Chapter 3- Nursing Process

• The nursing process


  1. Assessment

  2. Diagnosis

  3. Planning

  4. Implementation

  5. Evaluation
• The nursing process


  • Functions as a systematic guide to client-centered care
  • Employs a problem solving method of responding to the health care needs of the patients
• Critical thinking skills


  • Play a vital role in the development of patient care
• ADPIE


  Assessment, Diagnosis, Planning, Implementation, Evaluation
• Assessment


  1. Collection of Data

  2. Validation of data

  3. Organization of data

  4. Analyzing of data

  5. Recording/documentation of data
• Subjective data


  Information from the client's point of view or are described by the person experiencing it
• Objective data


  Those that can be detected observed or measured/tested using accepted standard or norm
• Sources of Data


  • Primary source
  • Secondary source
• Components of a Nursing Health History

  • Biographic data
  • Reason for visit/Chief complaint
  • History of present Illness
  • Past Health History
  • Family History
  • Review of systems
  • Lifestyle
  • Social data
  • Psychological data
  • Pattern of health care
• Cues


  Subjective or objective data observed by the nurse; it is what the client says, or what the nurse can see, hear, feel, smell or measure
• Inferences


  The nurse interpretation or conclusion based on the cues
• Gordon's Functional Health Patterns


  • Health perception-health management pattern
  • Nutritional-metabolic pattern
  • Elimination pattern
  • Activity-exercise pattern
  • Sleep-rest pattern
  • Cognitive-perceptual pattern
  • Self-perception-concept pattern
  • Role-relationship pattern
  • Sexuality-reproductive pattern
  • Coping-stress tolerance pattern
  • Value-belief pattern
• Diagnosis


  1. Data Analysis

  2. Problem Identification

  3. Formulation of Nursing Diagnosis
• Nursing Diagnosis


  A statement of a client's potential or actual health problem resulting from analysis of data
• Components of A nursing diagnosis

  • Problem statement/diagnostic label/definition
  • Etiology/related factors/causes
  • Defining characteristics/signs and symptoms
• Types of Nursing Diagnosis

  • Actual Nursing Diagnosis
  • Potential Nursing diagnosis
• Therefore may be written as 2-Part or a 3-Part statement
• Types of Nursing Diagnosis

  • Actual Nursing Diagnosis
  • Potential Nursing diagnosis
  • Risk Nursing diagnosis
• Actual Nursing Diagnosis


  A client problem that is present at the time of the nursing assessment, based on the presence of signs and symptoms
• Actual Nursing Diagnosis


  • Imbalanced Nutrition: Less than body requirements r/t decreased appetite nausea
  • Disturbed Sleep Pattern r/t cough, fever and pain
  • Constipation r/t long term use of laxative
  • Ineffective airway clearance r/t to viscous secretions
  • Noncompliance (Medication) r/t unknown etiology
  • Noncompliance (Diabetic diet) r/t unresolved anger about Diagnosis
  • Acute Pain (Chest) r/t cough 2nrdary to pneumonia
  • Activity Intolerance r/t general weakness
  • Anxiety r/t difficulty of breathing & concerns over work
• Potential Nursing diagnosis


  One in which evidence about a health problem is incomplete or unclear therefore requires more data to support or reject it; or the causative factors are unknown but a problem is only considered possible to occur
• Potential Nursing diagnosis


  • Possible nutritional deficit
  • Possible low self-esteem r/t loss job
  • Possible altered thought processes r/t unfamiliar surroundings
• Risk Nursing diagnosis


  A clinical judgment that a problem does not exist, therefore no S/S are present, but the presence of RISK FACTORS indicates that a problem is only is likely to develop unless nurse intervene or do something about it
• Risk Nursing diagnosis


  • Risk for Impaired skin integrity (left ankle) r/t decrease peripheral circulation in diabetes
  • Risk for interrupted family processes r/t mother's illness & unavailability to provide child care
  • Risk for Constipation r/t inactivity and insufficient fluid intake
  • Risk for infection r/t compromised immune system
  • Risk for injury r/t decreased vision after cataract surgery
• Formula in writing nursing diagnosis

