Nursing Process
Nursing Process
Nursing Process
Psychological Data
• Major stressors experienced and the • Identifying cues and making
client’s perception of them Inferences (how you interpret or perceive a
• Usual coping pattern with a serious cue, the conclusion you draw about a cue. The
problem or a high level of stress nurses ability to make inferences is influenced
• Communication style: ability to by : observational skills, nursing knowledge,
verbalize appropriate emotion; non- and clinical expertise
verbal communication – such as eye
movements, gestures, use of touch, 2. Validating (Verifying data) is checking if the
and posture; interactions with support data are factual and complete. It helps one to
persons; and the congruence of avoid making assumptions, missing pertinent
nonverbal behavior and verbal information, misunderstanding situations,
expression jumping to conclusions or focusing in the wrong
direction making errors in problem identification.
Patterns of health care
All health care resources the client is currently Guidelines in validating data :
using and has used in the past. These include 1. data that can be measured accurately
the primary care provider, specialists (e.g. can be accepted as factual
ophthalmologist, gynecologists), dentists, folk 2. data that someone else observes may
practitioners (e.g. herbalist or curandero), health be or may not be true
clinic, or health center; whether the client 3. validate questionable information
considers the care being provided adequate; 4. Look for factors that may alter accuracy
and whether access to health care is a problem 5. ask someone else preferably an expert,
6. double-check information that is
PHYSICAL ASSESSMENT extremely abnormal, clarify statements
and verify your inferences.
Physical Assessment Skills
• Inspection – observing carefully by 3. Organizing (Clustering ) data Cluster or
using your fingers, eyes, ears and sense organize using the following:
of smell
• Auscultation – listening with a
stethoscope
• According to a Nursing Model Many
nurses use the functional health patterns by
• Palpation – touching and pressing to Gordon
test for pain and feel inner structures,
such as the liver • According to Body Systems
• Percussion – directly or indirectly • According life-threatening
tapping a body surface to determine
reflexes or to determine whether are
What are the 12 FUNCTIONAL HEALTH
contains fluid
PATTERNS?
(Please refer to your copy)
Organization of Assessment is influenced by two
things
GORDON’S FUNCTIONAL HEALTH PATTERN
1. the person’s condition
2. your own preference
HEALTH-PERCEPTION/ HEALTH-
MANAGEMENT PATTERN
• Reporting data in a timely fashion
Describes the client’s perceived pattern of health expedites diagnosis and treatment of urgent
and well-being and how health is managed problems
NUTRITIONAL AND METABOLIC PATTERN • Guidelines for reporting significant
Describes the clients pattern of food and fluid findings:
consumption relative to metabolic need and
pattern indicators of local nutrient supply
– If you find yourself thinking, “ I am not
ELIMINATION PATTERN sure if there is anything abnormal here to
Describes the pattern of excretory function report,” you probably don’t have enough
(bowel, bladder and skin) knowledge to make the decision. You need help
ACTIVITY-EXERCISE PATTERN – Report abnormal findings as soon as
Describe the pattern of exercise, activity, leisure possible
and recreation – Before reporting, take a moment to be
SLEEP-REST PATTERN sure you have all the necessary information
Describes pattern of sleep, rest and recreation readily at hand
COGNITIVE-PERCEPTUAL PATTERN
Describes sensory-perceptual and cognitive – If you’re nervous about giving the report
patterns jot your report in order of importance and read.
SELF-PERCEPTION / SELF-CONCEPT
PATTERN • Give precise information State the
Described the client’s self concept pattern and facts rather than how you interpret the facts
perceptions of self (e.g. self-conception/worth,
comfort, body image, feeling state)
ROLE-RELATIONSHIP PATTERN DIAGNOSIS
Describes the client’s pattern of role participation
and relationships FIVE PHASES
SEXUALITY-REPRODUCTIVE PATTERN • Creating a list of suspected
Describes the client’s pattern of satisfaction and problems/diagnoses
dissatisfaction with sexuality pattern; describes
reproductive patterns • Ruling out similar problems/diagnoses
COPING-STRESS TOLERANCE PATTTERN
Describes the client’s general coping pattern
• Naming actual and potential
problems/diagnoses and clarifying what’s
and the effectiveness of the pattern in terms of causing or contributing to them
stress tolerance
VALUE BELIEF PATTERN • Determine risk factors that must be
Describes the patterns of values, beliefs managed
(including spiritual) and goals that guide the
client’s choices or decisions
• Identifying resources, strengths and
areas of health promotion
4. Identifying Patterns and Testing first
Impressions TERMINOLOGIES
• Get some initial impression of patterns • Competency – knowledge, skills, and
of health functioning behaviors necessary to perform actions safely
and efficiently in various patient situations.
