Nursing Process

Author: Meredith Scannell RN, MSN, MPH,

Nursing Process

• Specific to the nursing profession

• A frame work for critical thinking

• Its purpose is to:“Diagnosis and treat human responses

to actual or potential health problems.”

Nursing Process

• Organized framework to guide practice• Problem solving method• Patient focus• Systematic• Goal oriented• Dynamic • Utilizes critical think process

Nursing Process • Promotes continuity of care• Promotes more effective

communication• Develops clear plan of action

Following the Nursing Process

• Five steps are recognized as the universal approach to nursing practice. 

1. Nursing Assessment

2. Nursing Diagnosis3. Planning4. Implementation5. Evaluation

Nursing Assessment

• Interview patient, primary source

• Collecting Data• Health assessment• Observations• Signs and Symptoms• Review medical chart

and records

Obstetrical Nursing Assessment

Objective:Vital Signs: T 98.2 TA HR 72 B/P 116/64 Resp 18Pain Level: 4 (scale 1/10)B: Breasts soft, nipples intact. U: Uterus firm and midline, 1 fb below umbilicus B: Voiding QSB: Positive bowel sounds, all four quadrants.LBM: 2/4L: Moderate amount of lochia serosa E: REEDA; Abdominal incision: OTA, steri strips in tact. No redness, no drainage, no echymosis no edema, well approximatedH: Neg Homan’s sign, trace pedal edemaE: Pt. appears confident in breast feeding

Nursing Diagnosis • Interpret and analyze data

• Formulate nursing Diagnosis based on NANDA North American Nursing Diagnosis Association.

• Established in 1973 to identify standards and classify health problems treated by nurses

• Statement of how the patient is responding to an actual or potential problem that requires a nursing intervention.

Nursing Diagnosis

• Within the scope of nursing practice.

• Identify responses to health and illness.

• Can change from day to day• Actual problem, risk,

wellness diagnosis

Nursing Diagnosis

• 3 Parts:• Problem statement:

response to a problem.• Etiology: what’s

causing/contributing to the problem.

• Defining characteristics: what’s the evidence.

Nursing Diagnosis

Problem( Diagnostic Label)-based on your assessment of patient…(gathered information), pick a problem from the NANDA

Etiology- determine what the problem is caused by or related to (R/T)

Defining characteristics- then state as evidenced by (AEB) the specific facts the problem is based on

Example Nursing Diagnosis

Deficient fluid volume r/t fluid shift from intravascular to extravascular space AEB +3 pitting edema on lower extremities.

Pain: Acute r/t abdominal surgical trauma AEB pain rated 4/10 while ambulating.

Legal ramifications

•A nurse can only identify problems within the scope of practice

•A nurse cannot diagnose or treat medical disease

•A nurse must identify problems within his/her scope of practice, abilities and education

Planning

• Setting goals of care and desired outcomes.

• Identifying appropriate nursing actions.

• Expected outcomes are identified

Planning • Prioritizing list of needs

• Client Specific• Priorities can change• Differences in priorities

Implementation

• Performing the nursing actions identified in planning

• Interventions• Actions designed to assist

patients in moving from the present level of health to that which is describe in the goal and measured with the outcome criteria.

• Utilizes critical thinking

Interventions

• Nurse-Initiated• Physician initiated• Collaborative interventions• Standing orders• Protocols

Evaluation

• Determine if the goals were met.• Determine if outcomes were

achieved.• Appropriately revise care plan

based on patient’s response.• Worsening signs and symptoms or lack

of response require modification.• Prompt documentation.• Communicate effectiveness of

treatment.

The End