NURSING PROCESS

NURSING PROCESS
◆ LYDIA HALL (1955)
◆ Cyclic and dynamic nature
◆ Client centeredness
◆ Focus on problem-solving and decision-
making
◆ Interpersonal and collaborative style
◆ Universal applicability
◆ Use of critical thinking
NURSING PROCESS
NURSING PROCESS
Nursing Process:
ASSESSMENT
◆ Collecting data
◆ Organizing data
◆ Validating data
◆ Documenting data

Copyright 2008 by
Pearson Education, Inc.
Nursing Process:
ASSESSMENT
Types of assessment:
◆ Comprehensive = complete
◆ Focused = limited to risk, need or
concern.
◆ Ongoing = follow up after
identification of specific problem
Nursing Process:
ASSESSMENT
◆ Types of data:
a. Subjective Data
b. Objective Data
◆ Sources of data:
a. Primary
b. Secondary
 Nursing Process:
ASSESSMENT
EXAMPLE:
Eric’s mother states:
“ Eric vomited 8 ounces of his
formula this morning”
 Nursing Process: DIAGNOSIS

◆ Independent nursing function

◆ Interpretation of data for problem
identification
◆ Generate hypotheses
◆ Shows relationship of stem and
cause of the problem
Nursing Process: DIAGNOSIS
 Nursing Process: DIAGNOSIS
◆ Types:
a. Actual
b. Risk/Potential
c. Possible
d. Syndrome
e. Wellness
 Nursing Process: DIAGNOSIS
◆ Diagnostic Statements:
a. One – part
b. Two – part
c. Three – part
Avoid:
◆ Using medical diagnosis as the cause
◆ Using the s/sx as the cause
Nursing Process:
PLANNING
 Nursing Process:
PLANNING
◆ formulation of nursing outcomes
◆ GOAL is exact opposite of nursing
diagnosis ( stem )
◆ SMART

* Priority Setting
 Nursing Process:
PLANNING
Phases:
a.Initial
b.Ongoing
c.Discharge
 Nursing Process:
PLANNING
Prioritization:
◆ High priority (life-threatening)
◆ Medium priority (health-threatening)
◆ Low priority (developmental needs)
 Nursing Process:
PLANNING
Standardized Plans:
◆ Standards of care
◆ Standardized care plans
◆ Protocols
◆ Policies and procedures
 Nursing Process:
PLANNING
COMPONENTS OF A GOAL:
SUBJECT: the patient
VERB: will enumerate

MODIFIER: accurately
CRITERION 5 signs and symptoms of
DM
 Nursing Process:
PLANNING
Goal writing technique:
Write goals in terms of client responses.
Ex: The patient will demonstrate good
appetite.
Correct: The patient will consume 95%
of food served. 
Ex: Client will maintain good hydration.
Correct: Client will drink 100cc of
water per hour
 Nursing Process:
PLANNING
Components of nursing orders
a. Date = October 6, 2008
b. Verb = Discuss
c. Content = to patient the
importance of…
d. Time = in Saturday
e. Signature = ILI Alcazar, R.N.
 Nursing Process:
PLANNING
Types of Nursing Orders:
a. Observation orders
= auscultate lungs Q4H.
b. Prevention orders
= Turn, cough and encourage DBE Q2H.
c. Treatment orders
= Massage boggy fundus until firm.
d. Health promotion orders
= infant stimulation techniques.
Nursing Process: Implementation
 Nursing Process: Interventions
◆ Addresses what phase of nursing
process?
Types:
a. Independent
b. Dependent
c. Collaborative
 Example:
1. The nurse assists the client in
planning her diabetic diet in
collaboration with nutritionist
2. The nurse turns the bedridden client
every 1 to 2 hours
3. The nurse administers antibiotics to
the client with respiratory infection
4. The nurse teaches the mother on how
to burp her newborn after
breastfeeding
Nursing Process: Interventions

Domains of Learning
 Cognitive
 Psychomotor
 Affective
Relationship of Evaluating to
Other Phases
Nursing Process: EVALUATION
◆ Which phase of the nursing process
are we going to evaluate?
◆ “Changes continually”

Types:
a. Process Evaluation
b. Structure Evaluation
c. Outcome Evaluation
 Nursing Process: EVALUATION
Example:
1. Evaluates new I.V system if it resulted to
decrease incidence of phlebitis in patients
with IV lines
2. Evaluates the NCP developed for patients
3. Evaluates the size and location of nursing
unit in the delivery of nursing care
 DOCUMENTATION
Documentation:
◆ Guidelines for Documenting and Reporting

