Five-Step Nursing Process Model

Critical Thinking Synthesis

A reasoning process used to reflect on and analyze
thoughts, actions, and knowledge
Requires a desire
to grow intellectually
Requires the use of nursing process
to make nursing care decisions
Chapter 16
Nursing Assessment
Five-Step Nursing Process
Nursing Process
The nursing process is a variation of scientific
reasoning.
Practicing the five steps of the nursing process allows
you to be organized and to conduct your practice in a
systematic way.
You learn to make inferences about the meaning of a
patients response to a health problem or generalize
about the patients functional state of health.
Through assessment, a pattern begins to form.
Case Study
Ms. Carla Thompkins is being admitted to the medical-
surgical unit as a postop patient. Ms. Thompkins, a 52-
year-old schoolteacher, is recovering from a below-the-
knee amputation (BKA) secondary to complications of
type 2 diabetes.
Ms. Thompkins is admitted to the unit not only so her
recovery from the BKA may be monitored, but also
because Ms. Thompkins is going to receive preliminary
occupational and physical therapy to help her adapt to the
amputation.
Cues and Inferences
Comprehensive Assessment Approaches
Use of a structured database format, based
on an accepted theoretical framework or
practice standard
Example: Gordons model of functional health
patterns
Problem-oriented approach
Assessment moves from general to specific.
Process of Assessment
Collect data.
Cluster cues, make inferences, and identify
patterns and problem areas.
Critically anticipate.
Be sure to have supporting cues before
making an inference.
Knowing how to probe and frame questions
is a skill that grows with experience.
Interview Techniques
Open-ended vs. closed-ended questions
Back-channeling
Probing
-------------------------------------------
Because a patients report includes subjective
information, validate data from the interview
later with objective data.
Obtain information (as appropriate) about a
patients physical, developmental, emotional,
intellectual, social, and spiritual dimensions.
Case Study (contd)
During the assessment, Ms. Thompkins
complains of pain at the incision site.
Ms. Thompkins report of pain is an
example of what type of data?

Cultural Considerations
To conduct an accurate and complete
assessment, you need to consider a
patients cultural background.
When cultural differences exist between
you and a patient, respect the unfamiliar
and be sensitive to a patients uniqueness.
If you are unsure about what a patient is
saying, ask for clarification to prevent
making the wrong diagnostic conclusion.
Nursing Health History
Biographical information Patient expectations
Reason for seeking health
care
Present illness or health
concerns
Health history Family history
Environmental history Psychosocial history
Spiritual health Review of systems
Documentation of findings
Next Assessment Steps
Physical examination = An investigation of
the body to determine its state of health
Observation of patient behavior (verbal vs.
nonverbal)
Diagnostic and laboratory data
Interpreting and validating assessment
data. Validation of assessment data consists
of comparison of data with another source
to determine accuracy of the data.
Concept Mapping

A visual representation that allows
nurses to graphically illustrate the
connections between a patients health
problems