• Determine what is relevant and
irrelevant • Nursing Domain – actions which a
nurse is qualified to perform.
• Remember cause and effect
• Medical Domain – activities and actions
5. Deciding what to record and report a medical doctor is qualified to perform.
• Accountable – being responsible and
• The final phase of assessment is
answerable for something
recording and reporting • Definitive Intervention – the most
specific treatment required to prevent, resolve,
or manage a health problem.
• Taxonomy – is a classification system • Wellness Diagnosis – a clinical
or set of categories arranged based single judgment by an individual, family, or community
principle or set of principles in transition from a specific level of wellness to
• Outcome – The result of prescribed a higher level of wellness.
interventions or plan of care. Usually it is • Sign – objective data that have been
referred to as desired interventions. known to signify a health problem
• Diagnose – make judgment and name • Symptom – subjective data that have
actual and potential health problems or risk been known to signify a health problem.
factors based on evidence from an assessment • Defining characteristics a cluster of
• Diagnosis – may mean two things : signs and symptoms and risk factors usually
the process of analyzing data and putting related present patients with specific nursing diagnosis.
cues together to make judgments about health • Cues – signs, symptoms, and defining
status or it is the result of diagnostic process characteristics noted in a patient.
• Life Processes – events or changes
• Diagnose – make judgment and name
that happen during one’s lifetime
actual and potential health problems or risk
• NANDA – North American Nursing factors based on evidence from assessment
Diagnosis Association
• Diagnosing – reasoning process
• Nursing Diagnosis (NANDA, 1990) –
clinical judgment about individual, family, or
• Nursing Diagnosis – a clinical community responses to actual or potential
judgment about an individual, family, or health problems or life processes.
community response to actual and potential
health problems and life processes.
• Medical Diagnosis – health problem Over time, literatures reveal that Nursing
that requires definite diagnosis by a qualified Diagnosis had been and is being used in 3
primary care provider ( physicians, nurses or contexts :
physicians’ assistants 1. As the second step of the nursing process
2. As a list of diagnostic labels or titles
• Potential Complications- organ or 3. As a one-part, two-part, or three-part
system problems that may arise because of the statement
presence of certain diagnoses or treatment
modalities. 1. As the second step of the nursing
• Carpenito (2000) uses the term process
collaborative problem to address potential • The nurse analyzes data collected
physiologic complications during assessment and evaluates the client’s
• Multidisciplinary Problem – a problem health status
requiring treatment by more than 1 discipline.
• Some conclusions resulting from data
• Related Factor – something known to analysis lead to nursing diagnoses; while others
be associated with a specific health problem do not
• Risk Factor – something known to • Recognize that the outcome of this
cause or contribute to specific problem. The process can include problems treated primarily
terms related and risk factors are often used by
interchangeably
• nurses (INDEPENDENT)
• Etiology – something known to cause a
disease or problem. The terms risk factor and
• problems requiring treatment by
etiology are oftentimes used interchangeably. professionals from several disciplines
To completely understand a problem, one must (DEPENDENT AND INTERDEPENDENT)
know its cause. Ex. While assessing, the nurse may record
observations that point to medical problems of
• Risk (Potential ) Diagnosis – a health seizures, pneumonia, and hypertension, as well
problem that may develop[p if preventable if as nursing diagnosis of risk for injury)
preventive actions are not taken.
• Using the term nursing diagnosis to
Predict
designate the 2nd step of the nursing process Prevent
may be confusing and have the undesirable
effect of leading nurses to try to state all Manage
conclusions or problems as nursing diagnoses,
• After the 1st conference on nursing Promote
diagnosis in 1973, the term nursing diagnosis
was applied to specific labels describing health Key Points
states that nurses could legally diagnose and
treat • The PPMP model is more proactive than
the DT model.
