The Nursing Process

College of DuPage Developed by Dr. Linda Caputi, CNE

Attributes of the Nursing Process

Assertive, problem-solving approach to identification and tx of patient problems. Organizing framework Focus on patient responses to actual or potential health problems Requires: Critical thinking and reasoning Psychomotor skills Interpersonal skills
College of DuPage Developed by Dr. Linda Caputi, CNE

Attributes of the Nursing Process, Contd

Holistic approach: physical care, emotional care, teaching, guidance & counseling Healing and preventing Assist patient to meet own needs

College of DuPage Developed by Dr. Linda Caputi, CNE

Differentiation between Nursing and Medicine

College of DuPage Developed by Dr. Linda Caputi, CNE

Phases of the Nursing Process

All phases are interrelated Do not occur in isolation from one another Assessment is the FIRST step

College of DuPage Developed by Dr. Linda Caputi, CNE

Assessment

Always performed first May involve a length history and physical May be a quick with rapid identification of problems with immediate intervention Accurate and thorough the basis for the rest of the process A structured database helps ensure completeness
College of DuPage Developed by Dr. Linda Caputi, CNE

Assessment

Data derived from the patient, family, other healthcare providers. Validate information for accuracy and dependability

College of DuPage Developed by Dr. Linda Caputi, CNE

Types of Data

Objective Data can be measured, observed and verified by another person. Also called signs. Subjective Data information perceived only by the affected person. Also called symptoms. Together they are manifestations.
College of DuPage Developed by Dr. Linda Caputi, CNE

Nursing Diagnosis

Analyze the data Identify patient problems Write the nursing diagnosis

College of DuPage Developed by Dr. Linda Caputi, CNE

Nursing Diagnosis: Analyze the Data

Cluster related information (organizing into related scheme) Indicate the presence, possibility, or risk for problems Use both subjective and objective data
College of DuPage Developed by Dr. Linda Caputi, CNE

Nursing Diagnosis: Identify Problems/Write ND

Identify patient problems from the clustered data. Formulate the nursing diagnosis: A conclusion about an identified cluster of manifestations (actual and potential) Concisely stated According to NANDA
College of DuPage Developed by Dr. Linda Caputi, CNE

Nursing Diagnosis: provides the basis for planning interventions to achieve outcomes. Interventions for which the NURSE is accountable. Medical diagnosis: COPD Nursing diagnosis: Activity intolerance Inadequate intake of nutrients Anxiety Use your nursing diagnosis book when writing care plans College of DuPage Developed
by Dr. Linda Caputi, CNE

3 Kinds For Now

Actual nursing diagnosis: the presence of major defining characteristics has been validated Risk nursing diagnosis: the patient is vulnerable to develop the problem because risk factors are present Possible nursing diagnosis: Some data are present but not sufficient at this time
College of DuPage Developed by Dr. Linda Caputi, CNE

Parts of the Nursing Diagnosis Statement

Problem (P): a brief statement of the actual or potential health problem Etiology (E): probable cause of the problem; contributing or related factors. This direct the correct interventions. Connected with the words related to Signs and Symptoms (S): list of the cluster of data that leads to the identification of the problem. Connected with the words as College of DuPage Developed manifested by
by Dr. Linda Caputi, CNE

Example

Activity intolerance related to fatigue secondary to cardiac insufficiency and pulmonary congestion as manifested by dyspnea, shortness or breath, weakness, increase in heart rate on exertion, and patients statement, I feel too weak to do anything.
College of DuPage Developed by Dr. Linda Caputi, CNE

Parts of the Nursing Diagnosis Statement

Actual Nursing Diagnoses: all 3 clauses Risk or Possible diagnoses: first two clauses Risk for impaired skin integrity related to immobility secondary to broken femur Possible self-care deficit related to impaired ability to use left hand secondary to tendonitis Verify the defining characteristics (signs and symptoms) with the nursing diagnosis book
College of DuPage Developed by Dr. Linda Caputi, CNE

Collaborative Problems

Problems that nurses treat with other healthcare providers, most frequently with physicians. Can be potential or actual complications of disease or treatment.

College of DuPage Developed by Dr. Linda Caputi, CNE

Planning

Set priorities Develop goals and expected outcome criteria Select interventions: actions to move the patient toward the expected outcomes
College of DuPage Developed by Dr. Linda Caputi, CNE

Planning: Prioritize

Determine the urgency of the problem ABCs Maslows hierarchy Patients perception
College of DuPage Developed by Dr. Linda Caputi, CNE

Planning: Set goals and expected outcomes

Goals: broader concept Expected outcomes: measurable data that validates the goals has been met. Both long-term and short-term. Designate the time period
College of DuPage Developed by Dr. Linda Caputi, CNE

Planning: Nursing Interventions

Determine which interventions will accomplish the goals Treatment that a nurse performs to enhance patient outcomes: Nurse-initiated Physician-initiated Activities the patient cant perform
College of DuPage Developed by Dr. Linda Caputi, CNE

Nursing Interventions

College of DuPage Developed by Dr. Linda Caputi, CNE

Determining Interventions

Pre-written (standardized) care plans CAUTION. Patient and nurse together Focus on the related to clause BE SPECIFIC!! Push fluids. Offer 100 milliliters every hour
College of DuPage Developed by Dr. Linda Caputi, CNE

Implementation
Carrying out nursing interventions. Carrying out interventions/treatments as directed by physician (or other healthcare provider) Delegate interventions Make adjustments while implementing
College of DuPage Developed by Dr. Linda Caputi, CNE

Types of Interventions

Independent Dependent Collaborative MUST identify and prevent potential complications Potential Complication: pulmonary edema
College of DuPage Developed by Dr. Linda Caputi, CNE

Evaluation
Reassessment to determine if outcomes have been met. Evaluation is a continuous process. Occurs at the end of the process and during each step. Nurse determines: outcomes met, discontinue plan outcomes not met, continue plan outcomes not met, revise plan
College of DuPage Developed by Dr. Linda Caputi, CNE