a. Client information on every page

b. Date and time each entry
c. Sign each entry
d. No space in between
e. Chronological
f. Acceptable abbreviations
 DOCUMENTATION
◆ What to do if there is an error?
◆ Telephone order?
a. Graphic record:
b. Medication record
c. Progress Notes
◆ Avoid being judgmental
◆ Describe what you have observed:
 DOCUMENTATION
Forms for data recording:
A. Kardex
B. Flow sheet: TPR, Medication sheet.
C. Nurse’s progress notes
D. Discharge summary
E. Computerized documentation
NURSING PROCESS:
PRACTICE TEST
A primary source for
assessing how a patient slept
is the:
A. nurse
B. patient
C. physician
D. roommate
Which is an example
of objective data?
A. Pain
B. Fever
C. Nausea
D. Fatigue
Which of the following elements is best
categorized as secondary subjective
data?
A. The nurse measures a weight loss
of 10 pounds since the last clinic
visit.
B. Spouse states the client has lost all
appetite.
C. The nurse palpates edema in lower
extremities.
D. Client states severe pain when
walking up stairs.
An example of subjective
data is that the patient:
A. appears jaundiced
B. has a headache
C. looks tired
D. is crying
During the first day a nurse is caring for
a client who has been in the hospital for 2
days, the nurse thinks that the client’s
blood pressure (B/P) seems high. What is
the next step?
A. Ask the client about past blood
pressure ranges.
B. Review the graphic record on the
client’s record.
C. Examine the medication record for
antihypertensive medications.
D. Review the progress notes included in
the client’s record.
Which of the following behaviors is
most representative of the nursing
diagnosis phase of the nursing
process?
A. Identifying major problems or
needs
B. Organizing data in the client’s
family history
C. Establishing short-term and long-
term goals
D. Administering an antibiotic
Which of the following behaviors
would indicate that the nurse was
utilizing the assessment phase of
the nursing process to provide
nursing care?
A. Proposes hypotheses
B. Generates desired outcomes
C. Reviews results of laboratory
tests
D. Documents care
 Which of the following is an
incorrect statement of Nursing
Diagnosis?
A. Anxiety related to insufficient
knowledge regarding surgical
experience
B. Constipation related to decreased
activity and fluids
C. High risk for ineffective airway
clearance related to pneumonia
D.Readiness for Enhanced Coping
The nurse selects the nursing diagnosis of
Risk for Impaired Skin Integrity related
to immobility, dry skin, and surgical
incision. Which of the following
represents a properly states
outcome/goal? The client will:
A. Turn in bed q2h.
B. Report the importance of applying
lotion to skin daily.
C. Have intact skin during
hospitalization.
D. Use a pressure-reducing mattress.
 Which of the following is an incorrect
statement of outcome criteria?
A. Ambulates 30 feet with cane after
discharge
B. Discusses fears and concerns regarding
surgical procedures during
preoperative teaching
C. Demonstrates proper coughing
technique after the teaching session
D. Reestablishes normal pattern of bowel
elimination
 Which of the following client
should be attended first by the
nurse?
A. The client with cough and colds
B. The client with pain on the chest
C. The client with fever due to
infection
D.The client who is for discharge
Which action would meet a
patient’s basic physiologic needs?
A. Raising the side rails
B. Providing a bed bath
C. Explaining procedures
D. Conversing with the patient
Which of the following is the primary
purpose of the evaluating phase of the
care-planning process to determine
whether?
A. Desired outcomes have been
met.
B. Nursing activities were carried
out.
C. Nursing activities were
effective.
D. Client’s condition has changed.
The client has a high-priority nursing
diagnosis of Risk for Impaired Skin Integrity
related to the need for several weeks of
imposed bed rest. The nurse evaluates the
client after 1 week and finds the skin integrity
is not impaired. When the care plan is
reviewed, the nurse should perform which of
the following?
A. Delete the diagnosis since the problem has
not occurred.
B. Keep the diagnosis since the risk factors are
still present.
C. Modify the nursing diagnosis to Impaired
Mobility.
D. Demote the nursing diagnosis to a lower
priority.
If the nurse planned to evaluate
the length of time clients must wait
for a nurse to respond to the client
need reported over the intercom
system on each shift, which of the
following processes does this
reflect?
A. Structure evaluation
B. Process evaluation
C. Outcome evaluation
D. Audit
After making a documentation error,
which action should the nurse take?
A. Use correcting liquid to cover the
mistake and make a new entry.
B. Draw a line through it and write
error above the entry.
C. Draw a line through it and write
mistaken entry above it.
D. Draw a line through the mistake
and write mistaken entry with
initials above it.
A 74-year-old female is brought to E.D.
c/o right hip pain. The right leg is shorter
than the left and is externally rotated.
During inspection, the nurse observes
what appears to be cigarette burns on
the client’s inner thighs. Which of the
following is the most appropriate
documentation?
A. Six round skin lesions partially
healed, on the inner thighs bilaterally
B. Several burned areas on both of the
client’s inner thighs
C. Multiple lesions on inner thighs
possibly related to elder abuse
D. Several lesions on inner thighs
similar to cigarette burns
Under what circumstances is it
considered acceptable practice for the
nurse to document a nursing activity
before it is carried out?
A. When the activity is routine (e.g.,
raising the bed rails)
B. When the activity occurs at regular
intervals (e.g., turning the client in
bed)
C. When the activity is to be carried
out immediately (e.g., a stat
medication)
D. It is never acceptable.