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Fundamental Nursing Skills and Concepts


An organized sequence of problem-solving steps used to identify and to manage ... saw, smelled, touched, tasted, heard (always in quotes when the patient states) ... – PowerPoint PPT presentation

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Title: Fundamental Nursing Skills and Concepts

Fundamental Nursing Skills and Concepts
  • Chapter 2
  • Page 16

Definition of the Nursing Process
  • An organized sequence of problem-solving steps
    used to identify and to manage the health
    problems of clients. These steps assure high
    quality, efficient care in the minimum amount of
    time with maximum efficiency.
  • It is accepted for clinical practice established
    by the American Nurses Association
  • Nursing process is a set of actions leading to a
    particular outcome or goal.

The nursing process
  • Organized sequence of problem solving steps, used
    to identify and manage health problems of
  • Assessment-collect data. Subjective data is
    patient based, called symptoms. Something the pt.
    tells you, I itch, I have a headache, I have
    pain. Objective data- is
    observable and measureable, these are signs. Such
    as temp., B/P, lab reports.
  • Secondary source-family, reports, test results,
    current and past medical records.
  • Collect and organize data, using nursing
    knowledge and past experience, cluster related
    data. Pg.20 box 2-3

The nursing process
  • Diagnosis- 1. analyze data-is it normal or
    abnormal findings? A nursing dx. is a health
    issue that can be prevented, reduced, resolved or
    enhanced through independent nursing measures.
  • Catagories of nsg. dx. Are actual, risk,
    possible, syndrome and wellness. Top pg. 20
  • 2 Identify nursing dx. collaborative problems,
    physiologic complications whose tx. requires both
    nurse and physician prescribed interventions.
    NANDA, pg. 20a and well laid out on back cover
    shows NSG Dx.

The nursing process
  • Planning-
  • 1. prioritize problem, est. goals (short long
    term goals) always timed.
  • 2. identify measureable outcomes(goals),
    involves critical thinking.
  • 3. select nursing interventions that are
  • 4. document the plan of care. Please always
    consult with the patient in the planning of care.
    Planning is accompanied by a target date.

The nursing process
  • Implementation-
  • Carry out the plan of care. Nurse implements
    medical and nursing orders.
  • Document the nursing care and patient responses,
    shows if the plan is effective or not.

The nursing process
  • Evaluation-
  • Monitor patient outcomes.
  • Resolve, continue, revise the current plan of
  • Needs not met, may need to re-assess, plan care,
    and implement other interventions to meet the
    goal for better outcomes.

Characteristics of the Nursing Process
  • Within the legal scope of nursing -as defined by
    the Nurse Practice Act. Describes nursing in
    terms of an independent problem solving role,
    that involves the dx. and tx. of human
    responses to actual or potential health problems.
    Top pg. 20 shows categories of nsg. dx.
  • Based on knowledge-requiring critical thinking-
    the ability to identify and resolve pt. problems
    requires critical thinking, (process of objective
    reasoning, analyzing facts to reach a valid
  • Planned-organized and systematic

Characteristics of the Nursing Process
  • Client-centered- the patient and, or, family need
    to take part.
  • Goal-directed-to achieve certain goals and
    outcomes. The greatest problem has the highest
  • Prioritized-greatest threat to health are the
    problems that need to be resolved first.
  • Dynamic-changing, evaluation, begin the process
    again. Accomplished your goal? Initiate a new
    one, or move down to second problem on the list.
    It is a continuous loop. Did not accomplish your
    goal? Rethink it, re-assess, make new
    interventions to get the problem resolved, and
    implemented. Evaluate the outcome.

What are the steps of the Nursing Process
  • Assessment
  • Diagnosis
  • Planning
  • Implementation
  • Evaluation

  • Systematic collection of facts or data
  • Gather data-page 19 good admission assessment
    record tool. Data collection begins with first
    contact, and is ongoing.

Types of Data
  • Objective data-observable and measurable facts
    (Signs)- v/s, lab reports, gives you signs of a
  • Subjective data-information that only the client
    feels and can describe (Symptoms) feels pain,
    itch, has headache.

Sources of Data
  • Primary source Client
  • Secondary source Clients family, reports, test
    results, information in current and past medical
    records, and discussions with other health care

Types of Assessments
  • Data base assessment-initial assessment about the
    pts. physical, emotional, social and spiritual
    health. Lengthy and comprehensive.
  • Focus assessment-information that provides more
    details about specific problems (ie.

Organization of Data
  • Grouping of related information organizing data,
    use knowledge, previous experiences to group or
    cluster data.
  • Organization of assessment data into small groups
    to be analyzed

Nursing Diagnosis
  • Health issue that can be prevented, reduced,
    resolved, or enhanced through independent nursing
  • Nursing Diagnosis Categories
  • Actual-problem currently exists
  • Risk-potential for developing
  • Possible-unsure of existence, further data needed
  • Syndrome-cluster of problems present or predicted
    because of an event or situation
  • Wellness-healthy person obtains nursing
    assistance to maintain or perform at a higher

Diagnostic Statements
  • Name of the health-related issue or problem as
    identified in the NANDA list
  • NANDA North American Nursing Diagnosis
    Association, the authoritative organization for
    developing and approving nsg. dx.
  • Unable to find a nsg. dx. that fits the needs of
    your client, may use own terminology when stating
    nsg. dx.
  • Nursing diagnosis statement must contain, the
    health related issue, etiology(the cause), signs,
    symptoms. Something the nurse can treat.

