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Course: Fundamentals of Nursing

Topic: Nursing Process

The Nurses International Community

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Module Goals

Learners will be able to:

Define the Nursing Process
Explain the relationship between the nursing process and clinical judgment

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Basic Concepts

“Critical thinkers” possess certain attitudes that foster rational thinking including:

Independence of thought
Fair-mindedness: Treating every viewpoint with an unbiased perspective
Insight into egocentricity and sociocentricity: Thinking of the greater good and not just thinking of yourself
Intellectual humility: Recognizing your intellectual limitations and abilities
Nonjudgmental
Confidence: Believing in yourself to complete a task or activity
Curiosity: Asking “why” and wanting to know more

Ernstmeyer, & Christman, 2021

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Nursing Process

The nursing process is a critical thinking model based on a systematic approach to client-centered care

Nurses use the nursing process to perform clinical reasoning and make clinical judgments when providing client care

The nursing process is based on the Standards of Professional Nursing Practice established by the American Nurses Association (ANA).

Ernstmeyer, & Christman, 2021

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Nursing Process

Ernstmeyer, & Christman, 2021

Six components of the nursing process:

Assessment,
Diagnosis,
Outcomes Identification,
Planning,
Implementation, and
Evaluation

The mnemonic ADOPIE is an easy way to remember the nursing process

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Assessment

Ernstmeyer, & Christman, 2021

Is the first step in nursing process
The registered nurse collects pertinent data and information relative to the client’s health or the situation
Assessment includes:

Physiological data
Psychological
Sociocultural
Spiritual
Economic, and
Lifestyle data

assessment

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Assessment

There are two types of data collected using critical thinking;

Subjective Data and and Objective Data

Subjective data:

Verbal statements from the client or caregiver
Should be in quotation marks and start with verbiage such as, The client reports…
Example: The client reports, “My pain is a level 2 on a 1-10 scale.”
Two types:

Primary data: Information provided directly by the client
Secondary data: Information collected from a family member, chart, or other sources

Ernstmeyer, & Christman, 2021

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Assessment

Ernstmeyer, & Christman, 2021

Objective data:

Is anything that can be observed through the sense of hearing, sight, smell, and touch while assessing the client
Is measurable, tangible data such as:

Vital signs, intake and output, and height and weight
Physical examination findings, and laboratory results

An example is, “The client’s radial pulse is 58 and regular, and their skin feels warm and dry.”

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Assessment

Ernstmeyer, & Christman, 2021

Sources of assessment data include:

Interview/History taking
Physical Examination
Laboratory and diagnostic tests findings

Types of Assessment are:

Primary Survey
Admission Assessment
Ongoing Assessment
Focused Assessment
Time-lapsed Assessment

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Head to Toe Assessment

Doyle and McCutcheon, 2015

Head to Toe assessment is done on:

Client admission
At the beginning of each shift, and
when it is determined to be necessary by the client’s hemodynamic status and the context

Includes all the body systems, and the findings will inform the health care professional on the client’s overall condition
Any unusual findings should be followed up with a focused assessment specific to the affected body system

For the detailed bedside head to toe assessment:

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What Would the Nurse Do?

Miss Sharma, 52 yrs old, is admitted in a ward after visiting her physician because of shortness of breath, swelling in the ankles, and fatigue. Her medical history includes, hypertension for 5 years, and heart failure for 2 years. She takes metoprolol 50 mg twice a day. Her vitals on admission were:

BP: 160/100 mmHg, Spo2: 91% on room air, RR: 28 b/min

Her weight is up 5 pounds since her last office visit three weeks prior. The client states, “I am so short of breath” and “I am so tired and weak that I can’t get out of the house to shop for groceries and sometimes I’m afraid to get out of bed because I get so dizzy.” She confides, “I would like to learn more about my health so I can take better care of myself.” The physical assessment findings of Sharma are bilateral basilar crackles in the lungs and bilateral 2+ pitting edema of the ankles and feet.

Identify subjective and objective findings of Miss Sharma.

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Diagnosis

Performing Data analysis:

Analyze data for what is “expected” or “unexpected” or “normal” or “abnormal” according to their age, development, and baseline status
Example: Increase in blood pressure. This is called “relevant cues.”

