Nursing Process Flashcards
Nursing Process Definition
• An orderly, logical approach to nursing care so that the
patient’s needs are met consistently and effectively.
• It is used to develop an individualized plan of care for the
patient.
The Nursing Process is a form of communication between
nursing staff that is:
- Systematic
- Continuous
- Measurable
- Goal oriented
5 Steps in the Nursing Process
- Assessment
- Nursing Diagnosis
- Planning
- Implementation
- Evaluation
Assessment
Involves the collection of data or information about the
patient. Includes:
• Patient and family medical history (also called nursing history because it is collected by the nurse)
• Laboratory tests/ diagnostic tests
• Physical assessment using 5 senses
• seeing
• hearing
• touching
• smelling
The first source of information is the patient, and
then the family or caregiver with the patient’s
permission. Refer to Advance Directives.
Advance Directives
Medical power of attorney
- an appointed person to make healthcare decisions for you in case you are unable to speak for yourself
Subjective data
Is information that the patient tells you that he is feeling or
experiencing, but you cannot observe or measure it.
• Communicated concretely by the patient.
• Communication may be SUPPORTED by body language,
gestures, facial expression and body postures, but these are not subjective.
• Examples:
• I have a headache, I feel dizzy, I have pain in my ankle,
My stomach hurts
Objective data
Assessment data that is observable and measurable and
verifiable by different people
• Factual information only
• Can be seen, heard, felt, smelled
• Examples: pulse of 56, A1C of 11.5, Potassium level of 5,
cold clammy skin, abdominal girth of 100 cm, bloody
sputum, respiratory rate of 36
Data analysis
What data from all that you have collected is significant or
important?
• Does anything need to be verified?
• Is there a pattern?
• What are the patient’s problems?
• What are the patient’s strengths?
• Conclusions: compile the information and make
conclusions.
Cannot take the next step in the nursing process without a complete assessment.
Nursing Diagnosis
• After all the data has been gathered, analyzed and
prioritized, make your nursing diagnos(es)
• The nursing diagnosis describes a health problem that can
be treated by nursing measures. Refer to NANDA list.
• The problem may already exist or it may be a potential
problem depending on the data you have gathered.
• After selecting the nursing diagnos(es), prioritize the data
you have found under each nursing diagnosis.
• There will be times that you will develop a different
nursing diagnosis than the primary reason you are seeing the patient.
Nursing Diagnosis vs Medical Diagnosis
Nursing diagnosis
• Is the identification by the nurse of a problem or condition that can be treated with nursing measures. ie Fluid Volume Deficit
Medical diagnosis
• Is the identification by the doctor of a disease or condition that can be treated by medical intervention. ie tuberculosis
AMB definition
As manifested by
AEB definition
As evidence by
Planning: Setting Patient Goals
• The nurse, patient and family/ caregiver participate in the
planning stage.
• Planning involves setting goals that are prioritized based on assessment data that you have gathered. (goal is what PT/ fam / caregiver will do - they must consent and participate)
• Use your critical thinking skills. What is most important
for the patient?
• Use Maslow’s Heirarchy of Needs to prioritize the
patient’s goals. (circulation, food, oxygen, water, shelter,
safety, comfort)
• Planning sets short term and long term goals based on the episode of time you are dealing with the patient.
Maslow’s Hierarchy of Needs
Top to bottom
- Self-actualization: personal growth & fulfillment
- Esteem needs: achievement, status, responsibility, reputation, etc.
- Social (Belonging) needs: family, affection, relationships, etc.
- Safety needs: protection, security, stability, order, law, etc
- Physiological needs: air, food, water, shelter, clothing, warmth, sex, toileting, etc.
Measurable goal examples
• Examples of measurable goals:
• Patient will state 3 symptoms of hypoglycemia by day 2 of
hospitalization.
• Patient will demonstrate how to accurately draw up insulin dose
by day 3 of hospitalization.
• Daughter will demonstrate colostomy bag removal by day 3 post op.
• Mother will state 4 benefits of breastfeeding by second class session.
• Client will have a respiratory rate of 12 – 20 breaths per minute within 30 minutes of albuterol breathing treatment.
Planning: Setting Patient Goals (cont.)
• Goals must be measurable. How much? By when?
How will you know?
• After the goals are set, nursing actions or
interventions are chosen to help meet these patient
centered goals.
• Goals are aimed to give the patient the highest level
of independence and function.
• Goals may change as new information is gained
during assessment and reassessment.
Implementation (Nursing Interventions/ Actions)
• Actions taken by the nurse to help the patient meet
the goals set in the planning stage.
• Nursing interventions are classified as
• Dependent: need a doctor’s order to perform certain
treatments.
• Interdependent: performed collaboratively with other
disciplines.
• Independent: do not require a doctor’s order, nursing
actions that are based on your judgment/ critical
thinking.
Implementation
• Nursing interventions/ actions are prioritized in the
Nursing Process based on the assessment and plan.
What do I do first?
• In the Nursing Process the interventions are listed in
order of importance.
Implementation Examples
- Instruct patient in blood glucose monitor use
- Apply Oxygen at 2L/ min
- Elevate head of bed
- Administer Lisinopril
- Call Adult Protective Services
- Change coccyx dressing twice daily
- Insert foley catheter
Evaluation
- Evaluates the GOALS set in the planning stage.
- Look at each goal. Ask: Were they met? Partially met? Not met? How do you know?
- If goal was for patient to state that pain was 3/10 by the second day of hospitalization, did the patient state that it was 3/10? If goal was for patient’s wound to be 2 cm by the 60th day, was it?
- If goals are only partially met or not met, a new assessment is made and new goals are set. A n
Conclusion
• The nursing process is continuous
• Nurses continually collect information about the patient
• Assessments change, causing the nursing diagnos(es), plan, and interventions to change as the patient
changes.
Intervention with rationales
rationales: state the purpose for performing this intervention
EX:
Goal - improve O2 saturation to 96% within 4 hours
Intervention with rationales - Elevate head of the bed to prevent collapse of airway
Intervention = Elevate head of the bed
Rationales = to prevent collapse of airway
