Nursing Processes

1. The Nursing
Process

3. Nursing Process
The Nursing Process is a framework that helps organize
and deliver nursing care. It:
 Is orderly, systematic.
 Is central to all nursing care.
 Is used to identify, prevent and treat actual or potential
health problems and promote wellness.
 Encompasses all steps taken by the nurse in caring for
individuals, families, groups, and communities.
 Must be used by nurses

4. Definition of the Nursing
Process
 An organized sequence of problem-
solving steps used to identify and to
manage the health problems of clients
 It is accepted for clinical practice
established by the American Nurses
Association

5. Benefits of Nursing Process
 Provides an orderly & systematic method for
planning & providing care
 Enhances nursing efficiency by standardizing
nursing practice
 Facilitates documentation of care
 Provides a unity of language for the nursing
profession
 Is economical
 Stresses the independent function of nurses
 Increases care quality through the use of
deliberate actions

6. The Nursing Process
Utilizes The Following
Assessment
Nursing Diagnosis
Planning
Implementation
Evaluation

7. Characteristics of the
Nursing Process
 Within the legal scope of nursing
 Based on knowledge-requiring critical
thinking
 Planned-organized and systematic
 Client-centered
 Goal-directed
 Prioritized
 Dynamic

8. Being Accountable
 Using critical thinking before taking
actions
 Being responsible for your actions
 Entering the professional role
 Working at the level of your peers
 Using the nursing process

9. Something to think about:
 Nurses are responsible for a unique
dimension of healthcare – “ the
diagnosis and treatment of human
responses to actual or potential health
problems”

10. The Nursing Process Is:
 Cyclic and dynamic
 Goal directed and client centered
 Interpersonal and collaborative
 Universally applicable
 Systematic

11. NURSING PROCESS

12. Nursing Process
1. Assessment – The nurse gathers subjective & objective
information from the client & other sources in order to
understand the client’s situation.
2. Nursing Diagnosis –Organizes (in collaboration with the
client), interprets the data and makes nursing
diagnosis/diagnoses, which is nursing’s perspective on the
appropriate focus for client nursing care.
3.Planning- Sets, in collaboration with client, mutually agreed
upon goals of care, desired outcomes strategies to achieve
goals of care & the identification & prioritization of
appropriate nursing actions.

13. Nursing Process
4.Intervention- Perform the nursing
actions identified in planning.
5.Evaluation- Determine if the goals
are met and outcomes achieved.

14. Advantages of using the
Nursing Process
 Continuity of care
 Prevention of
duplication
 Individualized
care
 Promotes critical
thinking & safety
■ Increased client
participation
■ Collaboration of
care
■ Application of
Standards of care.

15. Critical Thinking
 CRITICAL THINKING - is an active,
organized cognitive process used to
examine one’s own thinking.
 It is a time for making decisions and
reflecting, and taking nothing for
granted.
 Nurses use critical thinking as they
begin to question “WHY”? What else?
Why not??? What?

16.  A nurse who is a good critical thinker
& uses the nursing process as
intended, faces problems without
forming a quick simple solution, but
considers the value of all reasonable
options.

17. Step #1 NURSING
ASSESSMENT
Information Gathering & Processing

18. Standards for Nursing
Practice CRNNS

19. What Is the Nursing
Assessment?
 Assessment is the first
step of the Nursing
Process. It includes the
collection & analysis of
subjective & objective
data pertinent to a client.

20. Nursing Assessment
 Initially, the nurse must determine if the assessment
should be a quick overview (consider the client’s
presenting priorities, specialty area of practice) or a
detailed examination of the client’s case.
 In facilities, data is usually collected on standardized
nursing assessment forms, designed to collect
targeted relevant data.
 Forms may differ depending on agency and setting.

21. Nursing Assessment
 After the initial assessment the nurse
focuses on the client’s potential
problems by conducting a more
comprehensive assessment.

