Nursing Process

Last Updated: Friday January 24, 2003

Mr R. is a 72-year-old man who suffered a "stroke" at home two days ago. He was admitted to your unit from the emergency room after being discovered at home today by his daughter. His condition is stable but he has very limited movement in his extremities. He shows evidence of dehydration: decreased skin turgor, dry lips and mucous membranes, low urinary output.

Height: 5" 10" Weight: 138 lbs

He is on bedrest and IV fluids.

PA Nurse Practice Act and ANA defines nursing as the diagnosis and treatment of human responses to actual and potential health problems

Nursing Process

Step 1 Assessment

• Initial step
• ongoing/ component of every step
• Collect data

Validate

Communicate

Types of data

• Subjective
• Objective

Subjective

	"symptom"
	information apparent only to person experiencing it
	cannot be validated by someone else for example
	includes pts perception of his situation-human response

Objective

	"sign"
	can be observed - seen, heard, felt smelled
	can compare to some standard

e.g. increased pulse rate BUT. due to

temp environment anxiety etc.

Sources of data

• Primary 
  • always the patient
• Secondary
  • family, S/O other health care personnel, medical records, lab reports, literature

For Mr. R:

Subjective data

 primary
 secondary

Objective data

 primary
 secondary

Data

	should describe, not interpret be relevant
	Data collection should involve active participation by client (individual, family or community) and nurse

How do I get these data?

Go through the process of assessment

Assessment

•  Initial assessment is the basis for the nursing care plan
•  Include actual and potential health problems

 Establish a data base

1.  nursing history
2. physical examination
3. review records and literature
4. consultation

1. Components on Nursing History

	Biographical information
	reasons for seeking health care
	present illness, health concern (HPI)
	past health history (PMH)
	family history (genogram)
	environmental history
	psychosocial/cultural history
	review of systems (ROS)

•  Most institutions have a nursing history or nursing admission form
•  There is some organizing framework
•  include pts perception of current health status and its meaning to pt and others

 Use communication techniques to conduct interview, obtain nursing health history

 Examples

 Does the pt have the right to refuse to answer questions?

 Maintain cofidentiality

2. Physical Examination

	Explain
	get permission
	assure privacy

 

	Height, weight, vital signs
	General survey

- mental status

- development

- nutritional status

- gender, race

- appearance

- speech

	Systematic head-to-toe exam
	Diagnostic and laboratory data

Techniques of Physical Assessment

•  Inspection
•  Palpation
•  Percussion
•  Auscultation

And then remember the Dick-and-Jane books and the first word you learned - the biggest word of all -

Look

 Inspection

deliberate visual exam

 Palpation

gather data with hands via sense of touch
feel skin and underlying tissue to detect/describe:

temp, texture, vibration, pulsation
mass,size, consistency, tenderness

 Percussion

tap body surfaces to produce vibration and sound

 Auscultation

listen to sounds produced by body heart, lung , bowel sounds, BP

Validate data

	support your findings
	integrate data from multiple sources
	review omissions
	check for inconsistencies
	consult

OK - what is relevant, significant, meaningful???

Interpret/analyze/cluster data

• look for patterns or cues

Pattern recognition is a characteristic of critical thinking!

Organize/cluster data by:

• Body systems
• Functional health patterns
• Nursing model

Problem List

	Interpret
	Make judgment about meaning of data Do pt needs require nursing intervention
	List problems in your own words

Assessment Conclusions

1. No problem evident (WNL)

- address risk factors

- consider pt strengths and resources

- possible health promotion activities

2. Collaborative problem

- consult, refer

3. Problem which requires nursing intervention

- problem list

- Nursing Diagnosis

>> actual, potential

Nursing Diagnosis

A statement that describes actual or potential health problems that can be prevented or resolved by independent nursing intervention

NANDA Definition:

Nursing diagnosis is a clinical judgment about individual, family, or community responses to actual and potential health problems/life processes. Nursing diagnoses provide the basis for selection of nursing interventions to achieve outcomes for which the nurse is accountable.

Form for writing Nursing Diagnosis

P - problem diagnostic statement (NANDA)

E - etiology/related to cause or contributing factor

Characteristics of a Diagnostic Statement

	is clear and concise
	is specific and patient centered
	relates to one pt problem
	is accurate
	is based on reliable and relevant assessment data

P: pain

E: surgical trauma

P: altered nutrition, less than body req.

