Nursing Process Nursing Process

The nursing process is based on a nursing theory developed by Ida Jean Orlando. She developed this theory in the late 1950's as she observed nurses in action. She saw "good" nursing and "bad" nursing.

From her observations she learned that the patient must be the central character. Nursing care needs to be directed at improving outcomes for the

patient, and not about nursing goals. The nursing process is an essential part of the nursing care plan.

Nursing Process

A systematic, rational method of planning and providing individualized nursing care

Historical Development of the Nursing Process

1955—nursing process term used by Hall

1960s—specific steps delineated

1967—Yura and Walsh published first comprehensive book on nursing process

1973—ANA Congress for Nursing Practice developed Standard of Practice

1982—state board examinations for professional nursing uses nursing process as organizing concept

Five Steps of the Nursing Process

Assessing—collecting, validating, and communicating of patient data

Diagnosing—analyzing patient data to identify patient strengths and problems

Planning—specifying patient outcomes and related nursing interventions

Implementing—carrying out the plan of care

Evaluating—measuring extent to which patient achieved outcomes

Question

Which step of the nursing process is a nurse using when she analyzes patient data to determine her patient’s strengths following a CVA?

A. Assessing

B. Diagnosing

C. Planning

D. Implementing

E. Evaluating

Answer

Answer: B. Diagnosing

Rationale:

The diagnosing step involves analyzing patient data to determine strengths and weaknesses.

The assessing step refers to the collection, validation, and communication of patient data.

In the planning step, the nurse determines patient outcomes and related nursing interventions, and in the Implementing step, the nurse carries out the plan.

When evaluating, the nurse measures the extent to which the patient achieved outcomes.

The Steps of the Nursing Process

Question

Which of the following characteristics of the nursing process describes the interaction and overlapping of steps within the process itself?

A. Systematic

B. Dynamic

C. Interpersonal

D. Universally Applicable

Answer

Answer: B. Dynamic

Rationale:

The nursing process is dynamic in that there is much interaction and overlapping of the steps.

It is systematic since it is an ordered sequence of activities.

Interpersonal refers to the human being at the heart of nursing.

The nursing process is universally applicable in that it is a framework for all nursing activities.

Characteristics of the Nursing Process

Systematic—part of an ordered sequence of activities

Dynamic—great interaction and overlapping among the five steps

Interpersonal—human being is always at the heart of nursing

Outcome oriented—nurses and patients work together to identify outcomes

Universally applicable—a framework for all nursing activities

Problem Solving and the Nursing Process

Trial-and-error problem solving

Scientific problem solving

Intuitive thinking

Critical thinking

Question

Tell whether the following statement is true or false.

Critical thinking occurs when a nurse directly apprehends a situation based on its similarity or dissimilarity to other situations.

A. True

B. False

Answer

Answer: B. False

Intuitive thinking occurs when a nurse directly apprehends a situation based on its similarity or dissimilarity to other situations.

Assessing: The Primary Source of Information Is the

Patient

Objective data Observable and measurable data that can be seen, heard,

or felt by someone other than the person experiencing them

For example, elevated temperature, skin moisture, vomiting

Subjective data Information perceived only by the affected person For example, pain experience, feeling dizzy, feeling anxious

Objective Data vs. Subjective Data

Nursing Diagnosis

Types:

Actual

Risk

Possible

Wellness

Syndrome

Diagnosing

Defining characteristics—identifies the subjective and objective data that signal the existence of a problem

Problem—identifies what is unhealthy about patient

Etiology—identifies factors maintaining the unhealthy state

Formulation of Nursing Diagnoses

Question

A patient who admits to smoking two packs of cigarettes a day is diagnosed with lung cancer based on his symptoms and a series of test results. Which of the following is the etiology in this scenario?

A. Lung cancer

B. Test results

C. Smoking cigarettes

D. The subjective and objective data

Answer

Answer: C. Smoking cigarettes

Rationale:

The etiology is the factor that maintains the unhealthy condition (smoking cigarettes). Lung cancer is the problem, and the remaining factors are the distinguishing characteristics.

Question

Which of the following nursing diagnoses is written correctly?

