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.
Assessment-
Data 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 Ass’t – 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
“I’m itching”
O – Objective – Detectable
by an observer or can be
tested
O = Objective
What are some examples?
Nursing Diagnosis Process
Data Validation \
> Interpretation of
Data Clustering / 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
Maslow’s 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
What’s 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
Don’t 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
Don’t state the Nsg Dx using medical
terminology; focus on the person’s response to
the medical problems
Mastectomy R/T Cancer vs.
Body Image disturbance R/T effects of surgical
procedure.
Don’t use 2 problems @ the same time.
Planning
Setting
Establish:
1. Realistic patient-centered goals
2. Measurable goal criteria
Address: 7 guidelines when writing goals
and outcomes
1. Patient centered 2. Singular
3. Observable 4. Measurable
5. Time Limited 6. Mutual
7. Realistic
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