Allows nurses to obtain a holistic
perspective of health care needs

Chapter 17
Nursing Diagnosis
Nursing Diagnosis
1. Medical
diagnosis
Identification of a disease condition
based on specific evaluation of signs
and symptoms
2. Nursing
diagnosis
Clinical judgment about the patient
in response to an actual or potential
health problem
3. Collaborative
problem
Actual or potential physiological
complication that nurses monitor to
detect a change in patient status
History of Nursing Diagnosis
First introduced in 1950
In 1953, Fry proposed the formulation of a
nursing diagnosis.
In 1973, the first national conference was held.
In 1980 and 1995, the American Nurses
Association (ANA) included diagnosis as a
separate activity in its publication Nursing: a
Social Policy Statement.
In 1982, NANDA was founded.
Case Study
John is a first semester nursing student who is particularly
interested in the cardiac system and specifically heart
disease since his father died of a heart attack at age 48.
John decided to go into nursing because of his fathers
death, which prompted him to select a career that
improves peoples lives.
John is studying nursing diagnoses in his nursing
fundamentals course and is learning the steps of the
nursing diagnostic process. He knows this information will
help him care for cardiac patients in the future.
Nursing Diagnostic Process
Assessment of patients health status:
Patient, family, and health care resources
constitute database.
Nurse clarifies inconsistent or unclear
information.
Critical thinking guides and directs line of
questioning and examination to reveal detailed
and relevant database.
Validate data with other sources.
Are additional data needed? If so, reassess.
If not, continue
Nursing Diagnostic Process (contd)
If no additional data are needed, proceed:
Interpret and analyze meaning of data
Data clustering
Group signs and symptoms.
Classify and organize.
Look for defining characteristics
and related factors.
Identify patient needs.
Formulate nursing diagnoses
and collaborative problems.
Data Clustering
A data cluster is a set of signs or
symptoms gathered during assessment
that you group together in a logical way.
Data clusters are patterns of data that
contain defining characteristicsclinical
criteria that are observable and verifiable.
Each clinical criterion is an objective or
subjective sign, symptom, or risk factor
that, when analyzed with other criteria,
leads to a diagnostic conclusion.
Case Study (contd)
Because of Johns interest in cardiac
nursing, he is familiar with the clinical
criteria for heart disease.
Which of the following is an example of a
clinical criterion?
(Select all that apply.)
Hypertension
Fatigue
Food preference
High cholesterol
Types of Nursing Diagnoses
Actual Nursing
Diagnosis
Describes human responses to
health conditions or life
processes
Risk Nursing
Diagnosis
Describes human responses to health
conditions/life processes that may
develop
Health Promotion
Nursing Diagnosis
A clinical judgment of motivation,
desire, and readiness to enhance
well-being and actualize human
health potential
Components of a Nursing Diagnosis
Diagnostic Label (NANDA-I) Definition
Related Factors/Etiology:
Treatment-related
Pathophysiological (biological or psychological)
Maturational
Situational (environmental or personal)
PES Format:
Problem
Etiology
Symptoms (or defining characteristics)
Case Study (contd)
John learns the four types of nursing
diagnoses.
Which of the following are the four types of
nursing diagnoses?
(Select all that apply.)
Actual diagnoses
Risk diagnoses
Wellness diagnoses
Health promotion diagnoses
Disease prevention diagnoses
Cultural Relevance of
Nursing Diagnoses
Consider patients cultural diversity when
selecting a nursing diagnosis. Ask questions
such as:
How has this health problem affected you and
your family?
What do you believe will help or fix the
problem?
What worries you most about the problem?
Which practices within your culture are
important to you?
Cultural awareness and sensitivity improve
your accuracy in making nursing diagnoses.
Case Study (contd)
John knows that a ______________
diagnosis is applied to vulnerable
populations.
Concept Mapping
Nursing Diagnosis


A visual representation of a patients
nursing diagnoses and their relationships
with one another
Concept maps promote problem solving and
critical thinking skills by
organizing complex patient data,
analyzing concept relationships, and identifying
interventions.
Diagnostic Statement Guidelines

1. Identify the patients response, not the medical diagnosis.
2. Identify a NANDA-I diagnostic statement rather than the
symptom.
3. Identify a treatable cause or risk factor rather than a clinical sign
or chronic problem that is not treatable through nursing
intervention.
4. Identify the problem caused by the treatment or diagnostic study
rather than the treatment or study itself.
5. Identify the patient response to the equipment rather than the
equipment itself.
Diagnostic Statement Guidelines
(contd)