Diagnostic Statements
  • 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

Collaborative Problems
  • Physiologic complications whose treatment
    requires both nurse- and physician-prescribed
  • They are an interdependent domain of nursing
  • Overlapping problems between nsg. dx. and medical
  • Complications that need further interventions.
  • Top pg. 21, shows an illustration of
    collaborative problems.
  • Beyond the realm of the nurse treatment
    independently, this is a Physician / Nurse

Collaborative Problems-Nurses Responsibility
  • Correlating medical diagnoses or medical
    treatment measures with the risk for unique
  • Documenting the complications for which clients
    are at risk
  • Making pertinent assessments to detect
  • Reporting trends that suggest development of
  • Managing the emerging problem with nurse- and
    physician-prescribed measures
  • Evaluating the outcomes

  • 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.

Setting Priorities
  • Determine problems that require immediate action
  • Maslows Hierarchy of Human Needs-is a basis to
    use to prioritize , ranking may change.
  • Establishing goals- a goal is an expected outcome
    or a desired outcome. Objective Has fever been
    lowered? Has constipation been resolved?

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

Long-Term Goals
  • Desirable outcomes that take weeks or months to
    accomplish for clients with chronic health

Goals for Collaborative Problems
  • Goals for collaborative problems are written from
    a nursing rather than from a client perspective.
  • The focus on what the nurse will monitor, report,
    record, or do to promote early detection and

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 (causes).
  • The nurse selects strategies based on the
    knowledge that certain nursing actions produce
    desired effects.
  • Nursing interventions must be planned and safe,
    within the legal scope of nursing practice, and
    compatible with medical orders.

  • Joint Commission on Accreditation of Health Care
    Organizations (JCAHO) requires that every
    patients medical record provide evidence of the
    planned nursing interventions for meeting the
    patients needs.

Nursing Orders
  • Directions for a clients care
  • Directions identifying specifically that all team
    members understand what, when, where, and how for
    performing nursing interventions
  • Nursing orders are signed to be accountable
  • Standards of care- policies that indicate which
    activities will be provided to ensure quality pt
  • Clinical pathways- relieve the nurse from writing
    time consuming care plans

Communicating The Plan
  • The nurse shares the plan of care with nursing
    team members, the client, and clients family.
    Some agencies require the patient sign the plan
    so they are accountable for taking part in their
    own care.
  • The plan is a permanent part of the medical
  • The plan is referred to daily, reviewed, revised.
  • Change if need be and re-implemented.

  • Carrying out the plan of care
  • The nurse implements medical orders and nursing
  • Implementation involves the client and one or
    more health care team. Enlist the participation
    by the client. The goals are client based and
    goal directed, so they need to be involved.

  • Health care team also transmits the plan of care
    to the on coming staff so continuity of care is
    in progress.
  • The information in the chart shows a correlation
    between the plan and the care that has been
    provided. Document nursing care and patient
    responses. The quantity and quality of pts.
    responses. Quote the patient whenever possible to
    get a pts. perspective of his care. Nurses notes
    should reflect a correlation between plan of care
    and the care that was rendered.
  • Nurses are accountable for carrying out nursing
    orders and physician orders.

  • Open lines of communication among health care
  • Shows continuing progress of pt.
  • Complies with JACHO
  • Facilitates reimbursment to hospital
  • If need be, paints with words a good picture of
    the care that was rendered to the patient, if the
    patients record goes to court for some reason.

  • The way nurses determine whether a client has
    reached a goal.
  • It is the analysis of the clients response,
    evaluation helps to determine the effectiveness
    of nursing care.
  • Monitor pt. outcomes. Was the plan effective? Was
    the goals met? Resolve, continue, revise the
    current plan of care to meet the goals needed for
    that individual patient.

Nursing Process
  • Using the nursing process is the standard for
    clinical nursing practice.
  • Nurse Practice Act holds nurses accountable for
    demonstration of these aspects when caring for
    patients. To do less implies negligence.
  • Sample Nsg. Care Plan page 24

Aspects of writing the Plan of Care
  • Based on your assessment data
  • what is obvious
  • what is apparent
  • The expected outcomes for the problems you found
    in your assessment
  • generally are timed
  • make sure the outcomes fit with in the
    medical diagnosis realm

Aspects of writing the Plan of Care
  • Nursing interventions specific for achieving
    goals set up in your outcomes phase
  • Implement your interventions
  • Evaluate the patients response
  • problems solved?
  • move on to new problem
  • problem not solved
  • change interventions, re-implement

Aspects of writing the Plan of Care
  • Document
  • what your 5 senses told you
  • saw, smelled, touched, tasted, heard (always
    in quotes when the patient states)
  • Document- your good teaching and the patients or
    / and patients family understanding and response.