E: lack of knowledge of calorie content, lack of exercise

P: high risk for injury

E: effects of narcotics,

weakness 20 bedrest

P: Problem statement (NANDA)

 Goal Statement

E: Etiology/causative factors

 Nursing actions

P/Problem statement

• identifies unhealthy response
• indicates what should change
• suggests pt goals (expectations for change)

E/Etiology

• identifies causative or contributing factors
• suggests nursing interventions

 Let's develop some diagnostic statements for Mr. R.

Planning

•  Patient-centered goals are established
•  Strategies are designed to meet goals

1. Set priorities

2. Determine goals

3. Develop expected outcomes

4. Design nursing interventions

5. Write Nursing Care Plan

6. Record and modify

Goals could be considered Long Term

Expected Outcomes " Short Term

Nursing diagnosis guides the type of goal

oriented toward: 

health restoration

health  maintenance

health promotion

Nursing care plan

written guideline for client care 
coordinates/communicates care
promotes continuity
lists outcomes/criteria to be evaluated

Nursing care plans vary depending on pt population, setting

 Institutional care plans may be

 3 column:

Problem

Goal

Nursing action

 4 column:

NDx

Goal

Nursing action

Eval

  5 column:

Assessment

NDx

Goal

Nursing action

Eval

Standardized care plans

include generalized

NDx

Goals

Nursing actions

Eval/Outcome criteria

Student care plans

include

NDx

Goals

Nursing actions

Scientific Rationale

Eval

Goals/Expected outcomes

	Anticipated patient responses
	specific statements of pt behavior or response that nurse anticipates from nursing care
	formulated for each diagnosis

Tips for writing goals

	Write a goal for each nsg dx
	Write step-by-step expected outcomes for each goal

helps to:

•  guide nursing actions
•  evaluate goal achievement

Guidelines for writing goals and Expected Outcomes

	Client-centered
	singular
	observable
	measurable
	time-limited
	mutual
	realistic

Formula for Writing Goals/Outcomes

Goal statement (long or short term) = patient behavior + criteria + time + conditions (if needed)

1. Subject - patient

2. Verb - action/behavior which pt performs

3. Criteria - acceptable performance

How well How far How long How much

4. Within specified time period

5. Condition (if needed) circumstances under which behavior performed

Example:

The patient (1) will walk (2) the length of the hall (3) with a walker (5) by the end of the shift (4).

P: high risk for impaired skin integrity

E: immobility, dehydration

Goal: TPW maintain intact skin.

P: high risk for impaired skin integrity

E: immobility, dehydration

Goal: TPW maintain intact skin.

Expected Outcomes: The pt will

1. change position every 2 hours

2. avoid pressure on bony prominences

3. maintain clean, well-hydrated skin

4. Drink 1000 cc liquid/24 hours

7 - 3 500 cc

3 - 11 400 cc

11- 7 100 cc

Nursing orders

May be called Implementation or Intervention

Actions designed to help pt achieve established goals

Developed according to standard of care

Examine alternative possible strategies Choose based on assessment and REASON for action

Scientific Rationale

	Explains WHY the nurse planned that action to help pt achieve goal
	researched data obtained from texts, journals, etc.
	Appears on student care plans, not in "real life"

SAMPLE

Mouth Care for the Unconscious Patient

Implementation

	Continue to assess pt
	Modify care plan
	Implement nursing orders
	Communicate nursing interventions

Evaluation

Compare ongoing assessment data with expected outcomes

1. Were goals, expected outcomes met

2. Did pt exhibit expected physiological response or behaviors

And

3. Quality assurance - evaluation of nursing and health care services based on legal guidelines and professional standards

Sample: Evaluation of Goal Achievement

Mr R. is a 72-year-old man who suffered a "stroke" at home two days ago. He was admitted to your unit from the emergency room after being discovered at home today by his daughter. His condition is stable but he has very limited movement in his extremities.  

He shows evidence of dehydration: decreased skin turgor, dry lips and  mucous membranes, low urinary output.

Height: 5" 10" Weight: 138 lbs

He is on bedrest and IV fluids.

P: high risk for impaired skin integrity

E: immobility, dehydration

Goal:
TPW maintain intact skin.

Expected Outcomes: The pt will

1. change position every 2 hours

2. avoid pressure on bony prominences

3. maintain clean, well-hydrated skin

4. Drink 1000 cc liquid/24 hours

7 - 3 500 cc

3 - 11 400 cc

11- 7 100 cc

Nursing Orders

1.TNW

2.

3.

4.