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