The Nursing Process

Module G

HOW OBERVANT ARE YOU????

Looking,
Listening, Feeling,
Smelling ---Do the above in
order too ---Assess, Diagnosis,
Plan, Implement,
and Evaluate

THE NURSING PROCESS 5 STEPS

1. Assessment
2. Diagnosis
3. Planning
4. Implementation
5. Evaluation
Each step is
dependent on the
accuracy of the step
preceding it.

AssessmentData Collection is a Primary Tool

Puzzle Pieces
Gathering Info about pt
Data collection requires us to
examine the data
Does it fit the picture?
Formal vs Informal
Pt is our primary source for
this data
What are secondary sources?

Focus vs Data Base Assessment

Focus Asst is
performed to gather
detailed information
about a specific condition.
Baseline Data - is
gathered on initial contact
with pt to gather info
about all aspects of
health status

Two Types of Data

S Subjective - What the

patient tells you
Subjective = Statements
Im itching
O Objective Detectable
by an observer or can be
tested
O = Objective
What are some examples?

Nursing Diagnosis Process

Data Validation \

>
Data Clustering /

Interpretation of
Data
\/
Identification of
Client needs
\/
Formulation of
Nursing Diagnosis

Organizing Data

Your assessment tool

will assist you with
this
Clustering into
categories helps you
get a better picture
Maslows Heiarchary
of Needs helps you
too

Steps in Data Analysis

1. Do you see a pattern or

trend
2. Compare your data to
Standards (Norms) i.e., B/P
168/102 (Normal 110/70)
Rales heard in lung fields
( Normal clear lung sounds)
3. Make a reasonable
conclusion

Four Methods Nurses use to:

Collect Data

1. Interview
2. Nursing Health
History
3. Physical
Examination
Head
4. Diagnostic and
Laboratory
Results

Whats Next ????

Once data collection & analysis is complete

we next DIAGNOSE using NANDA. You are
looking for the Diagnostic label (NANDA)
that addresses the problem.
Problem is an unmet need or anything
that interferes with a persons ability to
meet their needs.
Related factors Etiology : Follows the
Diagnostic label & directs interventions
Ex: Impaired skin integrity R/T immobility

Three Types of Diagnoses

Actual

Risk for

Wellness

Legalities in Stating Nursing

Diagnoses

Dont write the diagnostic statement in such a

way that it may be legally incriminating.
High risk for injury R/T Lack of side rails or
High Risk for injury R/T Disorientation
Dont state the Nsg Dx using medical
terminology; focus on the persons response to
the medical problems
Mastectomy R/T Cancer vs.
Body Image disturbance R/T effects of surgical
procedure.
Dont use 2 problems @ the same time.

Planning

Setting
Establish:

Address: 7 guidelines when writing goals

and outcomes

1. Realistic patient-centered goals

2. Measurable goal criteria

1.
3.
5.
7.

Patient centered
Observable
Time Limited
Realistic

2. Singular
4. Measurable
6. Mutual

Two Types of Goals: Short vs. Long Term

Planning Determining Nursing

Interventions

Types: Nurse Initiated,

Physician initiated,
Collaborative
Elements:
Requires decision making
Scientific rationale based
Psychomotor & IPR skills
Clinical functioning
Address: Who, What, When,
Where, How

Components of a Goal

Subject
Behavior
Condition (Time)
Criteria List
Each is a separate outcome
Each is specific & concrete
Each is measurable, seen,
heard, felt, observable
Must R/T goal
Realistic

Implementation

The actual process of

putting the PLAN into
action, a team effort
including:
1. Reporting
2. Performing the care
3. Setting Priorities
4. Documentation
5. Assessing &
reassessing
6. Adhere to polices

Evaluation

To judge or appraise
Determine if expected
outcomnes were met
A constant on-going
process for
determining if patient
goal(s) are being met
or if patient needs are
changing
3 Goal Possibilities:
Met, Partially Met, Not
Met

Nursing Process is Dependent On:

Knowledge
What to
Why
Skills
How to
Caring
Willing to
Able to

Critical Thinking? Who needs it?

Critical Thinkers look

beyond the obvious =
Sound Judgment
Sound Judgments =
Safe Care
Safe Care =
Accountability because
we critically think.

Questions often asked by critical

thinkers

What if? Do I have

enough data (facts)?
How can I? How could I
have missed that? What
did I assume & why?
What did I learn about?
*Critical Thinkers are
always learning.

Critical Thinking

Confidence
Contextual perspective
Creativity
Flexibility
Inquisitiveness
Intellectual integrity
Intuition
Open=Minded
Persistence
Reflection
= Habits of the Mind