The Nursing Process

Assessing:

Collecting Data:

– Subjective Data (symptoms), Objective Data (signs)

– Primary source is the client
– Secondary source is family or anyone else that is not the client
– Collect data by observing which uses your senses or through an
interview
○ Interview is planned communication with a purpose
○ Directive interview - Nurse directs interview, client responds
to questions and has limited chances to discuss concerns.
○ Nondirective interview – rapport-building where the client is
in control of the purpose, subject, and pace.
○ Questions :
 Open-ended – invites client to discover and explore,
elaborate, clarify, or illustrate their thoughts or
feelings. “How have you been feeling lately?”
 Closed-ended – used in directive interviewing, and are
questions that require a yes or no answer.
 Neutral question – a question that the client can
answer without direction. “Why do you think you had
the operation?”
 Leading question – directs the clients answer. “You’re
stressed about surgery tomorrow, aren’t you?”

Organizing Data:

– Using a written or computerized format that organizes the

assessment data.
– Most schools of nursing and health cause agencies have developed
their own structured assessment format.
– Frameworks:
○ Gordon – 11 functional health patterns
○ Orem – 8 universal self-care requisites of humans
○ Roy’s adaptation model
○ Maslow’s hierarchy of needs

Validating Data:
 – Double checking data to ensure that the assessment info is correct,
and to ensure that the subjective and objective data agree, as well
as to obtain additional info that may have been over looked.
– Cues vs. Inferences:
○ Cues – subjective or objective data that can be directly
observed by the nurse, either what the client says or what
the nurse can see.
○ Inferences – nurses interpretations or conclusions based on
the cues. (A nurse observes the cues that an incision is red,
hot, and swollen; the nurse makes the inference that the
incision is infected.)
– You don’t have to check all data (like birth dates, height, weight and
most lab studies)

Documenting Data:

– Data is recorded in a factual manner and not interpreted by the

nurse.
○ The nurse records the client’s breakfast intake (objective) as
“coffee 240 mL, 1 egg, and 1 slice of toast”

Diagnoses:

– Diagnostic Labels
○ Describes the client’s health problem or response for which
nursing therapy is given.
○ Qualifiers – additional info
 Deficient, Impaired, Decreased, Ineffective,
Compromised.
○ Etiology – Related factors and risk factors.
○ Example of Label :
 Activity Intolerance related to Generalized weakness
– Defining characteristics – clusters of s/s that indicate the presence
of a particular diagnostic label.
○ Actual nursing diagnoses – signs and symptoms
○ Risk nursing diagnoses – no-subjective or objective signs are
present.
– Differentiating Nursing Diagnoses from Medical Diagnoses
○ A client’s medical diagnosis remains the same for as long as
the disease process is present, but nursing diagnoses change
as the client’s responses change.
○ Independent function – areas of health care that are unique
to nursing and separate and distinct from medical
management.
 ○ Dependent function- Nurses are obligated to carry out
physician-prescribed therapies and treatments.
– Differentiating Nursing Diagnoses from Collaborative Problems
○ Collaborative – monitoring the client’s condition and
preventing development of the potential complication and
using physician-prescribed interventions.
○ Nursing Diagnoses – involve the human response, which vary
from one person to the next.
 More individualized.

Analyzing Data:

– Compare data against standards

○ Growth and development patterns, normal vital signs, and
lab values.
– Clustering Cues
○ The process of grouping cues to determine the relatedness of
facts and see if there are any patterns.
– Identify Gaps and inconsistencies in data
○ Conflicting data
 Client tells you that they haven’t been to the doctor in
15 years, but then says that they see their doctor
every year for a physical.

Indentifying Health Problems, Risks, and Strengths:

– Determining Problems and Risks

○ Client has no appetite and has not eaten today
 Problem/Risk is Imbalanced Nutrition: Less than Body
Requirements
– Determine Strengths
○ Anything that is at the client’s advantage
 The client may be physically fit and there for may
recover faster.