Clustering Information/Identifying hypothesis for potential nursing diagnosis:

Assessment frameworks such as Gordon’s Functional Health Patterns assist nurses in clustering information according to evidence-based patterns of human responses

Ernstmeyer, & Christman, 2021

Contact info: info@nursesinternational.org

Gordon’s Functional Health Patterns

Health Perception-Health Management: A client’s perception of their health and well-being and how it is managed

Nutritional-Metabolic: Food and fluid consumption relative to metabolic need

Elimination: Excretory function, including bowel, bladder, and skin

Activity-Exercise: Exercise and daily activities

Sleep-Rest: Sleep, rest, and daily activities

Cognitive-Perceptual: Perception and cognition

Self-perception and Self-concept: Self-concept and perception of self-worth, self-competency, body image, and mood state

Role-Relationship: Role engagements and relationships

Sexuality-Reproductive: Reproduction and satisfaction or dissatisfaction with sexuality

Coping-Stress Tolerance: Coping and effectiveness in terms of stress tolerance

Value-Belief: Values, beliefs (including spiritual beliefs), and goals that guide choices and decision

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Establishing Nursing Diagnosis Statement

A nursing diagnosis statement should contain the problem, related factors, and defining characteristics

Problem (P): the client problem (i.e., the nursing diagnosis)
Etiology (E): related factors (i.e., the etiology/cause) of the nursing diagnosis; phrased as “related to” or “R/T”
Signs and Symptoms (S): Defining characteristics manifested by the client (i.e., the signs and symptoms/subjective and objective data) that led to the identification of that nursing diagnosis for the client; phrased as “as manifested by” or “as evidenced by”

Ernstmeyer, & Christman, 2021

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Diagnosis

The second step of the nursing process
A nursing diagnosis is the nurse’s clinical judgment about the client's response to actual or potential health conditions or needs
The registered nurse analyzes the assessment data to determine actual or potential diagnoses, problems, and issues
Analyzing assessment data includes followings steps:

Performing data analysis
Clustering information
Identifying hypothesis for potential nursing diagnosis
Performing additional in depth assessment as needed
Establishing nursing diagnosis statement

Ernstmeyer, & Christman, 2021

Contact info: info@nursesinternational.org

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Types of Nursing Diagnosis

There are four types of NANDA-I nursing diagnoses:

Problem-Focused
Health Promotion – Wellness
Risk
Syndrome

Problem Focused Nursing Diagnosis: contains all three components of the PES

Example: Fluid Volume Excess related to excessive fluid intake as manifested by bilateral basilar crackles in the lungs, bilateral 2+ pitting edema of the ankles and feet

Health-Promotion Nursing Diagnosis: contains the problem (P) and the defining characteristics (S)

Ernstmeyer, & Christman, 2021

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Types of Nursing Diagnosis

Health-Promotion Nursing Diagnosis: contains the problem (P) and the defining characteristics (S)

“A clinical judgment concerning motivation and desire to increase well-being and to actualize human health potential.”
Example: Enhanced Readiness for Health Promotion as manifested by expressed desire to “learn more about my health so I can take better care of myself.”

Risk Nursing Diagnosis: Consists of Problem (P) and as evidenced by- Risk factors for developing problem

Example: Risk for Falls as evidenced by dizziness and decreased lower extremity strength.

Ernstmeyer, & Christman, 2021

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Types of Nursing Diagnosis

Syndrome Diagnosis:
“Clinical judgment concerning a specific cluster of nursing diagnoses that occur together, and are best addressed together and through similar interventions.”
Consists of:

Problem (P): the syndrome
Signs and Symptoms (S): the defining characteristics are two or more similar nursing diagnoses
Example: Risk for Frail Elderly Syndrome related to activity intolerance, social isolation, and fear of falling.

Open Resources for Nursing, 2021

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Ernstmeyer, & Christman, 2021

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Prioritization

Ernstmeyer, & Christman, 2021

After identifying nursing diagnoses, the next step is prioritization according to the specific needs of the client

There are several concepts used to prioritize:
Maslow’s Hierarchy of Needs,
“ABCs” (Airway, Breathing and Circulation), and
Acute, uncompensated conditions

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What Would the Nurse Do?

Referring to the above case A. The nursing diagnoses identified are:

Fluid Volume Excess
Enhanced Readiness for Health Promotion
Risk for Falls

Which one should the nuese prioritize and why?

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Outcome Identification

Third step of the nursing process
“The registered nurse identifies expected outcomes for a plan individualized to the health care consumer or the situation.”
An outcome is a “measurable behavior demonstrated by the client responsive to nursing interventions”
Outcomes should be identified before nursing interventions are planned
Outcome identification includes:

Setting short- and long-term goals and
Creating specific expected outcome statements for each nursing diagnosis

Ernstmeyer, & Christman, 2021

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Outcome Identification

Ernstmeyer, & Christman, 2021

Expected outcomes are statements of measurable action for the client within a specific time frame that are responsive to nursing interventions
Outcome statements should contain five components:

Specific
Measurable
Attainable/Action oriented
Relevant/Realistic
Timeframe

Can easily remembered using the “SMART”

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Outcome Identification

Measurable: Example:

Not measurable: “The client will drink adequate fluid amounts every shift.”
Measurable: “The client will drink 24 ounces of fluids during every day shift (0600-1400)

Action Oriented and Attainable: Outcome statements should be written so that there is a clear action to be taken by the client

Not action-oriented: “The client will get increased physical activity.”
Action-oriented: “The client will list three types of aerobic activity that he would enjoy completing every week.”

