Nursing Process :Nursing Process Barbara Dries, RN, MSN, EdD Assistant Professor Samuel Merritt College


Five Phases of the Nursing Process :Barbara Dries, RN, MSN, EdD 2 Five Phases of the Nursing Process Assessment Diagnosis Planning Implementation Evaluation


Assessment :Barbara Dries, RN, MSN, EdD 3 Assessment Obtain information about a patient’s response to health concerns/illness and their ability to manage these healthcare issues Collect data Organize data Validate data Document data


Assessment: Types of Data :Barbara Dries, RN, MSN, EdD 4 Assessment: Types of Data Subjective data Objective data Example: pain is __________ data Blood pressure is __________ data


Assessment: Sources of data :Barbara Dries, RN, MSN, EdD 5 Assessment: Sources of data Primary sources Client or patient Secondary sources Family members Current and past patient records Laboratory and diagnostic results


Assessment: Data Collection Methods :Barbara Dries, RN, MSN, EdD 6 Assessment: Data Collection Methods Observation Use of all senses Interviewing Closed-questioning Open-questioning Physical assessment


Diagnosis :Barbara Dries, RN, MSN, EdD 7 Diagnosis


NANDA (North American Nursing Diagnosis Association)Nomenclature to define actual or potential health problems :Barbara Dries, RN, MSN, EdD 8 NANDA (North American Nursing Diagnosis Association)Nomenclature to define actual or potential health problems Appendix B Nursing Diagnoses (Lewis, et al, text)


Nursing Diagnosis :Barbara Dries, RN, MSN, EdD 9 Nursing Diagnosis “a clinical judgment about individual, family, or community responses to actual and potential health problems/life processes. Nursing diagnoses provide the basis for selection of nursing interventions to achieve outcomes for which the nurse is accountable.” (as cited by NANDA International)


Types of Nursing Diagnoses :Barbara Dries, RN, MSN, EdD 10 Types of Nursing Diagnoses Actual diagnosis A problem that is present at the time of assessment Potential diagnosis The problem does not exist, but there is an increased potential of developing the problem due to the presence of risk factors


Basic three-part diagnosis: :Barbara Dries, RN, MSN, EdD 11 Basic three-part diagnosis: 1. What is the problem (potential or actual)? 2. What is the probable cause? 3. What is the data that lead you to 1 and 2?


Activity Intolerancerelated topneumoniaas evidenced by difficulty breathing (SOB) :Barbara Dries, RN, MSN, EdD 12 Activity Intolerancerelated topneumoniaas evidenced by difficulty breathing (SOB)


12 Functional Health Patterns :Barbara Dries, RN, MSN, EdD 13 HEALTH-PERCEPTION-HEALTH-MANAGEMENT NUTRITIONAL-METABOLIC ELIMINATION ACTIVITY-EXERCISE SLEEP-REST COGNITIVE-PERCEPTUAL SELF-PERCEPTION-SELF-CONCEPT ROLE-RELATIONSHIP SEXUALITY-REPRODUCTIVE COPING-STRESS-TOLERANCE VALUE-BELIEF Other 12 Functional Health Patterns


Answer NCLEX type questions about Nursing Process :Barbara Dries, RN, MSN, EdD 14 Answer NCLEX type questions about Nursing Process


Which of the following is the correct sequence of steps in making a nursing diagnosis? :Barbara Dries, RN, MSN, EdD 15 Which of the following is the correct sequence of steps in making a nursing diagnosis?


1. Generate hypotheses about possible nursing diagnoses, check for defining characteristics, cluster assessment data into meaningful sets, choose the appropriate diagnostic label, and determine the etiology. :Barbara Dries, RN, MSN, EdD 16 1. Generate hypotheses about possible nursing diagnoses, check for defining characteristics, cluster assessment data into meaningful sets, choose the appropriate diagnostic label, and determine the etiology.


2. Compare cue clusters with assessment data, generate differential diagnoses, determine the etiology, make the diagnosis, plan interventions, and write the “related to” statement. :Barbara Dries, RN, MSN, EdD 17 2. Compare cue clusters with assessment data, generate differential diagnoses, determine the etiology, make the diagnosis, plan interventions, and write the “related to” statement.


3. Review the assessment data, cluster the data into meaningful sets, compare clusters to defining characteristics of possible diagnoses, choose the appropriate nursing diagnosis, determine the etiology, and write the “related to” statement. :Barbara Dries, RN, MSN, EdD 18 3. Review the assessment data, cluster the data into meaningful sets, compare clusters to defining characteristics of possible diagnoses, choose the appropriate nursing diagnosis, determine the etiology, and write the “related to” statement.


The patient is a slim but well-nourished 72 year old who broke a hip two days ago. The patient underwent hip pinning surgery today and will be confined to bed for several days until able to ambulate. The nurse assists the patient to turn in bed frequently to reduce pressure on bony prominences and assists with elimination needs. :Barbara Dries, RN, MSN, EdD 19 The patient is a slim but well-nourished 72 year old who broke a hip two days ago. The patient underwent hip pinning surgery today and will be confined to bed for several days until able to ambulate. The nurse assists the patient to turn in bed frequently to reduce pressure on bony prominences and assists with elimination needs.