• These labels are concise descriptors of
a cluster of signs and symptoms such as Anxiety
or Risk for Injury
• It’s based on evidence and applies
technology
2. As a list of diagnostic labels or titles
TYPES OF NURSING DIAGNOSIS
• An individual, family, or group’s
• ACTUAL DIAGNOSIS
response to a situation or health problem
• POSSIBLE DIAGNOSIS
Thus it is necessary for us to be clear on
what context are we using the term Nursing • RISK DIAGNOSIS
Diagnosis • SYNDROME DIAGNOSIS
Diagnosis: A Pivotal Point • WELLNESS DIAGNOSIS
This is because of 3 reasons :
– The accuracy and relevance of the 1. ACTUAL NURSING DIAGNOSIS
entire plan of care depends on the nurse’s ability • Actual Nursing Diagnosis- represents
to clarify and specifically identify both the a problem that had been validated by the
problems and what is accusing them. presence of major defining characteristics
– Creating a proactive plan that promotes PARTS OF ACTUAL NURSING DIAGNOSIS
health and prevents problems before they begin • Diagnostic label or label (such as
depends on your ability to recognize risk factors those developed by NANDA) is a concise term
– The resources and strengths you that convey the meaning of the diagnosis.
identify are key to reducing costs and • Defining characteristics are signs and
maximizing efficiency. symptoms that, when seen together, represent
There are major factors that impact on the the nursing diagnosis
nurses’ diagnosis- role today, as follows :
• Major defining characteristics – for
– Shift from diagnosis and treat (DT) to
nonresearched diagnosis, at least 1 must be
Predict, Prevent, Manage (PPM) approach present for validation of the diagnosis and for
– Development and refinement of Critical researched diagnosis, at least 1 must be present
Pathways (Clinical Pathways, Care Maps) 80-100% of the time.
– Computer-assisted Diagnosis • Minor defining characteristics –
– Emphasis on the importance of characteristics provide supporting evidence but
collaborative and multidisciplinary approach may not be present.
– A greater awareness that nursing’s • Related Factors – in actual nursing
scope of practice has a flexible boundary that diagnosis, these are contributing factors that
responds to the changing needs of society and have influenced the change in health status.
its expanding knowledge base.
There are 4 categories :
Diagnose & Treat (DT) versus Predict, Prevent,
Manage, Promote (PPMP) 1. Pathophysiologic (Biologic or
Psychological) Ex.
Shift to Predictive Model
Compromised immune system. Inadequate
circulation
• The “at risk concept is also very useful
2. Treatment-Related – Ex. Medications, for healthy individuals who are vulnerable
diagnostic because of age or a condition such as
studies, surgery, and treatments pregnancy Pregnant women are not at high risk
3. Situational – Ex. Enviornmental, home, for injury but are at risk during the third semester
community,
instituion, personal, life experiences, and 3. POSIBLE NURSING DIAGNOSIS
roles • the person’s data base does not
4. Maturational – age related influences demonstrate the defining characteristics or
related factors of the diagnosis but your intuition
• Risk Factors – represent those tells you that the diagnosis may be present
situations that increase the vulnerability of the • Statements that describe a suspected
client or group. data but require additional data. It is unfortunate
The related factors for risk that nurses had been socialized to avoid
nursing diagnosis are the same risk factors appearing tentative.
previously explained for actual nursing
diagnosis. That is why the terms related and • In scientific decision-making a tentative
risk factors are used interchangeably approach is not a sign of weakness or
indecision, but an essential part of the process.
• Etiology is something known to cause a
disease or problem. The terms risk factor and • The nurse should delay a final diagnosis
etiology are often used interchangeably. until he / she has gathered and analyzed all
• Unknown Etiology – if the defining necessary information to arrive at a sound
characteristics of a nursing diagnosis are scientific conclusion
present, but the etiologic and contributing factors
are unknown. Ex. Fear related to unknown 4. WELLNESS NURSING DIAGNOSIS
etiology as evidenced by rapid speech, pacing, • recognizing when healthy clients
and “I am worried.” The use of unknown etiology indicate a desire to achieve a higher level of
alerts the physician or the nurse to assess for functioning in a specific area.
contributing factors as they intervene.