22. How Is Data Obtained?
 Data are obtained through:
Interviews- patient, nurses, support
persons, HCPs
Physical examinations
Observations
Review of records and diagnostic
reports
Collaboration with colleagues

23. Data Collection: Sources of Data
 Client-usually the best source of information, pay attention to your
client, act interested.
 Family and Significant Others- used as primary sources of information
about infants, children, and critically ill, intellectually disabled,
disoriented, or unconscious clients. Can be used as secondary
sources of information.
 Health Care Team /nurse caring for patient -change of shift report
 Nurse’s Own Experience- Through experience the nurse learns to ask
questions that yield important information
 Medical or Other Records- medical hx, lab tests, diagnostic study tests,
educational, military records ect.
 Literature Review, Standards of Care, Procedures

24. Assessment
Data Gathering
Tools/Reports
 Health History –
 Health promotion & disease prevention
behaviours, health problems & responses & risk
factors (biological & environmental).
 Requisites (needs): Universal SCR, Health
Deviation SCR, Developmental SCR (physiological,
psychological, sociological, spiritual) Other: Health
practices, family and social support, goals, values,
and expectations about the health care system.
 Physical assessment: Head to toe assessment

25. During Assessment Use:
 Critical thinking
 Broad knowledge base
 Effective communication skills
 Keen observation and physical
assessment skills

26. ASSESSMENT ALSO INCLUDES
CLIENT’S:
• current and past health and functional status
• present and past coping patterns (strengths and
limitations)
• response to therapy (past/present, nursing/medical)
• risk for potential problems
• desire for a higher level of wellness
• health practices
• support system
• goals, values & expectations re health care system
• need for nursing

27. Importance of Client
Expectations
 Client/patient expectations
influence the nurses’ success in
developing a relationship with the
client that leads to a directed,
purposeful and comprehensive
assessment.

28. Subjective vs. Objective
Data
 Subjective data- information reported by the client.
Only the client can determine this data. Ex: “I am
scared, about surgery”
 Objective data- observations or measurements
made by nurse - i.e. vital signs, physical
assessments, laboratory tests/values, changes in
behavior (physical assessment)
Based on assessment data gathering tools
modeled on Orem’s Self-Care Model.

29. Nursing Health History
 The Nursing Health History is the
systematic collection of subjective and
objective data used to determine a
clients self care requisites, functional
ability and ways of coping.

30. Purpose of the Subjective Component of
the Nursing Health History
 Provides subjective data on the client’s
health care experiences and current
health and lifestyle habits.
i.e. patient’s level of wellness, present
and past family history, changes in life
patterns, review of systems etc

31. Nursing Health History
 Nurses need to
…document all relevant
information on time… Pay attention to
facts and be as descriptive as
possible.

32. What Are Your
Responsibilities?
 Recognize health problems.
 Anticipate complications.
 Initiate actions to ensure appropriate
and timely treatment.
Begin to think CRITICALLY !!!!!!

33. Critical Thinking
 MENTAL OPERATIONS –decision
making & reasoning
 KNOWLEDGE-having the facts &
understanding the reason behind the
knowledge
 ATTITUDES- curious/open-minded/non-
judgmental….

34. Assessment of Well-Being
 According to the World Health
Organization is well-being in
these domains:
Emotional
Physical
Social
Spiritual

35. TYPES OF INTERVIEWS
 DIRECTED
 NON-DIRECTED
THINGS THAT IMPAIR COMMUNICATION:
 PRESENTING QUICK SOLUTIONS
 UNWARRANTED CHEERFULNESS
 FALSE REASSURANCE
 GIVING ADVICE
 CHANGING THE SUBJECT

36. CULTURAL DIVERSITY
 MUST PROVIDE CARE CONGRUENT
WITH A CLIENT’S EXPECTATIONS
 “This is not about you” ?
 Respect INDIVIDUAL’S DIFFERENCES,
What is the significance of the problem
or illness to the client?
 What does it mean in the
family/community?

37. COMMON Challenges:
Defense Mechanisms
 COMPENSATION
 DENIAL
 DISPLACEMENT
RATIONALIZATION
 PROJECTION
 REPRESSION
 SUPPRESSION
 REGRESSION

38. Continued
 THE NURSING PROCESS HELPS
NURSES UNDERSTAND THE
STRATEGIES CLIENTS USE IN
their attempt at coping:
This knowledge will help you
FURTHER INDIVIDUALIZE THEIR
CARE

39. Resources
 Client
 Other individuals
 Previous records
 Consultations
 Diagnostics studies
 Relevant literature

40. Assessment
 Data base assessment –
comprehensive information you
gather on initial contact with the
person to assess all aspects of health
status.
 Focus assessment – the data you
gather to determine the status of a
specific condition.

41. Sources of Data
 Primary source: Client
 Secondary source: Client’s family,
reports, test results, information in
current and past medical records, and
discussions with other health care
workers

42. Disease Prevention
 Primary prevention – protection from
a disease while still in a healthy state.
 Secondary prevention – early
detection and treatment of disease.
 Tertiary prevention – prevent
complications and to maintain health
once the disease process has
occurred.

43. Verifying Data
 Essential in critical thinking!!!!!
 Measurable data
 Double check personal observations
 Double check equipment
 Check with experts and team members
 Recheck out-liers
 Compare objective and subjective data
 Clarify statements

44. Planning
 Establish the goals, interventions
and outcomes

45. General Guidelines for
Setting Priorities
1. Take care of immediate
life-threatening issues.
2. Safety issues.
3. Patient-identified issues.
4. Nurse-identified priorities based on
the overall picture, the patient as a
whole person, and availability of
time and resources.

46. Nurse Identified Priorities
 Composite of all patient’s strengths
and health concerns.
 Moral and ethical issues.
 Time, resources, and setting.
 Hierarchy of needs.
 Interdisciplinary planning.

47. Identifying Client-centered
Outcomes
 State what the patient will do
or experience at the completion
of care.
 Give direction to the patient’s
overall care.
 Patient behaviors not nurse
behaviors!!
 “The patient will…”

48. DIAGNOSIS
 Sort, cluster, analyze information
 Identify potential problems and
strengths
 Write statement of problem or
strength
 Risk of infection related to
compromised nutrition

49. Nursing Diagnosis (cont.)
 Potential for effective breastfeeding
related to knowledge level and
support system
 Prioritize the problems
 Not a medical diagnosis

50. Steps for deriving outcomes
from Nursing Diagnosis
 Look at the first clause of the nursing
dx and restate in a statement that
describes improvement, control or
absence of the problem.
 Risk for infection r/t surgical
procedure.
 The client will demonstrate no signs
or symptoms of infection.

51. Components of Outcomes
 Subject: who is the person expected to
achieve the outcome?
 Verb: what actions must the person take to
achieve the outcome?
 Condition: under what circumstances is
the person to perform the actions?
 Performance criteria: how well is the
person to perform the actions?
 Target time: by when is the person
expected to be able to perform the actions?

52. Nursing Interventions
 Road maps directing the best ways to
provide nursing care.
 Evidence based nursing.
1. Monitor health status.
2. Minimize risks.
3. Resolve or control a problem.
4. Assist with ADLs.
5. Promote optimum health and
independence.

53. Interventions
 Direct interventions: actions
performed through interaction
with clients.
 Indirect interventions: actions
performed away from the client,
on behalf of a client or group of
clients.

54. Nursing Diagnosis
 Health issue that can be prevented,
reduced, resolved, or enhanced
through independent nursing
measures

55. Documenting the Plan of
Care
 To ensure continuity of care, the plan
must be written and shared with all health
care personnel caring for the client.
 Consists of:
1. Prioritized nursing
diagnostic statements.
2. Outcomes.
3. Interventions.

