Nursing Process: Five-Step Process

Nursing Process: Five-Step Process. Copyright © 2017 Elsevier Inc. All Rights Reserved..

Is an organizing framework for professional nursing practice. Is used in nursing to identify and treat the nursing diagnoses (problems) of a client. Dynamic (Overlap and Interaction among the 5 steps) Outcome Oriented (patient Outcomes).

Decisions are made for and with the client. The nurse assesses and interprets the information that is gathered while performing the steps of the nursing process..

Caring is a major part of the nursing process: “ Caring is essential to curing and pervades all efforts to help an individual recover after an illness and be cured. ” ( Leininger , 1996) “ Caring is the most important and central focus of nursing .” ( Leininger , 1996) “… we first love and care for ourselves, so as a beginning nurse you are to believe in yourself, identify your strengths, and put your abilities to work. ” (Watson & Ray, 1988).

Use the acronym ADPIE: A ssessment D iagnosis (Nursing Diagnosis Not medical) P lanning (outcomes and interventions) I mplementation E valuation.

Collection of information about the client: Is holistic and detailed. Supports clinical reasoning and critical thinking. Determines the client problems and strengths. Occurs at the initiation of care and is ongoing during all of the phases of the nursing process..

Assess the client. Perform a thorough holistic comprehensive nursing assessment . Use the format adopted by the facility or educational institution. Nursing assessments may be based on conceptual models: Gordon ’ s functional health patterns ( wholistic /comprehensive) Focused Assessment – A specific identified problem.

Nursing assessment and health history: Patient centered interview Physical assessment: client Medical records Diagnostic test results Health team members Significant others if appropriate https://www.youtube.com/watch?v=oHreolyshYY video 1 https://www.youtube.com/watch?v=wAEEUzcL5P4 video 2.

Types of Data Objective Data vs. Subjective Data.

Ask open-ended questions : “ Describe what you are feeling. ” “ Tell me about these symptoms. ” “What do you do to alleviate your symptoms?” “What aggravates your symptoms?” “ How does it affect your daily routine? ” “ What can we help you with? ” Focus on Patient Listen to patient Use Touch appropriately.

Perform a thorough physical assessment. Medical model: head-to-toe or body system Carefully assess each area for normal and abnormal findings. Inspect,palpate , percuss and auscultate (IPPA) ..

Is often described as the ability to reason in context, as a clinical situation changes, while taking into account the client and family concerns..

Look for normal and abnormal findings. Validate the data with the client. “ This is what I have noticed. ” “ Does this describe how you feel? ” “ Tell me more. ”.

Using the assessment information: Organize the information : Identify patterns in the assessment (highlight or underline problems). Make a list of all problems and potential problems. Group together problems that are similar. Make initial inferences or impressions. Prioritize the problems: Maslow’s hierarchy Safety Start with unstable client problems Record and report the information.

Report and document information that requires immediate action. Some examples include: Sharp, unrelenting pain Vital signs deviate from normal Change in the level of consciousness When in doubt, report. Be prepared immediately to follow instructions that are given..

Independent nursing practice knowledge to treat human responses to health problems. Clinical judgment Individual, family, or community Response to actual or potential health problems or life processes Basis for outcomes and interventions ( Herdman & Kamitsuru , 2014).

Select the appropriate nursing diagnosis for the client from the North American Nursing Diagnosis Association—International (NANDA-I) approved list. Nursing Diagnoses: Definitions and Classification 2015-2017 List of “ approved nursing diagnoses ”.

Is based on assessment information Information is analyzed. Questions to ask include: Can a change occur with a nursing intervention? Does it fit the NANDA-I definition? Are the defining characteristics in the assessment?.

How To Make A Nursing Diagnosis. Look for common patterns in the assessment. Cluster or group common patterns. Verify defining characteristics. Identify possible nursing diagnosis. Use clinical reasoning skills to determine an accurate diagnosis. Ask: “Does the client information match NANDA-I information?” “Is it important to the client? ” “ What other information do I need? ”.

Writing a Nursing Diagnosis Statement PES. P roblem—Choose the label. Nursing diagnosis E tiology—Write an r/t phrase. Etiology S —Write the defining characteristics. Signs and symptoms.

“ Related to ” Phrase or Etiology. Etiology Relationship to nursing diagnosis Is NOT the medical diagnosis Ideal: related factor is something nurse can treat independently Independent nursing diagnosis May need to be treated by nurse in collaboration with other members of the health care team. Collaborative nursing diagnosis.

