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

 5 steps
  • Assess
  • Diagnose
  • Plan
  • Implement
  • Evaluate
4 steps
  • Assess
    • diagnose
  • Plan
  • Implement
  • Evaluate

Step 1 Assessment

Validate

Communicate

Types of data

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

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

 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)

 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

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

Pattern recognition is a characteristic of critical thinking!

Organize/cluster data by:

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

E/Etiology

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

Planning

1. Set priorities

2. Determine goals

3. Develop expected outcomes

4. Design nursing interventions

5. Write Nursing Care Plan

6. Record and modify

Write 

Goals

Expected Outcomes

Nursing orders
(i.e. develop the nursing care plan)

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

Nursing Orders 

1. Assess for gag reflex.

2. Cleanse mouth with H2O2

3. Apply thin layer of petroleum jelly to lips.

Scientific Rationale

 1. Intact gag reflex prevents aspiration. (Potter, 1999, p.121)

2. Dilute solution of H2O2 (1:1) hydrogen peroxide acts as an antiinfective and loosens debris. (Perry, 1996, p.77)

 3. Lubricates lips to prevent drying and cracking.(Taylor & Perry, 1998, p. 348)

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

Goal  ExpOut Client Response  Evaluation
Pt will self-administer insulin by 9/23. Pt will demo self-injection by 9/23. Pt administered accurate dosage correctly on 9/23. Goal was met.
Pt will be able to perform ADLs w/o discomfort in 3 days (9/22). Pt will verbalize pain of 3 on 10-point scale within 3 days  (9/22).  Pt reports R-sided abdominal pain  at 5/10 while bathing on 9/22.  Goal not met.

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.