• Clinical judgment about an individual,
2. RISK NURSING DIAGNOSIS group, or community in transition from a specific
level of wellness to a higher level of wellness.
• the person’s data base contains
evidence of the related (risk) factors of the • Diagnostic statements for wellness
diagnosis but no evidence of defining nursing diagnosis are one-part, containing the
characteristics. label only (which begins with Potential for
The concept of “at risk” is useful clinically enhanced…….) followed by the higher level
because, it allows nurses to routinely prevent wellness that individuals or groups desire
problems in people who are at high risk. (readiness for enhanced family processes)
• All operative patients are at risk for • It does not contain a related factor
infection related to loss of protective barrier
secondary to incision. This generic diagnosis for
• The NANDA taxonomy (2001)uses
“readiness for enhanced” as a prefix for
all surgical clients is routine, as such nurses do wellness diagnosis. In most acute e care
not (actually) need to include it in the client’s settings, however only the actual and potential
plan of care in the hospitals because it is part of diagnoses are addressed but there is more
the unit’s standard of care. opportunitit6esyto focus wellness diagnoses
• In contrast, a patient with diabetes who .
has undergone emergency surgery for a 5. SYNDROME NURSING DIAGNOSIS
perforated gastric ulcer may have a nursing
diagnosis of High risk for infection related to the
• Used when the diagnosis is associated
with a cluster of other diagnoses
surgical incision and impaired healing secondary
to diabetes mellitus and blood loss
Impaired – made worse, weakened, damaged,
• They comprise a cluster of predictive
reduced, deteriorated
actual or high- risk nursing diagnosis related to a Decreased – lesser in size, amount or degree
certain event or situation. Ineffective – not producing the desired effect
• The clinical advantage of a syndrome Compromised – to make vulnerable to threat
diagnosis is that it alerts the nurse o a complex NANDA approved meaning
clinical condition requiring expert nursing All diagnostic labels have meaning that clarifies
assessment and intervention. the definition of each
Example:
• Examples are : Rape Trauma Open your NANDA list Dx Handbook recite the
Syndrome, Disuse Syndrome, Post Trauma meaning of…
Syndrome Ineffective Breathing Pattern
Imbalanced Nutrition: less than body
3. As a one-part, two-part, or three-part requirements
statement
• THE ETIOLOGY
One-Part (Problem or Diagnostic Label) Identifies one or more probable causes of the
1. Wellness diagnosis health problem, gives direction to required
2. Syndrome diagnosis nursing therapy and enables the nurse to
Two-Part (Problem or Diagnostic Label + individualized client care
Risk Factor) Example:
1. Risk Diagnosis Recite the etiologies of the following:
2. Possible Diagnosis Sleep Disturbance
Three-Part (Problem or Diagnostic Label + Deficient Fluid Volume
Etiology+Symptom)
1. Actual • THE DEFINING CHARACTERISTICS
Are the cluster of signs and symptoms that
COMPONENTS OF NANDA NURSING indicate the presence of the diagnostic label
DIAGNOSIS Characteristics are listed separately according to
• The problem whether they are subjective or objective in
nature
• The etiology In actual nursing dx, the defining characteristics
• The defining characteristics are the signs and symptoms
In risk nursing dx, no subjective or objective
signs are present
• THE PROBLEM
Describes the client’s health problem or
Writing Diagnostic Statements
response for which nursing therapy is given
Describes the client’s health status briefly and
concisely in a few words
Problem Etiology
PURPOSE: to direct the formation of client goals
Symptom
and desired outcomes and may also suggest
(Diagnostic Contributing Factor Signs &
some nursing interventions
Symptoms
Specify
Label)
When the word specify follows the NANDA label
the nurse states the area in which the problem
ONE-PART STATEMENT
occurs:
Diagnostic labels that are well refined and does
Example: Deficient Knowledge (Medications)
not need etiology
Qualifiers
Wellness diagnosis:
Words that have been added to some NANDA
Readiness for Enhanced + desired higher level
labels to give additional meaning to the
of functioning
diagnostic statement
Example: Readiness for enhance Parenting
EXAMPLE
Or with descriptor
Deficient – inadequate in amount, quality or
Health Seeking Behavior (Low-Fat Diet)
degree, not sufficient, incomplete
TWO-PART STATEMENT
5. using descriptors – making it more precise
• Problem (P) – statement of the client’s
and specific
response (NANDA label) Example:
• Etiology (E) – factors contributing to or Impaired skin integrity (Left Lateral Ankle)
probable causes of the responses
AVOIDING ERRORS IN DIAGNOSTIC
Use “related to” to join 2 parts, because this REASONING
implies relationship Verify
Example:
Risk for infection related to _____________ Build a good knowledge base and
acquire clinical experience
THREE-PART STATEMENT Have a working knowledge of what is
• Problem (P) normal
• Etiology (E) Consult resources
• Signs and Symptoms (S) – defining Base diagnosis on patterns—that is, on
characteristics as manifested by the client behavior over time—rather than on an isolated
Example: incident
Noncompliance (Diabetic Diet) related to
unresolved anger about diagnosis as manifested
Improve critical-thinking skills
by verbalization “I can’t live without sugar in my
GUIDELINES FOR WRITING NURSING
food”
DIAGNOSTIC STATEMENTS
VARIATIONS FROM BASIC FORMAT
GUIDELINE #1
1. unknown etiology- when the defining
State in terms of a problem, not a need.