A. Child Abuse related to maternal hostility

B. Breast Cancer related to family history

C. Deficient Knowledge related to alteration in diet

D. Imbalanced Nutrition related to insufficient funds in meal budget

Answer

Answer: D. Imbalanced Nutrition related to insufficient funds in meal budget

Rationale:

Answer A makes legally inadvisable statements, answer B is a medical diagnosis, and answer C reverses the clauses in the statement.

Premature diagnoses based on incomplete database

Erroneous diagnoses resulting from inaccurate or faulty database

Routine diagnoses resulting from failure to tailor data to patient

Errors of omission

Common Sources of Error in Nursing Diagnoses

If used incorrectly, patient might be “misdiagnosed.”

Nursing practice might be restricted.

Limitations of Nursing Diagnosis

Question

Which of the following nursing diagnoses would most likely be considered a high priority?

A. Disturbed personal identity

B. Impaired gas exchange

C. Risk for powerlessness

D. Activity intolerance

Answer

Answer: B. Impaired gas exchange

Rationale:

Impaired gas exchange poses a threat to the patient’s well-being.

Disturbed personal identity and risk for powerlessness are non–life-threatening and are ranked as medium priorities.

Activity intolerance, if not specifically related to the current health problem, is a low priority.

Physiologic needs

Safety needs

Love and belonging needs

Self-esteem needs

Self-actualization needs

Maslow’s Hierarchy of Human Needs

Planning

Establish priorities.

Identify and write expected patient outcomes.

Select evidence-based nursing interventions.

Communicate the plan of care.

Outcome Identification & Planning

Three Elements of Comprehensive Planning

Initial

Ongoing

Discharge

Initial Planning

Developed by the nurse who performs the nursing history and physical assessment

Addresses each problem listed in the prioritized nursing diagnoses

Identifies appropriate patient goals and related nursing care

Ongoing Planning

Carried out by any nurse who interacts with patient

Keeps the plan up to date

States nursing diagnoses more clearly

Develops new diagnoses

Makes outcomes more realistic and develops new outcomes as needed

Identifies nursing interventions to accomplish patient goals

Discharge Planning

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 home care behaviors are performed competently

Long-term—requires a longer period to be achieved and may be used as discharge goals

Short-term—may be accomplished in a specified period of time

Long-Term vs. Short-Term Outcomes

Expressing patient outcome as nursing intervention

Using verbs that are not observable or measurable

Including more than one patient behavior or manifestation in short-term outcomes

Writing vague outcomes

Common Errors in Writing Patient Outcomes

Failure to involve patient

Insufficient data collection

Nursing diagnoses developed from inaccurate or insufficient data

Outcomes stated too broadly

Outcomes derived from poorly developed nursing diagnoses

Failure to write nursing order clearly

Nursing orders that do not solve problems

Failure to update the plan of care

Problems Related to Outcome Identification and

Planning

Subject

Verb

Conditions

Performance criteria

Target time

Parts of a Measurable Outcome

Question

Which one of the following nursing actions would most likely occur during the ongoing planning stage of the comprehensive care plan?

A. The nurse collects new data and uses them to update the plan and resolve health problems.

B. The nurse uses teaching and counseling skills to help the patient carry out self-care behaviors at home.

C. The nurse who performs the admission nursing history develops a patient care plan.

D. The nurse consults standardized care plans to identify nursing diagnoses, outcomes, and interventions.

Answer

Answer: A. The nurse collects new data and uses them to update the plan and resolve health problems.

Rationale:

In the ongoing planning stage, any nurse who interacts with the patient updates the plan to facilitate the resolution of health problems, manage risk factors, and promote function.

Teaching and counseling are the key to discharge planning.

The nurse performing the admission nursing history consults standardized care plans during initial planning to formulate the initial care plan.

Nursing Intervention/Implementatio

n

Types of Nursing Interventions

Independent nursing actions Nurse-initiated interventions

Protocols Standing orders

Collaborative nursing actions Physician-initiated interventions Collaborative interventions

Question

Tell whether the following statement is true or false.

A nurse who follows the protocol for taking vital signs following surgery is performing a physician-initiated intervention.

A. True

B. False

Answer

Answer: B. False

A nurse who follows the protocol for taking vital signs following surgery is performing a nurse-initiated intervention.

