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A comprehensive overview of the nursing process, outlining its five key stages: assessment, diagnosis, planning, implementation, and evaluation. It delves into each stage in detail, explaining the steps involved, key considerations, and examples. The document also highlights the importance of patient-centered care, communication, and documentation in the nursing process. It is a valuable resource for nursing students seeking to understand the fundamental principles and practices of nursing care.
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Describe the Nursing Process
Assessment
Diagnosis
Planning
Implementation
Evaluation
Define Assessment
Systematic and continuous collection, analysis, validation and communication of patient data
Steps Preparing for data collection
Collecting data
Identifying cues and making inferences
Validating data
Clustering related data and identifying patterns
Reporting and recording data
Steps of Data interpretation & Analysis
Recognizing: Reorganizing significant data comparing data to standards
Recognizing: Recognizing patterns or clustersIdentifying: Identifying strengths and current or potential problems
Identifying: Identifying potential complications
Reaching: Reaching conclusions
Partnering: Partnering with the patient and family
Diagnosis
Problem identification
Planning
Establish priorities
Identify expected patient outcomes
Promote nurse's professional development
Implementation
Carry out the plan
Continue data collection and modify the plan of care as needed
Document care
Purpose of Implementation
Help the patient achieve valued health outcomes
promote health
prevent disease and illness
Restore health
Facilitate coping with altered functioning
Evaluation
Measure how well the patient has achieved desired outcomes
Identify factors contributing to the patient's success or failure
Mostly the plan of care, if indicated
Database
Includes all the pertinent patient information collected by the nurse and other providers
Nursing history
identifies the patient's health status, strengths, actual and potential health problems, health risks, and needs for nursing care
Communication errors to avoid
Using first names without permission
Using honey, dear, sweetie, pop, grandma, or other terms of endearment
Talking down (ex. so you have a pain in your tummy?)
Using medical terminology with lay people
Ignoring patients' nonverbal communication
Initial assessment
scheduled to compare a patient's current status to the baseline data obtained earlier
Triage
screen patients to determine the extent and severity of the problems and recommend the appropriate follow ups
Patient-Centered Assessment Method (PCAM)
a tool health care practitioners can use to assess patient complexity using the social determinants of health; PCAM helps gain understanding of
health and wellbeing
social environment
Health literacy and communication skills
Minimum data set
information that must be collected from every patient and uses a structured assessment form to organize or cluster their data.
Subjective data
information perceived only by the affected person; these data cannot be perceived or verified or another person; also known as symptoms or covert data
ex. feeling nervous, nausea, or chilly, and experiencing pain
Objective data
observable and measurable data that can be seen, heard, felt, or measured by someone other than the person experiencing them
temperature reading
HELP Mnemonic for Patient Observation
Help: Observe the first signs patients may need help; look for distress signals (pallor, pain, labored breathing)
Environmental equipment: Look for safety hazards; ensure that all equipment is working (IVs, oxygen, catheter)
Look: Examine the patient thoroughly
People: Who are the people in the room? What are they doing?
Interview
planned communication that occurs in four phases (preparatory phase, introduction, working phase, and termination)
Physical assessment
the examination of the patient for objective data that may better define the patient's condition and help the nurse plan care
normally following the nursing history and interview
Nursing physical assessment focuses on the patient's functional abilities; aims to appraise health status
Review of Systems
Nursing physical assessment involves the examination of all body systems using this head to toe format
Four methods to collect data for physical assessment
Inspection
Palpation
Percussion
Auscultation
Inspection
the process of performing deliberate, purposeful observations in a systematic manner
Palpation
use of the sense of touch to assess skin temperature, turgor, texture, and moisture as well as vibrations within the body
Percussion
the act of striking one a=object against another to produce a sound
Auscultation
the act of listening with a stethoscope to sounds produced within the body
Actual or potential health problems that can be presented or resolved by independent nursing intervention
Medical diagnosis
identify diseases, whereas problem statements focus on unhealthy responses to health and illness; focus on correcting or preventing pathology of specific organs or body systems
Diagnostic error
erroneously labeling selected patient health patterns as unhealthy while failing to detect actual unhealthy behavior
Standard
a generally accepted rule, measure, pattern, or model to which data can be compared in the same class or category
problem-focused nursing diagnosis
clinical judgment concerning an undesirable human response to a health condition/life process that exists in an individual, family, group, or community
Risk nrusing diagnosis
clinical judgment concerning the vulnerability of an individual, family, group, or community for developing an undesirable human response to health conditions/life processes
Health promotion nursing diagnosis
a clinical judgment concerning motivation and desire to increase well- being and to actualize human health potential
Problem
identified what is unhealthy about the patient, indicating the need for change (clear, concise statement of the patient's health problem)
suggests the patients outcomes (expectations for change)
Ex. activities of daily living deficit
specific, measurable criteria used to evaluate the extent to which a goal has been met
Initial planning
performed by the nurse with the admission nursing history and the physical assessment; addresses each problem listed in the prioritized nursing diagnosis and identified patient goals related to nursing care
Begin educating the patient at admission
ongoing planning
Carried out by any nurse who interacts with the patient
Keeps the plan up to date, manages risk factors, promotes function
States problem statements more clearly
Develops new problem statements
Makes outcomes more realistic and develops new outcomes as needed
Identifies nursing interventions to accomplish patient goals
Discharge
Carried out by the nurse who worked most closely with the patient
Begins when the patient is admitted for treatment
Uses teaching and counseling skills effectively to ensure that home behaviors are performed competently
Discharge begins when the patient is admitted to the floor
Standardized care plans
prepared care plans that identify the nursing diagnosis, outcomes, and related nursing interventions common to a specific population or health problem.
Ongoing plan
carried out by any nurse who interacts with the patient and aims to keep the plan up to date to facilitate the resolution of health problems, manage risk factors, and promote function
describe increases in patient knowledge or intellectual behavior
Psychomotor outcomes
describe the patient's achievement of new skills
Affective outcomes
describe changes in patients values, beliefs, and attitudes
Clinical outcomes
describe the expected status of health issues at certain points in time, after treatment is complete. They address whether the problems are resolved or to what degree they are improved
Functional outcomes
describe the person's ability to function in relation to the desired usual activities
Quality-of-life outcomes
focus on key factors that affect someone's ability to enjoy life and achieve personal goals
SMART - writing goals and patient outcomes
S: Specific
M: Measurable
A: Attainable
R: Realistic
T: Time bound
Ensuring Quality Outcomes
Safe: avoiding injury
Effective: avoiding overuse and underuse
Patient centered: responding to patient preferences, needs, and values
Timely: reducing waits and delays
Efficient: avoiding waste
Equitable: providing care that does not vary in quality to all recipients