characteristics are present but the nurse does
CORRECT STATEMENT
not know the contributing factors
Deficient Fluid Volume (problem) related
Example:
to fever
Noncompliance (Medication Regimen) related to
INCORRECT OR AMBIGUOUS STATEMENT
unknown etiology
Fluid Replacement (need) related to
fever
2. complex factors – when there are too many
etiologic factors or they are to complex to state
GUIDELINE #2
in a brief phrase
Word the statement so that it is legally
Example:
advisable.
Chronic Low Self-Esteem related to complex
CORRECT STATEMENT
factors
Impaired Skin Integrity related to
immobility (legally acceptable)
3. possible – when the nurse believes more
INCORRECT OR AMBIGUOUS STATEMENT
data are needed about the client’s problem or
Impaired Skin Integrity related to
etiology
improper positioning (implies legal liability)
Example:
Possible low self-esteem related to loss of job
GUIDELINE #3
and rejection by family
Use nonjudgmental statements.
Altered thought processes possible related to
CORRECT STATEMENT
unfamiliar surroundings
Spiritual Distress related to inability to
attend church services secondary to immobility
4. secondary to – to divide the etiology in 2
(nonjudgmental)
parts, thereby making the statement more
INCORRECT OR AMBIGUOUS STATEMENT
descriptive and useful
Spiritual Distress related to strict rules
Example:
necessitating church attendance (judgmental)
Risk for impaired skin integrity related to
decreased peripheral circulation secondary to
GUIDELINE #4
diabetes
Make sure that both elements of the
statement do not stay the same thing
CORRECT STATEMENT DEFINITION OF TERMS
Risk for Impaired Skin Integrity related
to immobility PLANNING- Is a deliberative, systematic phase
INCORRECT OR AMBIGUOUS STATEMENT of the nursing process that involves decision
Impaired Skin Integrity related to making and problem solving
ulceration of sacral area (response and probable CONCEPT MAP – a visual tool in which ideas
cause are the same) or data are enclosed in circles or boxes of some
shape and relationships between these are
GUIDELINE #5 indicated by connecting lines or arrows.
Be sure that the cause and effect are NURSING CARE PLAN – end product of the
correctly stated (i.e., the etiology causes the planning phase, include the actions nurses must
problem or puts the client at risk for the take address the client’s nursing diagnoses and
problem). produce desired outcomes.
CORRECT STATEMENT INFORMAL NSG CARE PLAN – is a strategy
Pain: Severe headache related to fear of for action that exists in the nurse’s mind.
addiction to narcotics FORMAL NSG CARE PLAN – is a written or
INCORRECT OR AMBIGUOUS STATEMENT computerized guide that organizes information
Pain related to severe headache about the client’s care.