6. Identify the patients problems rather than your problems with
nursing care.
7. Identify the patient problem rather than the nursing intervention.
8. Identify the patient problem rather than the goal of care.
9. Make professional rather than prejudicial judgments.
10. Avoid legally inadvisable statements.
11. Identify the problem and its cause to avoid a circular statement.
12. Identify only one patient problem in the diagnostic statement.
Nursing Diagnosis:
Application to Care Planning
By learning to make accurate nursing
diagnoses, your care plan will help
communicate the patients health care
problems to other professionals.
A nursing diagnosis will ensure that you
select relevant and appropriate nursing
interventions.
Chapter 19
Implementing Nursing Care
Nursing Intervention
A nursing intervention is any treatment
based on clinical judgment and knowledge
that a nurse performs to enhance patient
outcomes.
Interventions include direct and indirect
care measures aimed at individuals,
families, and/or the community.
Case Study
Miranda is a nursing student who is assigned to Mr.
Bagley. Mr. Bagley is a 52 y/o Asian male admitted to the
medical-surgical unit for management of tuberculosis. Mr.
Bagley travels internationally because of his executive
position with a global company and most likely contracted
tuberculosis during his travels.
Mr. Bagleys current symptoms are shortness of breath,
night sweats, muscle pain, fatigue, and a productive
cough. Miranda reviews Mr. Bagleys plan of care to
determine which interventions are to be implemented
first.
Critical Thinking in Implementation
Review the set of all possible nursing
interventions.
Review all possible consequences
associated with each possible nursing
action.
Determine the probability of all possible
consequences.
Make a judgment of the value of that
consequence to the patient.
Standard Nursing Interventions
Clinical practice guidelines and protocols
Standing orders
NIC interventions
ANA Standards of Professional Practice
Protocols and Standing Orders
Guidelines and
Protocols


Standing Orders
Systematically developed
set of statements that helps
nurses, physicians, and other
health care providers make
decisions about appropriate
health
care for specific clinical
situations
A preprinted document
containing orders for
the conduct of routine
therapies, monitoring
guidelines, and/or
diagnostic procedures for
specific patients with
identified clinical
problems
Implementation Process
Reassessing
the patient
Reviewing
and
revising the
existing
nursing
care plan
Organizing
resources
and care
delivery
Anticipating
and
preventing
complications
Anticipate and Prevent Complications
Identify risks to the patient.
Adapt interventions to the situation.
Evaluate the relative benefit of a treatment
vs. the risk.
Initiate risk prevention measures.
Modification of an Existing Written Care Plan
Revise data assessment.
Revise the nursing diagnoses.
Revise specific interventions.
Determine how to evaluate whether you
have achieved outcomes.
Quick Quiz!
1. Nurse-initiated interventions are
A. Determined by state Nurse Practice Acts.
B. Supervised by the entire health care team.
C. Made in concert with the plan of care
initiated by the physician.
D. Developed after interventions for the
recent medical diagnoses are evaluated.
Implementation Skills
Cognitive skills
Application of critical thinking in the nursing
process
Interpersonal skills
Developing a trusting relationship, expressing a
level of caring, and communicating clearly with
a patient and his or her family
Psychomotor skills
Integration of cognitive and motor activities
Direct Care vs. Indirect Care
Direct Care Indirect Care
Treatments performed
through interactions with
patients

Examples:
-Medication administration
-Insertion of an intravenous
(IV) infusion
-Counseling during a time of
grief
Treatments performed away
from the patient but on
behalf of the
patient or group of patients

-Managing the patients
environment (e.g., safety
and infection control)
-Documentation
-Interdisciplinary
collaboration
Direct Care
Activities of Daily
Living
(ADLs)
Instrumental
Activities of Daily
Living (IADLs)
Physical care
techniques
Lifesaving measures
Direct Care (contd)
Counseling
Teaching
Controlling for adverse
reactions

