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Nursing Process


Nursing Process NUR101 Fall 2009 Lecture #6 and #7 K. Burger, MSEd, MSN, RN, CNE PPP By: Sharon Niggemeier RN MSN Revised KBurger 8/06 Nursing Process Specific to the ... – PowerPoint PPT presentation

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Title: Nursing Process

Nursing Process
  • NUR101
  • Fall 2009
  • Lecture 6 and 7
  • K. Burger, MSEd, MSN, RN, CNE
  • PPP By Sharon Niggemeier RN MSN
  • Revised KBurger 8/06

Nursing Process
  • Specific to the nursing profession
  • A framework for critical thinking
  • Its purpose is to
  • Diagnose and treat human responses to actual or
    potential health problems

Nursing Process
  • Organized framework to guide practice
  • Problem solving method - client focused
  • Systematic- sequential steps
  • Goal oriented- outcome criteria
  • Dynamic-always changing, flexible
  • Utilizes critical thinking processes

Scientific Method of problem solving
  • ID problem
  • Collect data
  • Form hypothesis
  • Plan of action
  • Hypothesis testing
  • Interpret results
  • Evaluate findings

Advantages of Nursing Process
  • Provides individualized care
  • Client is an active participant
  • Promotes continuity of care
  • Provides more effective communication among
    nurses and healthcare professionals
  • Develops a clear and efficient plan of care
  • Provides personal satisfaction as you see client
    achieve goals
  • Professional growth as you evaluate effectiveness
    of your interventions

5 Steps in the Nursing Process
  • Assessment
  • Nursing Diagnosis
  • Planning
  • Implementing
  • Evaluating

  • First step of the Nursing Process
  • Gather Information/Collect Data
  • Primary Source - Client / Family
  • Secondary Source - physical exam, nursing
    history, team members, lab reports, diagnostic
  • Subjective -from the client (symptom)
  • I have a headache
  • Objective - observable data (sign)
  • Blood Pressure 130/80

Assessment-collecting data
  • Nursing Interview (history)
  • Health Assessment -Review of Systems
  • Inspection
  • Palpation
  • Percussion
  • Auscultation

Assessment-collecting data
  • Make sure information is complete accurate
  • Validate prn
  • Interpret and analyze data Compare to standard
  • Organize and cluster data

Example of Assessment
  • Obtain info from nursing assessment, history and
    physical (HP) etc...
  • Client diagnosed with hypertension
  • B/P 160/90
  • 2 Gm Na diet and antihypertensive medications
    were prescribed
  • Client statement I really dont watch my salt
    Its hard to do and I just dont get it

Nursing Diagnosis
  • Second step of the Nursing Process
  • Interpret analyze clustered data
  • Identify clients problems and strengths
  • Formulate Nursing Diagnosis (NANDA North
    American Nursing Diagnosis Association)-Statement
    of how the client is RESPONDING to an actual or
    potential problem that requires nursing

Nsg Dx vs MD Dx
  • Within the scope of nursing practice
  • Identify responses to health and illness
  • Can change from day to day
  • Within the scope of medical practice
  • Focuses on curing pathology
  • Stays the same as long as the disease is present

Formulating a Nursing Diagnosis
  • Composed of 3 parts
  • Problem statement- the clients response to a
  • Etiology- whats causing/contributing to the
    clients problem
  • Defining Characteristics- whats the evidence of
    the problem

Nursing Diagnosis
  • Problem( Diagnostic Label)-based on your
    assessment of client(gathered information), pick
    a problem from the NANDA list...
  • Etiology- determine what the problem is caused by
    or related to (R/T)...
  • Defining characteristics- then state as evidenced
    by (AEB) the specific facts the problem is based

Example of Nursing Dx
  • Ineffective therapeutic regimen management
  • R/T difficulty maintaining lifestyle changes and
    lack of knowledge
  • AEB B/P 160/90, dietary sodium restrictions not
    being observed, and client statements of I
    dont watch my salt Its hard to do and I just
    dont get it.