STANDARDIZED CARE PLAN – is a formal
GUIDELINE #6 care plan that specifies the nursing care for
Word the diagnosis specifically and groups of clients with common needs.
precisely to provide direction for planning INDIVIDUALIZED CARE PLAN – is tailored to
nursing intervention meet the unique needs of a specific client –
CORRECT STATEMENT needs that are not addressed by the
Impaired Oral Mucous Membrane standardized plan.
related to decreased salivation secondary to MULTIDISCIPLINARY CARE PLAN
radiation of neck (specific) (collaborative care plans/critical pathway) – is a
INCORRECT OR AMBIGUOUS STATEMENT standardized plan that outlines the care required
Impaired Oral Mucous Membrane for clients with common, predictable – usually
related to noxious agent (vague) medical – conditions.
GOAL – (intent) what you intend to do
GUIDELINE #7 EXPECTED OUTCOME – (results) what you
Use nursing terminology rather than expect the patient to be able to do
medical terminology to describe the client’s INDICATOR is “a more concrete individual,
response. family, or community state, behavior, or
CORRECT STATEMENT perception that serves as a cue for measuring
Risk for Ineffective Airway Clearance an outcome.”
related to accumulation of secretion in lungs GOAL/ OBJECTIVES/ OUTCOMES/
(nursing terminology) INDICATORS may be used interchangeably
INCORRECT OR AMBIGUOUS STATEMENT DEFINITION OF TERMS
Risk for Pneumonia (medical PRIORITY SETTING – is the process of
terminology) establishing a preferential sequence for
addressing nursing diagnosis and interventions
GUIDELINE #8 NURSING INTERVENTION – any treatment,
Use nursing terminology rather tha based upon clinical judgment and knowledge,
medical terminology to describe the probable that a nurse performs to enhance patient/client
cause of the client’s response. outcomes.
CORRECT STATEMENT RATIONALE – is the scientific principle given as
Risk for Ineffective Airway Clearance the reason for selecting a particular nursing
related to accumulation of secretions in lungs intervention.
(nursing terminology)
INCORRECT OR AMBIGUOUS STATEMENT Purposes of Planning
Risk for Ineffective Airway Clearance
related to emphysema (medical terminology)
• Promote communication among
PLANNING caregivers
• Direct care and documentation
3. Deciding problems that must be recorded
• Create a record that can later be used
4. Determine Interventions
for evaluation, research, and legal reasons. 5. Ensuring plan is adequately recorded
• Provide documentation of health care
needs for insurance reimbursement purposes 1. Setting priorities
– is an essential critical thinking skill that
TYPES OF PLANNING requires you to be able to decide :
1. Initial Planning Which problems need immediate
- Planning should be initiated as soon as attention, which ones can wait ?
possible after the initial assessment. The nurse Which problems are your responsibility
has the benefit of the slient’s body language as and which do you need to refer to someone else
well as some intuitive kinds of info that are not ?
available solely from the written database.
2. Ongoing Planning Which problems will be dealt with by
- occurs at the beginning of a shift as the using standard plans
nurse plans the care to be given that day. As Which problems aren’t covered by
nurses obtain new information and evaluate the protocols or standard plans but must be
client’s responses to care to be given that day. addressed to ensure a safe hospital stay and
3.Discharge Planning timely discharge ?
– the process of anticipating and planning for
the needs after discharge. Effective discharge Priority-Setting Principles
planning begins at first client contact and In setting priorities, be guided by the following
involves comprehensive and ongoing principles :
assessment to obtain information about the • Choose a method of assigning priorities
client’s ongoing needs. and use it consistently
• Assign a high priority to problems that
FORMAT OF NURSING contribute to other problems
CARE PLAN
• Your ability to understand priorities is
influenced by your understanding of the patient’s
• NURSING DIAGNOSIS understanding of priorities, the whole picture of
problems, patient’s overall health status,
• GOALS / EXPECTED OUTCOME expected length of stay, and whether there are
• NURSING INTERVENTIONS standard plans that apply
***In developing plans, applies laws and
• EVALUATION standards practice
LIFE THREATENNG/
• Skin shows no sign of discoloration or
HEALTH-THREATENING irritation
Assign high priority problems that contribute to • Control of listed risk factors (nutrition,
other problems. hydration, skin care every 8 hours)
Example : EXAMPLES
if someone has chest pain and difficulty OUTCOME: With the help of printed materials,
breathing, pain management is a high priority the patient will demonstrate knowledge of
because pain causes increased stress and medication regimen by discharge
oxygen demand. INDICATORS: