Chapter 2 Nursing Process

Chapter 2 Nursing Process

Definition of the Nursing Process Organized sequence of problem-solving steps Used to identify and manage the health problems of clients Accepted standard for clinical practice: American Nurses Association (ANA) Framework for nursing care

Characteristics of the Nursing Process Within the legal scope of nursing Based on knowledge Planned Client centered Goal directed Prioritized Dynamic

Steps of the Nursing Process Assessment First step of nursing process o Systematic collection of facts or data Types of data Objective data: observable and measurable facts, referred to as signs of disorder

Assessment (cont d) Types of data (cont d) o Subjective data: information only client feels and can describe; called symptoms Sources of data: primary source client; secondary sources client s family, reports, or discussion with other health care professionals

Question Is the following statement true or false? Objective data, consisting of information that only the client feels and can describe, are called symptoms. An example is pain.

Answer False. Objective data are observable and measurable facts and are referred to as signs of a disorder. Subjective data consists of information that only the client feels and can describe, and are called symptoms

Assessment (cont d) Types of assessment o Data base assessment Initial information: client s physical, emotional, social, and spiritual health Obtained during admission interview and physical examination

Assessment (cont d) Types of assessment (cont d) o Focus assessment Information: details about specific problems; expands original data base Repeated frequently or on a scheduled basis

Question Which of the following is a primary source for information? a. Client s family b. Client c. Medical records d. Test results

Answer b. Client The primary source for information is the client. The client s family, test results, and medical records are secondary sources of information.

Assessment (cont d) Organization o Involves grouping related information o Nurses: organize assessment data; cluster related data using knowledge and past experiences

Diagnosis Second step of the nursing process o Identification of health-related problems o Nursing diagnosis Health issue that can be prevented, reduced, resolved, or enhanced through independent nursing measures

Diagnosis (cont d) Nursing diagnosis (cont d) Categorized into 5 groups: actual; risk; possible; syndrome; wellness o The NANDA list Authoritative organization for developing and approving nursing diagnoses

Diagnosis (cont d) Nursing diagnosis (cont d) o Diagnostic statement Contains 3 parts: Name of health-related issue or problem identified in the NANDA list

Diagnosis (cont d) Nursing diagnosis (cont d) o Diagnostic statement (cont d) Etiology (its cause): phrase related to Signs and symptoms: phrase as manifested (or evidenced) by

Diagnosis (cont d) Nursing diagnosis (cont d) o Diagnostic statement (cont d) Potential diagnoses: risk for Uncertainty: possible Wellness diagnoses: potential for enhanced

Diagnosis (cont d) Nursing diagnosis (cont d) o Diagnostic statement (cont d) Potential nursing diagnoses: signs or symptoms not manifested Possible nursing diagnoses: data incomplete

Diagnosis (cont d) Nursing diagnosis (cont d) o Diagnostic statement (cont d) Syndrome diagnoses and wellness diagnoses are one-part statements; they are not linked with an etiology or signs and symptoms

Diagnosis (cont d) Nursing diagnosis (cont d) o Collaborative problem Physiologic complications require both nurse- and physicianprescribed interventions Written using the abbreviation potential complication (PC)

Planning Third step of the nursing process o Setting priorities Determine which problems require most immediate attention o Establishing goals Goal: expected or desired outcome

Planning (cont d) Establishing goals (cont d) o Short-term goals: Outcomes achievable in a few days to 1 week Characteristics: developed from; client-centered

Planning (cont d) Establishing goals (cont d) o Short-term goals (cont d) Characteristics (cont d) Measurable Realistic Target date for accomplishment

Planning (cont d) Establishing goals (cont d) o Short-term goals (cont d) Characteristics (cont d) Predicted time Time line for evaluation

Planning (cont d) Establishing goals (cont d) o Long-term goals Desirable outcomes take weeks or months to accomplish o Goals for collaborative problems Written for the nurse

Planning (cont d) Establishing goals (cont d) o Goals for collaborative problems (cont d) Focus: what the nurse will monitor, report, record, or do to promote early detection and treatment

Planning (cont d) Selecting nursing intervention o Planning measures: to accomplish identified goals involves critical thinking o Planned interventions: must be safe; within legal scope of nursing practice; and compatible with medical orders

Planning (cont d) Documenting plan of care o Plan of care: written by hand; standardized form; computer generated; based on an agency s written standards or clinical pathways o Nursing order: performing nursing interventions; providing specific instructions

Planning (cont d) Documenting plan of care (cont d) o Standardized care plan: preprinted; computer generated o Agency-specific standards for care and clinical pathways: indicate activities provided to ensure quality, consistent care

Planning (cont d) Communicating the plan of care o Nurses share plan with nursing team members, client, and the client s family o Permanent part of client s medical record placed in client s chart; nurses refer to it, review it, and revise it

Implementation Fourth step in the nursing process: carrying out the plan of care Implementation of: o Medical records: legal evidence o Record: quantity and quality of client response

Evaluation Fifth and final step of the nursing process: nurses determine whether client has reached the goal Analyze client s response

Question Is the following statement true or false? Evaluation is the fifth and final step in the nursing process.

Answer True. Evaluation, the fifth and final step in the nursing process, is the way by which nurses determine whether a client has reached a goal. The other steps in the nursing process are assessment, diagnosis, planning, and implementation.

Use of the Nursing Process Standard for clinical nursing practice Nurse practice act Holds nurses accountable for demonstrating all the steps in the nursing process To do less implies negligence

Concept Mapping Method of organizing information in graphic or pictorial form Formats used: spider diagram, hierarchy, linear flow chart Uses: Enables students to integrate previous knowledge with newly acquired information

Concept Mapping (cont d) Uses (cont d): Increases critical thinking and clinical reasoning skills Enhances retention of knowledge Correlates theoretical knowledge with nursing practice Helps students recognize information Promotes better time management