Lack of family support

Lack of understanding about the benefits

Low value attached to outcomes

Adverse physical or emotional effects of treatment

Inability to afford treatment

Common Reasons for Noncompliance

Question

Tell whether the following statement is true or false.

When a patient fails to cooperate with the plan of care despite the nurse’s best efforts, it is time to reassign the patient to another caretaker.

A. True

B. False

Answer

Answer: B. False

When a patient fails to cooperate with the plan of care despite the nurse’s best efforts, it is time to reassess the strategy.

Evaluation

Evaluating Step

Allows achievement of outcomes

Directs nurse–patient interactions

Measures patient outcome achievement

Identifies factors to achieve outcomes

Modifies the plan of care, if necessary

Question

Tell whether the following statement is true or false.

The purpose of evaluation is to allow the patient’s achievement of expected outcomes to direct future nurse–patient interactions.

A. True

B. False

Answer

Answer: A. True

The purpose of evaluation is to allow the patient’s achievement of expected outcomes to direct future nurse–patient interactions.

Terminate plan of care when expected outcome is achieved.

Modify plan of care if there are difficulties achieving outcomes.

Continue plan of care if more time is needed to achieve outcomes.

Action Based on Outcome Achievement

Question

Which of the following actions should the nurse take when a patient has achieved each expected outcome in the plan of care?

A. Terminate the plan of care

B. Modify the plan of care

C. Continue the plan of care

Answer

Answer: A. Terminate the plan of care

Rationale:

The plan of care is terminated when the patient has achieved all of its goals.

The plan of care is modified when there are difficulties achieving outcomes.

The plan of care is continued if more time is needed to achieve the outcomes.

Cognitive—increase in patient knowledge

Psychomotor—patient’s achievement of new skills

Affective—changes in patient values, beliefs, and attitudes

Physiologic—physical changes in the patient

Four Types of Outcomes

Question

Which one of the following examples is a psychomotor outcome?

A. A patient learns how to control his weight using the MyPyramid Food Guide.

B. A patient is able to test for glucose levels and inject insulin as needed.

C. A patient values his health enough to decide to quit smoking.

D. A patient is able to ambulate the hallway following knee surgery.

Answer

Answer: B. A patient is able to test for glucose levels and inject insulin as needed.

Rationale:

Psychomotor outcomes involve the patient’s achievement of a new skill, such as controlling diabetes.

Cognitive outcomes involve an increase in patient knowledge (Answer A).

Affective outcomes pertain to changes in patient values (Answer C).

Physiologic outcomes target physical changes in the patient (Answer D).

Cognitive—asking patient to repeat information or apply new knowledge

Psychomotor—asking patient to demonstrate new skill

Affective—observing patient behavior and conversation

Physiologic—using physical assessment skill to collect and compare data

Evaluating Outcomes

Question

Tell whether the following statement is true or false.

Asking a patient to plan an exercise program to lower blood pressure based on information provided to him in an A/V presentation is an excellent method to evaluate a physiologic outcome.

A. True

B. False

Answer

Answer: B. False

Asking a patient to plan an exercise program to lower blood pressure based on information provided to him in an A/V presentation is an excellent method to evaluate a cognitive outcome.

Delete or modify the nursing diagnosis.

Make the outcome statement more realistic.

Increase the complexity of the outcome statement.

Adjust time criteria in outcome statement.

Change nursing interventions.

Revisions in the Plan of Care

Peer review

Quality assurance programs

Structure evaluations

Process evaluations

Outcome evaluations

Quality improvement

Nursing audit

Concurrent and retrospective evaluations

Improving Professional Performance

Standards for Establishing and Sustaining Health Work Environments

Four Domains of Critical Thinking

Elements of thought—basic building blocks of thinking

Abilities—the skills essential to higher-order thinking

Affective dimensions—attitudes, dispositions, passions, traits of mind essential to higher-order thinking

Intellectual standards—used to critique higher-order thinking

Critical Thinking and Clinical Reasoning

Is purposeful, informed, outcome-focused thinking

Is driven by patient, family, and community needs

Is based on principles of nursing process and scientific method

Uses both intuition and logic, based on knowledge, skills, and experience

Requires strategies that make the most of human potential

Is constantly reevaluating, self-correcting, and striving to improve