Types of Nursing Diagnoses
  • ActualImbalanced nutrition less than body
    requirements RT chronic diarrhea, nausea, and
    pain AEB height 55 weight 105 lbs.
  • RiskRisk for falls RT altered gait and
    generalized weakness
  • WellnessFamily coping potential for growth RT
    unexpected birth of twins.

Collaborative Problems
  • Require both nursing interventions and medical
  • EXAMPLE Client admitted with medical dx of
  • Collaborative problem respiratory insufficiency
  • Nsg interventions Raise HOB, Encourage CDB
  • MD interventions Antibiotics IV, O2 therapy

  • Third step of the Nursing Process
  • This is when the nurse organizes a nursing care
    plan based on the nursing diagnoses.
  • Nurse and client formulate goals to help the
    client with their problems
  • Expected outcomes are identified
  • Interventions (nursing orders) are selected to
    aid the client reach these goals.

Planning Begin by prioritizing client problems
  • Prioritize list of clients nursing diagnoses
    using Maslow
  • Rank as high, intermediate or low
  • Client specific
  • Priorities can change

PlanningDeveloping a goal and outcome statement
  • Goal and outcome statements are client focused.
  • Worded positively
  • Measurable, specific observable, time-limited,
    and realistic
  • Goal broad statement
  • Expected outcome objective criterion for
    measurement of goal
  • Utilize NOC as standard
  • Goal
  • Client will achieve therapeutic management of
    disease process.
  • Outcome Statement
  • AEB B/P readings of 110-120 / 70-80 and client
    statement of understanding importance of dietary
    sodium restrictions by day of discharge.

Planning- Types of goals
  • Short term goals
  • Long term goals
  • Cognitive goals
  • Psychomotor goals
  • Affective goals

Planning-select interventions
  • Interventions are selected and written.
  • The nurse uses clinical judgment and professional
    knowledge to select appropriate interventions
    that will aid the client in reaching their goal.
  • Interventions should be examined for feasibility
    and acceptability to the client
  • Interventions should be written clearly and

Interventions 3 types
  • Independent ( Nurse initiated )- any action the
    nurse can initiate without direct supervision
  • Dependent ( Physician initiated )-nursing actions
    requiring MD orders
  • Collaborative- nursing actions performed jointly
    with other health care team members

  • The fourth step in the Nursing Process
  • This is the Doing step
  • Carrying out nursing interventions (orders)
    selected during the planning step
  • This includes monitoring, teaching, further
    assessing, reviewing NCP, incorporating
    physicians orders and monitoring cost
    effectiveness of interventions
  • Utilize NIC as standard

Implementing- Doing
  • Teach potential complications of hypertension to
    instill importance of maintaining Na restrictions
  • Assess for cultural factors affecting dietary
  • Monitor VS q4h
  • Maintain prescribed diet (2 Gm Na)
  • Teach client amount of sodium restriction, foods
    high in sodium, use of nutrition labels, food
    preparation and sodium substitutes

Implementing Doing
  • Teach the client- hypertension cant be cured but
    it can be controlled.
  • Remind the client to continue medication even
    though no S/S are present.
  • Teach client importance of life style changes
    (weight reduction, smoking cessation, increasing
  • Stress the importance of ongoing follow-up care
    even though the patient feels well.

  • Final step of the Nursing Process but also done
    concurrently throughout client care
  • A comparison of client behavior and/or response
    to the established outcome criteria
  • Continuous review of the nursing care plan
  • Examines if nursing interventions are working
  • Determines changes needed to help client reach
    stated goals.

  • Outcome criteria met? Problem resolved!
  • Outcome criteria not fully met? Continue plan of
    care- ongoing.
  • Outcome criteria unobtainable- review each
    previous step of NCP and determine if
    modification of the NCP is needed.