Preventive measures
Case Study (contd)
Mr. Bagleys plan of care calls for oxygen
therapy to improve his respiratory status.
A preprinted document that contains orders for
the conduct of routine therapies, such as
oxygen therapy, is referred to as a __________
_____________.
Quick Quiz!
2. You are writing a care plan for a newly
admitted patient. Which one of these outcome
statements is written correctly?
A. The patient will eat 80% of all meals.
B. The nursing assistant will set the patient up
for a bath every day.
C. The patient will have improved airway
clearance by June 5.
D. The patient will identify the need to increase
dietary intake of fiber by June 5.
Indirect Care
Communicating nursing interventions
Written or oral
Delegating, supervising, and evaluating the
work of other health care team members
Case Study (contd)
Mr. Bagley is placed on Isolation
Precautions.
Isolation Precautions as a treatment
intervention are an example of which type of
care?
A. Direct
B. Indirect
C. Prevention
D. Safety
Achieving Patient Goals
Nurses implement care to meet patient
goals.
At times, multiple interventions may be
needed.
Priorities help nurses to anticipate and
sequence nursing interventions.
Patient adherence means that patients and
families invest time in carrying out required
treatments.
Chapter 18
Planning Nursing Care
Establishing Priorities
Ordering of nursing diagnoses or patient
problems uses determinations of urgency
and/or importance to establish a preferential
order for nursing actions.
Helps nurses anticipate and sequence nursing
interventions
Classification of priorities:
HighEmergent
Intermediate
LowAffect patients future well-being
Establishing Priorities (contd)
The order of priorities changes as a
patients condition changes.
Priority setting begins at a holistic level
when you identify and prioritize a patients
main diagnoses or problems.
Patient-centered care requires you to
know a patients preferences, values, and
expressed needs.
Ethical care is a part of priority setting.
Priorities in Practice
Case Study
Fulmala is a first semester nursing student who is
assigned to Ms. Nadine Skyfall, a 35 y/o American
Indian patient diagnosed with severe anemia
secondary to a bleeding peptic ulcer. Ms. Skyfall
experiences pain because of the ulcer and
weakness and fatigue resulting from the anemia.
Fulmala develops Ms. Skyfalls plan of care, which
addresses pain, weakness, and fatigue. Fulmala
includes nutrition and patient safety as part of
the plan of care.
Critical Thinking in Setting Goals and Expected
Outcomes
Goal
A broad statement that describes the desired
change in a patients condition or behavior
An aim, intent, or end
Expected outcome
Measurable criteria to evaluate goal achievement
Goals of Care



Patient-centered goal:
A specific and measurable behavior or response
that reflects a patients highest possible level of
wellness and independence in function
Short-term goal:
An objective behavior or response expected
within hours to a week
Long-term goal:
An objective behavior or response expected
within days, weeks, or months
Goals of Care (contd)
Always partner with patients when setting
their individualized goals.
For patients to participate in goal setting, they
need to be alert and must have some degree of
independence in completing activities of daily
living, problem solving, and decision making.
Patients need to understand and see the value
of nursing therapies, even though they are often
totally dependent on you as the nurse.
Expected Outcomes
An objective criterion for goal achievement
A specific, measurable change in a patients
status that you expect in response to nursing
care
Direct nursing care
Determine when a specific, patient-centered
goal has been met
Are written sequentially, with time frames
Usually, several are developed for each
nursing diagnosis and goal.
Nursing Outcomes Classification
A nursing-sensitive patient outcome is a measurable
patient, family, or community state, behavior, or
perception largely influenced by and sensitive to nursing
interventions.
The Iowa Intervention Project published the Nursing
Outcomes Classification (NOC) and linked the outcomes
to NANDA International nursing diagnoses.
NOC outcomes provide a common nursing language for
continuity of care and measuring the success of nursing
interventions.
Seven Guidelines for Writing Goals
Patient centered
Singular goal or outcome Observable
Measurable Time limited
Mutual factors Realistic
Quick Quiz!
1. A patient is suffering from shortness of breath.
The correct goal statement would be written as
A. The patient will be comfortable by the morning.
B. The patient will breath unlabored at 14 to 18
breaths per minute by the end of the shift.
C. The patient will not complain of breathing
problems within the next 8 hours.
D. The patient will have a respiratory rate of 14 to
18 breaths per minute.
Critical Thinking in Planning Care
Nursing interventions are treatments or
actions based on clinical judgment and
knowledge that nurses perform to meet
patient outcomes.
Nurses need to:
Know the scientific rationale for the
intervention
Possess the necessary psychomotor and
interpersonal skills
Be able to function within a setting to use
health care resources effectively

