Nursing Process

• systemic collection, verification, organization, interpretation and documentation of data performed on every pt used to identify the current health status
• provides a baseline for future care and can be evaluated
• used to evaluate the effectiveness of the current plan
• COMPREHENSIVE; complete health hx, lab and diagnostic tests; usually completed on admission but is dependent on the pt's status
• FOCUSED; on a particular need or risk; usually focuses on one body system; used where short stays are anticipated ie outpatient facilities
• ONGOING; intervention includes ongoing assessment, after we have identified the problem we continue to assess the pt responses to actions, the frequency depends on the severity of the problem
• EMERGENCY; rapid assessment, the pt has a life threatening problem

• active listening prompts such as "all right," "go on," or "uh-huh."
• these indicate that you have heard what the pt said and you are attentive to the full story

questions that limit the pts response to one or two words

information about the pt's perceived needs, health problems and responses to the problems

your judgement or interpretation of cues ( cues are information that you obtain through the use of senses)

• an organized conversation with the pt.
• consists of three phases; orientation, working and termination.

established by laying the groundwork for the nurse to u/s the clients needs and begin the relationship that allows the pt to become a partner in the decisions about care

• done during the working phase
• includes data about the clients current level of wellness, including a ROS, family and health hx, sociocultural hx, spiritual health and mental and emotional reactions to illness

• observations made and data measured and collected by the nurse
• can also be measured by others
• Primary Source; what you (RN) measured or saw
• Secondary Source; lab results or diagnostic tests
• *we look to verify subjective data with objective findings.*

• questions that encourage the pt to answer the question in more then 1 or 2 words.
• encourages discussion and builds trust with the pt

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• pt or families perception of the health problem gathered from the interview
• this data is not measurable, no one else can quantify or measure it
• Primary Source; is what the pt tells you
• Secondary Sources; other people report it, such as spouse, friends or family

• problems that actually exist
• ex a pt with a break in their skin actually has impaired skin integrity
• there are defining characteristics that lead you to conclude what the actual problem is

• indicated that there is potential for a problem
• if a pt has a hx of falls they are more at risk for falls than someone who does not have that hx

• the abnormal data that we collected that supports the dx
• can be objective or subjective
• the clinical criteria of assessment findings that validate the presence of a diagnostic category
• clinical criteria are objective and subjective signs and symptoms or risk factors

• use of the assessment data that you collected about a pt to logically explain a clinical dx
• in this case the nursing dx
• the steps include data clustering, identifying pt needs and formulating the dx

• the related factor
• associated with the clients actual or potential response to the health problem
• what we aim to change with the nursing interventions

• the identification of a disease condition based on a specific evaluation of physical signs and symptoms, the pt's medical hx and the results of diagnostic tests and procedures
• physicians are licensed to treat diseases or pathological processes described in medical diagnostic statements

• a clinical judgement about an individual, family or community responses to actual and potential health problems or life processes
• it is a statement that describes the pt's actual or potential response to a health problem that the nurse is licensed to treat

• a professional association
• purpose is to develop, refine and promote a taxonomy of nursing diagnostic terminology of general use for professional nurses
• provides a common language for the health problems that nurses deal with

• specific and measurable behavior or response that reflects the pt's highest possible level of wellness and independence in fx
• ex. pt will perform self-care hygiene independently or pt will remain free of infection

• also called interdependent nursing interventions
• are therapies that require the combined knowledge, skill and expertise of multiple health care professionals

• independent nursing interventions
• actions that the nurse initiates
• do not require a direct order from another health care professional
• autonomous actions based on scientific rationale

• dependent nursing interventions
• actions that require and order from a physician or another health care professional
• based on the MD's response to treat or manage a medical dx
• as a nurse you carry out the the providers written or verbal orders
• ex. med administration, implementing an invasive procedure, changing a dressing or preparing the pt for diagnostic test

• minimum level of care accepted to ensure high quality of care to clients
• define types of therapies typically administered to clients with defined problems or needs

• a professional nurses approach to identify, diagnose and treat human responses to health and illness
• this process enables the nurse to organize and deliver nursing care

• Assessment
• Diagnosis
• Planning
• Implementation
• Evaluation

• Assessment: data collection
• Diagnosis: a statement that describes the pt's actual or potential response to a health problem that the nurse is licensed or competent to treat, analyze and interpret and form clusters of data
• Planning: determining how to prevent, reduce or resolve the identified pt problems; determine pt centered goals and expected outcomes, establish priorities and select appropriate interventions
• Implementation: methods to achieve the goals of nursing care; assist in the performance of ADL's, counseling and education, provide direct nursing care, supervise and evaluate the work of other staff; can be either dependent, dependent or interdependent
• Evaluation: measures the degree to which goals and outcomes have been achieved

subjective is what the pt tells you and objective is what you observe

• Client
• Family or significant other
• Healthcare team members
• Medical records
• Other records (education, military or employment)
• Literature review
• Nurse's experience