Formulating Diagnostic Statements:

– Two-part Statement PE
○ Problem(P) Related to Etiology(E)
– Three-part Statement PES
○ Problem(P) Related to Etiology(E) as manifested by Signs and
symptoms(S).
– One-Part Statement
○ Nursing intervention can be derived from the label and
doesn’t need a etiology.
 Health-Seeking Behaviors ( Low-Fat Diet)
 Avoiding Errors in Diagnostic Reasoning

– Verify, build a good knowledge base and acquire clinical experience,

know what is normal, consult resources, base diagnoses on
patterns- that is, on behavior over time- rather than on an isolated
incident, and improve critical thinking skills.

Planning:

– Nursing intervention: any treatment based upon clinical judgment

and knowledge, that a nurse performs to enhance patient outcomes
– Planning :
○ Initial Planning
 Done asap
 Using client’s body language as well as intuitive kinds
of information.
○ Ongoing Planning:
 Done by all nurses who work with the client.
• Determine whether the client’s health status
has changed
• Set priorities for the client’s care during the shift
• Decide which problems to focus on during the
shift
• Coordinate the nurse’s activities so that more
than one problem can be addressed at each
client contact
○ Discharge Planning:
 Process or anticipating and planning for needs after
discharge, is a crucial part of comprehensive health
case and should be addressed in each client’s care
plan.
– Informal Nursing care plan
○ Strategy for action that exists in the nurse’s mind.
– Formal Nursing care plan
○ Written or computerized guide for organizing information
– Standardized care plan
○ Formal plan that specifies the nursing care for groups of
clients with common needs.
○ Not for individuals
○ Preprinted guides for the nursing care of a client who has a
need that arises frequently in the agency.
○ Problem -> Goals/desired outcomes -> Nursing interventions
-> Evaluation
  Protocols – preprinted to indicate the actions
commonly required for a particular group of clients.
• Ex. An agency may have a protocol for
admitting a client to the intensive care unit.
 Policies/procedures – are developed to govern the
handling of frequently occurring situations.
• Ex. How many visitors are allowed in
 Standing orders – are written document about policies,
rules, regulations, or orders regarding client care. They
also give nurses the authority to carry out specific
actions under circumstances, often when a physician is
not immediately available.
– Individualized care plan
○ Is tailored to meet the unique needs of a specific client.
– When nurses use the client’s nursing diagnoses to develop goals
and nursing interventions, the result is a holistic, individualized plan
of case that will meet the client’s unique needs.
– During planning phase, the nurse must decide which of the client’s
problems need individualized plans and which problems can be
addressed by standardized plans and routine care, and write unique
desired outcomes and nursing interventions for client problems that
require nursing attention beyond preplanned, routine care.
– Formats for nursing care plans
○ Student – have a rationale column
○ Computerized - visual tool
– Multidisciplinary (collaborative) Care Plans – is a standardized plan
that outlines the care required for clients with common, predictable-
usually medical-conditions.
– Guidelines for writing a care plan
○ Date and sign the plan
○ Use category headings
 “Nursing Diagnoses” “Goals/Desired Outcomes”
○ Use standardized medical or English symbols and key words
rather that complete sentences to communicate your ideas.
○ Be specific
 When it comes to time
○ Refer to procedure books or other sources of info rather than
including all steps on something
○ Tailor plan to the client
 Ask when the best time is for the client to do
interventions
○ Ensure that the plan incorporates preventive and health
maintenance aspects as well as restorative ones.
 ○ Ensure that the plan contains interventions for ongoing
assessment of the client.
○ Include collaborative and coordination activities in the plan
○ Include plans for the client’s discharge and home care needs

Setting Priorities

-establishing a preferential sequence for addressing nursing

diagnoses and interventions.

○ Clients health values and beliefs

○ Clients priorities
○ Resources available to the nurse and client
○ Urgency of the health problem
○ Medical treatment plan

Establishing Client Goals/Desired Outcomes

○ What you want to see happen

○ Include the client in this part
○ Goal must be broad
○ Desired outcome must be specific
○ Nursing Outcomes Classification (NOC)
 Taxonomy that describes the client outcomes.
○ Goals and outcomes provide direction for planning
interventions, they serve as a criteria for evaluating client
progress, enable client and nurse to determine when the
problem has been resolved, and help motivate the client and
nurse by providing a sense of achievement.
○ Short-term and long-term goals should be used

Selecting Nursing Interventions and Activities

○ Independent interventions
 Activities that the nurse is licensed to initiate on the
basis of their knowledge and skills
○ Dependent interventions
 Activities carried out under the physicians’ orders or
supervision, or according to specific routines.
○ Collaborative interventions
 Actions carried out by nurses and other health care
providers
○ Consider the consequences of each intervention
○ Makes sure that the intervention is safe and appropriate for
the client’s age, health, and condition
 ○ Interventions must be congruent with the client’s values and
beliefs.