Open Resources for Nursing, 2021

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Outcome Identification

Realistic and Relevant: Physical and mental condition, cultural and spiritual values, beliefs, and preferences; and socioeconomic status of the client should be consider to attain the outcomes

Not realistic: “The client will jog one mile every day when starting the exercise program.”
Realistic: “The client will walk ½ mile three times a week for two weeks.”

Time Limited: Outcome statements should include a time frame for evaluation and may evaluated every shift, daily, weekly or monthly

Not time limited: “The client will stop smoking cigarettes.”
Time limited: “The client will complete the smoking cessation plan by December 12, 2021.”

Ernstmeyer, & Christman, 2021

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Outcome Identification

Specific: Outcome statements should state precisely what is to be accomplished
Example:

Not specific: “The client will increase the amount of exercise.”
Specific: “The client will participate in a bicycling exercise session daily for 30 minutes.”
Additionally, only one action should be included in each expected outcome

Measurable: Measurable outcomes have numeric parameters or other concrete methods of judging whether the outcome was met

Use objective data to measure outcomes.

Ernstmeyer, & Christman, 2021

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Classification of Nursing Intervention

University of St.Augustine, 2021

There are three types of nursing interventions:

Independent
Dependent
Collaborative

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Classification of Nursing Intervention

Dependent: Requires a prescription before it can be performed.
Example: “Administer scheduled diuretics as prescribed.”
Independent: Nurse independently provides care without obtaining a prescription.

Example: 24 hour intake/output record for trends because of a risk for imbalanced fluid volume.

Collaborative: Intervention carries out in collaboration with other health team members, such as physicians, social workers, respiratory therapists, physical therapists, and occupational therapists.

Ernstmeyer, & Christman, 2021

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Implementation of Intervention

Fifth step of the nursing process
The registered nurse implements the identified plan
Requires the RN to use critical thinking and clinical judgment
Prioritizing Implementation of Interventions:

Maslow’s Hierarchy of Needs and the ABCs of airway, breathing, and circulation are used to establish top priority interventions

Client Safety:

Essential to consider client safety when implementing interventions

Ernstmeyer, & Christman, 2021

Contact info: info@nursesinternational.org

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Implementation of Nursing Interventions

Key Nursing Interventions to perform each shift are:

Pain control: Ensuring that the client is comfortable.
Position changes: Promoting position change to prevent bedsores.
Active listening: Listening to the client and repeating back information so they feel heard.
Cluster care: Informing other nurses and medical staff of the client’s needs each shift.
Fall prevention: Educating the elderly or recovering post-surgery clients to avoid the risk of fall and injury.
Fluid & Nutritional requirements: Encouraging intake if appropriate

University of St. Augustine, 2021

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Evaluation

The sixth step of the nursing process
Evaluates progress toward attainment of goals and outcomes
Both the client’s status and the effectiveness of the nursing care must be continuously evaluated, and the care plan modified as needed
Questions used as a guide when revising the nursing care plan are:

Did anything unanticipated occur?
Has the client’s condition changed?
Were the expected outcomes and their time frames realistic?
Are the nursing diagnoses accurate for this client at this time?

Ernstmeyer, & Christman, 2021

Contact info: info@nursesinternational.org

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Critical Thinking Question:

For Miss sharma Case, priority nursing diagnosis statement was Fluid Volume Excess related to excess fluid intake as manifested by bilateral basilar crackles in the lungs,bilateral 2+ pitting edema of the ankles and feet, an increase weight of 5 pounds, and the client reports, “My ankles are so swollen.”

What would be the expected outcome?

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References

Doyle, GR., & McCutcheon, JA., (2015). Head -to- Toe Assessment. Clinical Procedure for Safer Patients Care. https://opentextbc.ca/clinicalskills/chapter/2-2-head-to-toe-assessment-checklist/

Ernstmeyer, K., & Christman, E. (Eds.). (2021). Open RN Nursing Fundamentals by Chippewa Valley Technical College is licensed under CC BY 4.0.. https://wtcs.pressbooks.pub/nursingfundamentals/

Jones, AD., 2016. Bedside Assessment and Documentation Basics: A Pocket Card for Beginning Nursing Students. QSBEN Institute.

https://qsen.org/bedside-assessment-and-documentation-basics-a-pocket-card-for-beginning-nursing-students/

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References

Toney-Butler TJ, Thayer JM. Nursing Process. [Updated 2020 Jul 10]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2021 Jan- https://www.ncbi.nlm.nih.gov/books/NBK499937/

University of St. Augustine, (2021). Nursing Interventions and Their Role in client Care. https://www.usa.edu/blog/nursing-interventions/

University of St, Augustine, (2021). How to Write a Care Plan: A Guide for Nurses. https://www.usa.edu/blog/how-to-write-a-care-plan/

https://www.youtube.com/watch?v=J0JCM3f6lPU

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