56. Documentation
 Clear and concise
 Appropriate terminology
Usually on a designated form
 Physical assessment
Usually by Review of Systems
• Overview of symptoms
• Diet
• Each body system

57. Documentation
 Use patient’s own words in subjective
data – enclose in “ ___” (quotation
marks)
 Avoid generalizations – be specific
 Don’t make summative statements –
describe - e.g. patient is being ornery
should be patient resists instruction or
patient states “Don’t talk to me, I don’t
care about that”

58. Evaluation
1. Determining outcome achievement
2. Identifying the variables affecting
outcome achievement
3. Deciding whether to continue,
modify, or terminate the plan

59. Determining Outcome
Achievement
 Must be aware of outcomes set for the
client.
 Must be sure patient is ready for
evaluation.
 Is patient able to meet outcome criteria?
 Is it:
Completely met?
Partially met?
Not met at all?
 Record in progress in notes.
 Update care plan.

60. Identifying Variable Affecting
Outcome Achievement
 Maintain individuality of care plan:
1. Is the plan realistic for the client?
2. Is the plan appropriate at the time for
this particular client?
3. Were changes made in the plan when
needed?
4. How does the client feel about the plan?

61. Predict, Prevent, and
Manage
 Focus on early intervention
 Based on research
 Predict and anticipate problems
 Look for risk factors

62. Diagnostic Statements
 Name of the health-related issue or
problem as identified in the NANDA
list
 Etiology (its cause)
 Signs and Symptoms
 The name of the nursing diagnosis is
linked to the etiology with the phrase
“related to,” and the signs and
symptoms are identified with the
phrase “as manifested (or evidenced)
by”

63. Collaborative Problems-
Nurse’s Responsibility
 Correlating medical diagnoses or
medical treatment measures with the
risk for unique complications
 Documenting the complications for
which clients are at risk
 Making pertinent assessments to
detect complications

64. Continued
 Reporting trends that suggest
development of complications
 Managing the emerging problem with
nurse- and physician-prescribed
measures
 Evaluating the outcomes

65. The Nursing Process
Nursing Diagnosis
Judgment or conclusion about the risk for—
or actual—need/problem of the patient
NANDA format

66. NANDA – North American
Nursing Diagnosis Association
 Identifies nursing functions
 Creates classification system
 Establishes diagnostic labels
 Risk of infection related to compromised
nutritional state
 Potential complication of seizure disorder
related to medication compliance

67. Planning
 The process of prioritizing nursing
diagnoses and collaborative problems,
identifying measurable goals or
outcomes, selecting appropriate
interventions, and documenting the
plan of care.
 The nurse consults with the client
while developing and revising the plan.

68. Setting Priorities
 Determine problems that require
immediate action
 Maslow’s Hierarchy of Human Needs

69. Short-Term Goals
 Outcomes achievable in a few days or
1 week
 Developed form the problem portion of
the diagnostic statement
 Client-centered
 Measurable
 Realistic
 Accompanied by a target date

70. Long-Term Goals
 Desirable outcomes that take weeks
or months to accomplish for client’s
with chronic health problems

71. The Nursing Process
Planning
Identification of goals and outcome criteria
Prioritization
Time frame

72. Selecting Nursing
Interventions
 Planning the measures that the client
and nurse will use to accomplish
identified goals involves critical
thinking.
 Nursing interventions are directed at
eliminating the etiologies.

73. Selecting an intervention
 The nurse selects strategies based on
the knowledge that certain nursing
actions produce desired effects.
 Nursing interventions must be safe,
within the legal scope of nursing
practice, and compatible with medical
orders.

74. Communicating The Plan
 The nurse shares the plan of care with
nursing team members, the client, and
client’s family.
 The plan is a permanent part of the
record.

75. Evaluation
 The way nurses determine whether a
client has reached a goal.
 It is the analysis of the client’s
response, evaluation helps to
determine the effectiveness of nursing
care.

76. The Nursing Process
Evaluation
Ongoing part of the nursing process
Determining the status of the goals
and
outcomes of care
Monitoring the patient’s response to
drug therapy

77. Documentation
 Clear and concise
 Appropriate terminology
Usually on a designated form
 Physical assessment
Usually by Review of Systems
• Overview of symptoms
• Diet
• Each body system