Implementing :

– Skills:
○ Cognitive
 Intellectual skills including problem solving, decision
making, critical thinking, and creativity
○ Interpersonal
 Required in all nursing
 Verbal and nonverbal, people use when interacting
directly with each other
○ Technical
 Hands on skills
 Using equipment, giving injections, bandaging,
moving, lifting, and repositioning clients.

Reassessing the Client

Determining the Nurse’s Need for Assistance

Implementing the Nursing Intervention

 Base intervention on scientific knowledge, nursing

research, and professional standards of care
 Understand the intervention
 Adapt to client
 Use safe care
 Teach
 Be holistic
 Respect dignity or the client
 Encourage clients to participate
○ Even though you delegate care to someone else, you are
responsible for making sure that the task was done right and
you are responsible for anything that goes wrong.

Document everything

Evaluating:

– Evaluation is continuous
– Evaluating and assessing phase overlap
– The desired outcomes are related to the collection of data
– Collecting Data
○ Objective
○ Subjective
– Comparing Data with Outcomes
○ Goal Met
○ Goal partially met – what changes need to be made?
○ Goal was not met – what changes need to be made?
 After goal was met, writes an evaluative statement

• Consists of two parts

○ Conclusion
○ Supporting data
 “Goal Met: Oral intake 300Ml more
than output skin turgor resilient
mucous membrane moist
– Relating Nursing Activities to Outcomes
○ Make sure that it is what you are doing that is bring any
change to the client
○ Ask them if they are doing anything extra
– Drawing Conclusions about problem Status
○ Have actual or potential problems been resolved
○ Prevention
○ Actual problem still exists even though some goals were met
– If the goals have been partially met or when goals have not been
met, 2 things may be drawn
○ Care plan needs to be revised
○ Care plan doesn’t need to be revised, because the client
merely needs more time to achieve the goals.
– Continuing, Modifying, and Terminating the Nursing Care Plan
○ After drawing conclusions about the statue of the client’s
problem, the nurse modifies the care plan as indicated.
 Discontinue, or “goal met” with the date
– Evaluating the Quality of Nursing Care
○ Quality-assurance (QA) Program
 An ongoing systematic process designed to evaluate
and promote excellence in the health care provided to
clients.
• Structure evaluation – focuses on the setting in
which care is given. It answers this question:
“what effect does the setting have on the
quality of care.”
• Process Evaluation – Focuses on hoe the care
was given. It answers the question, “Is the care
relevant to the client’s needs? Is the care
appropriate, complete, and timely?”
 • Outcome Evaluation – focuses on demonstrable
changes in the client’s health status as result of
nursing care.
○ Quality Improvement
 Evaluating and improving the quality of health care
based on internal assessment by health care providers
and increasing awareness by the public that medical
errors are not uncommon and can be lethal.
 Sentinel Event – is an unexpected occurrence involving
death or serious physical or psychological injury.
 Root cause analysis – process for indentifying the
factors that bring about deviations in practices that
lead to the event.
 Quality improvement (QI) – focuses on client care
rather than organizational structures, focuses on
process rather than individuals, and uses a systematic
approach with the intention of improving the quality of
care rather than ensuring the quality of care.
– Nursing Audit
○ To examine or review records
○ Retrospective Audit – is the evaluation of a client’s health
record after discharge from as agency.
○ Concurrent audit – is the evaluation of a client’s health care
while the client is still receiving care from the agency.
○ Peer review – nurses reviewing other nurses
 Individual peer review – focuses on the performance of
an individual nurse
 Nursing audits (peer review) – evaluation the nursing
care through review of the records.
• Depends on accurate documentation