assessment, decision, nursing action (1959)
• Ida Jean Orlando


  Identified three steps of nursing process: client's behavior, nurse's reaction, nurse's actions (1961)
• Yura and Walsh


  Suggested the four components of nursing process: assessing, planning, implementing and evaluating (1967)
• Knowles


  Described nursing process as discover, delve, decide, do, discriminate (1967)
• Innovations in the nursing process by American Nurses Association

  1. Diagnosis distinguished as separate step (1973)

  2. Diagnosis of actual and potential health problems delineated as integral part of nursing practice (1980)

  3. Outcome identification differentiated as a distinct step (1991)
• Nursing process


  • Organized
  • Systematic
  • Efficient
  • Goal-oriented
  • Effective
  • Humanistic care
• Characteristics of the nursing process

  • Problem oriented
  • Goal oriented
  • Systematic
  • Dynamic
  • Interpersonal
  • Creative
  • Cyclical
  • Universal
• Benefits of the nursing process for the patients

  • Quality patient care
  • Continuity of care
  • Respect for human dignity
• Benefits of the nursing process for the nurse

  • Consistent and systematic nursing education
  • Job satisfaction
  • Professional growth
  • Avoidance of legal action
  • Meeting professional nursing standards
  • Meeting standards of accredited hospitals
• Knowledge


  Broad and varied
• Skills

  • Manual
  • Intellectual
  • Interpersonal
• Caring behaviors


  • Inspiring someone/instilling hope and faith
  • Demonstrating patience, compassion and willingness to persevere
  • Offering companionship
  • Helping someone stay in touch with positive aspect of his life
  • Demonstrating thoughtfulness
  • Bending the rules when it really counts. Doing the "little things"
  • Keeping someone informed
  • Showing your human side by sharing "stories"
• Assessment


  1. Collecting, validating, organizing and recording data about the client's health status

  2. Purpose: To establish a data base

  3. Activities: Collection of data, Verifying/Validating data, Organizing data
• Types of data

  • Subjective data (symptoms)
  • Objective data (signs)
• Methods of data collection

  • Interview
  • Observation
• Sources of data


  • Primary: Patient/Client
  • Secondary: Family members, Significant Others, Patient's Record/Chart, Health Team Members, Related Literature
• Patient-centered interview


  Requires communication skills: Courtesy, Comfort, Connection, Confirmation
• Subjective data assessment

  • Nursing Health History - interview
• Objective data assessment

  • Physical Assessment
  • General Survey
  • Supplemental Data (Lab and Dx Exams)
• Diagnosing


  The clinical act of identifying problems, analyzing assessment information and deriving meaning from this analysis
• Nursing diagnosis


  A statement of client's potential or actual alteration of health status, using the critical-thinking skills of analysis and synthesis, in PRS/PES format
• Purposes of standard formal nursing diagnostic statement (NANDA)


  • Provides precise definition of a patient's responses to health problems
  • Allows nurses to communicate what they do
  • Distinguishes the nurse's role from other health care providers
  • Helps nurses focus on the scope of nursing practice
  • Fosters the development of nursing knowledge
  • Promotes creation of practice guidelines
• Types of nursing diagnoses

  • Problem-focused
  • Risk
  • Health promotion
• Critical thinking and the nursing diagnostic process


  1. Organize, cluster or group data

  2. Compare data against standards

  3. Analyze data after comparing with standards

  4. Identify gaps and inconsistencies in data

  5. Determine the client's health problems, health risk and strengths

  6. Formulate nursing diagnoses statements
• Organize, Cluster or Group Data

  1. Organize, Cluster or Group Data

  2. Compare data against standards

  3. Analyze data after comparing with standards

  4. Identify gaps and inconsistencies in data

  5. Determine the client's health problems, health risk and strengths

  6. Formulate Nursing Diagnoses statements
• Nursing Diagnosis


  A statement that describes a client's health problem that nurses can treat
• Correct Nursing Diagnoses


  • High risk for ineffective airway clearance related to thick, copious mucus secretions
  • High risk for injury related to disorientation
  • High risk for self-concept disturbance related to the effects of mastectomy (surgical removal of breast)
• Incorrect Nursing Diagnoses

  • High risk for ineffective airway clearance related to pneumonia
  • High risk for injury related to absence of side rails
  • Mastectomy related to cancer
• Identify only one patient problem in the nursing diagnosis
• Do not use the medical diagnosis for nursing diagnostic statement
• Do not use the medical diagnostic or procedure as related factor
• Planning


  1. Establishing priorities

  2. Setting goals and expected outcomes

  3. Planning nursing interventions appropriate for each diagnosis

  4. Writing a nursing care plan
• Priority


  Something that takes precedence in position, deemed the most important among several items
• Factors to consider when establishing priorities

  • Life-threatening situations should be given highest priority
  • Use the principle of ABC's (airway, breathing, circulation); airway should always be given the highest priority
  • Use Maslow's hierarchy of needs; Physiologic needs are given priority over psychosocial needs
  • Consider something that is very important to the client, e.g. pain, anxiety
  • Clients with unstable condition should be given priority over those with stable conditions
  • Consider the amount of time, materials, equipment required to care for clients
  • Actual problems take precedence over potential concerns
  • Attend to the client before equipment
• Nursing diagnoses priority levels

  • High-priority
  • Medium-priority
  • Low-priority