Defining Characteristics Phrase. Signs and symptoms are identified during the assessment. The phrase as evidenced by (AEB) may be used to connect the etiology (r/t phrase) with the defining characteristics. Example: Activity intolerance r/t generalized weakness AEB complaints of fatigue and a shortness of breath (SOB) with activity..

Nursing Diagnosis. Three types of nursing diagnoses: Problem-focused diagnosis (3 part) Problem(Label) + Etiology (related to) + Symptoms (as evidenced by) Undesirable response to health condition/process Risk diagnosis ( 2 part) Two part – Potential problem (risk for )+ Etiology (related to) Vulnerable to having an undesirable response Health-promotion diagnosis Focus is on being as healthy as possible Focus is NOT on preventing an illness.

Prioritizing Nursing Diagnoses. High priority—greatest threat to patient well-being Medium priority—nonthreatening diagnoses Low priority—diagnoses not specifically related to current health problem.

Does the selected diagnosis fit the NANDA-I definition? Are the defining characteristics in the assessment?.

Step three is taken after the nursing diagnosis is determined. Consists of writing measurable client outcomes and nursing interventions to accomplish the outcomes. These outcomes and interventions are designed to change the client ’ s nursing diagnosis or problem..

Write measurable client outcomes. Identify nursing interventions to accomplish the outcomes. Review outcomes with client..

Outcomes What does the client hope to accomplish? How should these client outcomes be prioritized? How will the outcomes be measured? How long will it take? Interventions What nursing interventions can the nurse do to help the client with satisfactory outcomes? Who will assist the client? Nurse Ancillary personnel.

Is an individual, a family, or a community state, behavior, or perception that is measured along a continuum in response to nursing intervention(s). Outcomes are variable concepts that can be measured along a continuum. Outcomes are stated as concepts that reflect a patient, family caregiver, family, or community actual state rather than expected goals. (Moorhead, 2013).

Set client-centered short-term and long-term goals and outcomes. Long-term— longer period to be achieved and may be used as discharge goals (weeks, months) Short-term—may be accomplished in a shorter specified time (usually within a week) Prioritize by what is most important. Use Maslow ’ s hierarchy..

Questions Does it come from the nursing diagnosis? Is it measurable? Does the client agree with it? Is it realistic? Is it attainable? Is there a time frame? Does it provide direction for care?.

Initiating the nursing care plan Performing the nursing interventions Delegating appropriate nursing interventions Using skills Psychomotor Interpersonal Cognitive Performing continuous assessment.

The nursing interventions classification (NIC) is a comprehensive, standardized language describing treatments that nurses perform in all settings and in all specialties. NIC includes both physiological and psychosocial interventions and covers all nursing specialties. ( Bulechek , 2013).

Criteria for interventions: Activity is done for and with the client. Accomplishes outcomes. Removes or reduces related factors that contributed to the nursing diagnosis. Is individualized. Is specific and safe..

Intervention is a road map to guide nursing care. The more clearly a nurse writes an intervention, the easier it will be to complete the journey and arrive at the destination of successful client outcomes..

Is a set of interventions or guidelines that have been shown to be effective in helping clients. Evidence-based nursing is a systematic process that uses current evidence in making decisions about care..

Critical thinking questions to ask: What nursing interventions can the nurse perform to help the client with satisfactory outcomes? Who will assist the client? The nurse? Ancillary personnel? What equipment is needed? How long will the intervention take? How often should the intervention be done? What is the evidence that supports its effectiveness?.

Although evaluation is listed as the last phase of the nursing process, it is actually an integral part of each phase and something that is continually done. Client outcomes are evaluated to determine whether they are satisfactory. If the outcomes were not satisfactory, the nursing process should begin again with an assessment to determine the reasons why the outcomes were not satisfactory..

Critical thinking questions to ask when checking client outcomes: Were the outcomes satisfactory? Is an additional assessment needed? Were the outcomes realistic? Was the right nursing diagnosis selected? Does the nursing care plan need to be modified?.

Re-asses and determine whether the evidence-based practice interventions that were followed were effective. Necessary revisions may be made at this time. If patient outcome is met you may discontinue the plan of care..

Copyright © 2017 Elsevier Inc. All Rights Reserved..

Steps of the nursing process: ADPIE A ssessment D iagnosis P lan (outcomes and interventions) I mplementation E valuation Document and report interventions and outcomes Continuous Evolving Process in the Ongoing Care of the Client and Family..