• Interview
• Nursing health hx
• Physical exam
• Lab and diagnostic tests

• Open ended questions
• Closed ended questions
• Back channeling
• Problem seeking interview (focusing in on the stated problem)

• Orientation Phase: before beginning the nurse reviews the purpose for the interview, the types of data to be obtained and the methods most appropriate for conducting the interview; establishing the nurse- client relationship by laying the groundwork for the nurse to u/s the clients needs and begin the relationship that allows the pt to become a partner in the decisions about care
• Working Phase: the nurse asks questions to form the database from which the nursing care plan will be developed. this is where the 4 interview techniques are implemented
• Termination Phase: the client should be given a clue in the interview is about to end. the interview ends in a friendly manner and the nurse specifically indicates when there will be additional contact

• Biographical information
• Reason for seeking health care
• Client expectations
• Present illness
• PMH
• Family hx
• Environmental hx
• Psychosocial hx
• Spiritual health
• ROS
• Physical exam
• Diagnostic and lab data

• RN dx focuses on and defines the nursing needs of the pt where as the MD dx identifies a specific disease state.
• The MD focus is on dx and tx of disease where as the RN cannot tx a medical dx but they can tx the effects of the medical dx
• ex- a RN cannot cure lung cancer but we can tx the effects of the lung cancer

• Diagnostic process: gathering the assessment database, identifies actual or potential client problems
• Analyzing and Interpreting data: look for clusters in the assessment data
• Identifying client needs: analyze the pt's general health care problems, move from general to specific, could be an actual or at risk problem
• Formulating the nursing dx: once data and clusters are sorted and the pt needs are identified the RN is ready to form the dx

• Interpretation of data
• Identification of pt needs
• Formulation of the nursing dx

defining characteristics SUPPORT the nursing dx

• goals of care planning are guideposts to the selection of nursing interventions and criteria in the evaluation of nursing interventions
• the nurse uses critical thinking to develop goals and expected outcomes that are relevant to the pt needs as evidenced by the assessment database and the nursing diagnosis
• there are long term and short term goals

• expected outcomes are specific step by step objectives that lead to attainment of the goals and the resolution of the etiology for the nursing dx.
• an outcome is a measurable change in the pt's status in response to nursing care
• the EO's determine whether a goal has been met

• Client-centered factors: reflect expected client behavior and responses to intervention; focuses on the pt and specific dx
• Singular factor: each goal and EO addresses only one behavioral response
• Observable factors: EO's should be observable, can also be physiological finding, knowledge or behavior
• Measurable factor: allows the RN to objectively quantify changes in the pt's status
• Time-limiting factors: indicate when the expected outcome should occur, determines whether progress is being made at a reasonable rate
• Mutual factors: when pt and RN agree on the goal setting and outcome there is an increase in the pt's motivation and cooperation
• Realistic factors: short-term realistic goals and EO's quickly provide the RN and the pt with a sense of accomplishment

• NCP is a written guideline for pt care
• NCP's document the pt's health care needs and communicate to other nurses and health care professionals the pt's pertinent assessment data, problems and therapies
• NCP's decrease the risk for incomplete, incorrect or inaccurate care
• the care plan is organized so the RN can quickly identify nursing actions to be given
• it makes possible for the coordination of nursing care, subspecialty consults and the scheduling of diagnostic tests.
• it organizes information exchanged by nurses at end of shift reports, transfers and discharges.
• the complete care plan is the blueprint for nursing action
• it provides direction for implementation of the plan and a framework for evaluation of the pt's response to the nursing actions
• Critical pathways allow staff from all disciplines (medicine, nursing, pharmacy and social work) to develop integrated care plans for a projected length of stay or number of visits for pt's with a specific case type

• reassess the pt
• review and revise the existing NCP
• organize resources and care delivery
• anticipating and preventing complications
• implementing nursing interventions

• assisting with ADL's
• counseling
• teaching
• providing direct nursing care
• compensation for adverse reactions
• preventative care
• lifesaving measures
• delegating, supervising and evaluating the work of others

• examine the goals statement to identify the exact desired pt behavior or response
• assess the pt for the presence of that behavior or response
• compare the established outcome criteria with the behavior or response observed
• if there is no agreement or partial agreement between the expected outcome and the observed outcome then determine what are the barriers? why did they not agree? what needs to be altered?

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