Types of Interventions
Nurse initiated
IndependentActions that a nurse initiates
Physician initiated
DependentRequire an order from a physician or
other health care professional
Collaborative
InterdependentRequire combined knowledge,
skill, and expertise of multiple health care
professionals

Clarifying an Order
When preparing for physician-initiated or
collaborative interventions, do not
automatically implement the therapy, but
determine whether it is appropriate for the
patient.
The ability to recognize incorrect therapies
is particularly important when
administering medications or implementing
procedures.
Selection of Interventions
Six factors to consider:
Characteristics of nursing diagnosis
Goals and expected outcomes
Evidence base for interventions
Feasibility of the interventions
Acceptability to the patient
Nurses competency
Nursing Interventions Classification (NIC)
The Iowa Intervention Project developed a
set of nursing interventions that provides a
level of standardization to enhance
communication of nursing care across health
care settings and to compare outcomes.
The NIC model includes three levels:
domains, classes, and interventions for ease
of use.
NIC interventions are linked with NANDA
International nursing diagnoses.
Systems for Planning Nursing Care
Nursing care plan = Nursing diagnoses, goals and
expected outcomes, and nursing interventions,
and a section for evaluation findings so any nurse
is able to quickly identify a patients clinical needs
and situation
Reduces the risk for incomplete, incorrect, or
inaccurate care
Changes as the patients problems and status change
Interdisciplinary care plan = Contributions from
all disciplines involved in patient care.
Change of Shift
A critical time, when nurses collaborate and share
important information that ensures the continuity of
care for a patient and prevents errors or delays in
providing nursing interventions
Change-of-shift report: Communicates information from
offgoing to oncoming patient care personnel = Nurse
handoff
Focus your reports on the nursing care, treatments,
and expected outcomes documented in the care
plans.
Student Care Plans
A student care plan
Helps you apply knowledge gained from the nursing
and medical literature and the classroom to a practice
situation
Is more elaborate than a care plan used in a hospital
or community agency because its purpose is to teach
the process of planning care
Planning care for patients in community-
based settings involves
Educating the patient/family about care
Guiding them to assume more of the care over
time
Critical Pathways
Critical pathways are patient care plans that
provide the multidisciplinary health care team
with activities and tasks to be put into practice
sequentially.
The main purpose of critical pathways is to
deliver timely care at each phase of the
care process for a specific type of patient.
Concept Maps
Provide a visually graphic way to show the
relationship between patients nursing
diagnoses and interventions
Group and categorize nursing concepts to
give you a holistic view of your patients
health care needs and help you make
better clinical decisions in planning care
Help you learn the interrelationships
among nursing diagnoses to create a
unique meaning and organization of
information
Case Study (contd)
What are some examples of independent
nursing interventions that Fulmala may
develop for Ms. Skyfall?
(Select all that apply.)
A. Medication administration
B. Medication teaching
C. Patient positioning
D. Family teaching
Consulting Other Health Care Professionals
Planning involves consultation with members of the
health care team.
Consultation is a process by which you seek the expertise of a
specialist such as your nursing instructor, a physician, or a
clinical nurse educator to identify ways to handle problems in
patient management or in planning and implementation of
therapies.
Consultation occurs at any step in the nursing process,
most often during planning and implementation.
When and How to Consult
When: The exact problem remains unclear
How: Begin with your understanding of the patients
clinical problem.
Direct the consultation to the right professional.
Provide the consultant with relevant information about
the problem area: Summary, methods used to date, and
outcomes
Do not influence consultants.
Be available to discuss the consultants findings.
Incorporate the suggestions.
Case Study (contd)
Fumala works with the nutritionist to develop
a meal plan for Ms. Skyfall.
True or False: Collaborative interventions are
therapies that involve multiple health care
professionals.