  • Actual nursing diagnosis = Problem + Etiology + S/S
  • Risk Nursing diagnosis = Problem + Risk Factors
  • Possible nursing diagnosis = Problem + Etiology
• Qualifiers


  • deficient - inadequate in amount, quality, degree, insufficient, incomplete
  • impaired - made worse, weakened, damaged, reduced, deteriorated
  • decreased - lesser in size, amount, degree
  • ineffective - not producing the desired effect
• Activities during diagnosis


  • Compare data against standards
  • Cluster or group data
  • Data analysis after comparing with standards
  • Identify gaps and inconsistencies in data
  • Determine the client's health problems, health risks, strengths
• Formulate Nursing Diagnosis - prioritize nursing diagnosis based on what problem endangers the client's life
• Planning


  Involves determining before and the strategies or course of actions to be taken before implementation of nursing care. To be effective, the client and his family should be involve in planning.
• Purpose of Planning


  • To determine the goals of care and the course of actions to be undertaken during the implementation phase
  • To promote continuity of care
  • To focus charting requirements
  • To allow for delegation of specific activities
• Activities during planning


  • Establish/Set priorities
  • Plan nursing interventions/nursing orders to direct activities to be carried out in the implementation phase
  • Write a Nursing Care Plan
• Priority


  Something that takes precedence in position, and considered the most important among several items. It is a decision making process that ranks the order of nursing diagnosis in terms of importance to the client.
• Guideline for setting priorities

  • Life-threatening situations should be given highest priority
  • Use the principle of ABC's (airway, breathing, circulation)
  • Use Maslow's hierarchy of needs
  • Consider something that is very important to the client
  • Actual problems take precedence over potential concerns
  • 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
  • Attend to client before equipment
• Nursing interventions


  Any treatment, based upon clinical judgment and knowledge, that a nurse performs to enhance client outcomes. They are used to monitor health status; prevent, resolve or control a problem; assist with activities of daily living; or promote optimum health and independence.
• Types of Nursing Interventions

  • Independent Nursing Intervention - those activities that the nurse is licensed to initiate as a result of the nurse's own knowledge and skills
  • Dependent Nursing Intervention - those activities carried out on the order of a physician, under a physician's supervision, or according to specific routines
  • Interdependent/Collaborative - those activities the nurse carries out in collaboration or in relation with other members of the health care team
• Nursing Care Plan (NCP)


  A written summary of the care that a client is to receive. It is the "blueprint" of the nursing process. It is nursing centered in that the nurse remains in the scope of nursing practice domain in treating human responses to actual or potential health problems.
• Steps in the Nursing Care Plan

  • Sufficient data are collected to substantiate nursing diagnosis
  • At least one goal must be stated for each nursing diagnosis
  • Outcome criteria must be identified for each goal
  • Nursing interventions must be specifically designed to meet the identified goal
  • Each intervention should be supported by a scientific rationale, which is the justification or reason for carrying out the intervention
  • Evaluation must address whether each goal was completely met, partially met or completely unmet
• Implementation


  Putting the nursing care plan into action. The purpose is to carry out planned nursing interventions to help the client attain goals and achieve optimal level of health.
• Activities during Implementation


  • Reassessing - to ensure prompt attention to emerging problems
  • Set priorities - to determine the order in which nursing interventions are carried out
  • Perform nursing interventions - these may be independent, dependent or collaborative measures
  • Record actions - to complete nursing interventions, relevant documentation should be done
• Requirements of Implementation


  • Knowledge - include intellectual skills like problem-solving, decision-making and teaching
  • Technical skills - to carry out treatment and procedures
  • Communication skills - use of verbal and non-verbal communication to carry out planned nursing interventions
  • Therapeutic use of self - being willing and being able to care