What is the most appropriate nursing diagnoses for this patient? :Barbara Dries, RN, MSN, EdD 20 What is the most appropriate nursing diagnoses for this patient? Feeding self-care deficit and Impaired skin integrity. Impaired skin integrity and Toileting self-care deficit Toileting self-care deficit and risk for impaired skin integrity Risk for Impaired skin integrity and Feeding self-care deficit.


Planning :Barbara Dries, RN, MSN, EdD 21 Planning Development of client goals and desired outcomes Prioritize problems/diagnoses and interventions Formulate nursing interventions to prevent, reduce, and alleviate health problems Product is the nursing care plan Ongoing process


Nursing care plans :Barbara Dries, RN, MSN, EdD 22 Nursing care plans Standardized nursing care plan A formal plan Specifies nursing care for patients with common needs Individualized nursing care plan Tailored to the client Meets unique needs Addresses needs not addressed in standardized care plan


Multidisciplinary Care Plans :Barbara Dries, RN, MSN, EdD 23 Multidisciplinary Care Plans Standardized care plan Includes multidisciplinary approach Respiratory Medical Nursing Physical therapy Occupational therapy Social work


Which of the following actions is performed during the planning phase of the nursing process? :Barbara Dries, RN, MSN, EdD 24 Which of the following actions is performed during the planning phase of the nursing process?


1. Establishing baseline data 2. Selecting nursing interventions 3. Identifying risk factors contributing to the patient’s problem. 4. Interpreting and analyzing patient data. :Barbara Dries, RN, MSN, EdD 25 1. Establishing baseline data 2. Selecting nursing interventions 3. Identifying risk factors contributing to the patient’s problem. 4. Interpreting and analyzing patient data.


Implementing :Barbara Dries, RN, MSN, EdD 26 Implementing Implementation of nursing interventions Performs or delegates the interventions Doing and documenting Continually assessing during this phase


Evaluating :Barbara Dries, RN, MSN, EdD 27 Evaluating Judging or appraising the care plan Ongoing process Determine client’s progress towards achieving goals/outcomes Evaluate effectiveness of the nursing care plan Make necessary modifications to the care plan and interventions Continue or terminate nursing diagnoses


Which of the following is a benefit of the evaluation process? :Barbara Dries, RN, MSN, EdD 28 Which of the following is a benefit of the evaluation process?


1. It promotes modifications and improvements in care.2. It enhances accurate diagnosis of the client's needs.3. It facilitates the selection of realistic, client-centered outcomes.4. It facilitates collaboration between members of the health care team. :Barbara Dries, RN, MSN, EdD 29 1. It promotes modifications and improvements in care.2. It enhances accurate diagnosis of the client's needs.3. It facilitates the selection of realistic, client-centered outcomes.4. It facilitates collaboration between members of the health care team.


Prep Sheet :Barbara Dries, RN, MSN, EdD 30 Prep Sheet Data Collection; pathophysiology of primary disease process Assessment Care Plan


Break :Barbara Dries, RN, MSN, EdD 31 Break


Movement and Coordination :Barbara Dries, RN, MSN, EdD 32 Movement and Coordination Four basic elements of normal movement Body alignment (posture) Joint mobility Balance (equilibrium) Coordinated movement


Body Alignment :Barbara Dries, RN, MSN, EdD 33 Body Alignment Be aware of center of gravity and base support Enhances lung expansion Promotes efficient function Circulation Renal Gastrointestinal


Joint Mobility :Barbara Dries, RN, MSN, EdD 34 Joint Mobility Musculoskeletal system Muscles categorized by the movement produced during contraction Flexors Extensors Internal rotators Flexors stronger than extensors Inactive joints result in contractures (fixed in the flexed positions) Range of motion exercises important (Review tables in Kozier, pp. 1060-1064)


Balance :Barbara Dries, RN, MSN, EdD 35 Balance Controlled by structures in the inner ear Receives input from Inner ear Vision Stretch receptors of the muscles and tendons


Coordinated Movement :Barbara Dries, RN, MSN, EdD 36 Coordinated Movement Requires proper functioning of Cerebral cortex Voluntary motor activity Cerebellum Motor activity of movement Basal ganglia Maintains posture


Effects of Immobility :Barbara Dries, RN, MSN, EdD 37 Effects of Immobility


Effects on the cardiovascular system :Barbara Dries, RN, MSN, EdD 38 Effects on the cardiovascular system Orthostatic hypotension Increased work load Increased valsalva maneuver Increased tachycardia Thrombus formation Venous vasodilation Stasis


Effects of Immobility :Barbara Dries, RN, MSN, EdD 39 Effects of Immobility Effects on the respiratory system Reduced lung expansion Reduced ventilation Increase in atelectasis Increase in pulmonary secretions Possible pneumonia


Effects of Immobility :Barbara Dries, RN, MSN, EdD 40 Effects of Immobility Effects on metabolic equilibrium Decreased metabolic rate Decreased gastrointestinal motility Negative nitrogen balance Loss of muscle Catabolic state


Effects Of Immobility :Barbara Dries, RN, MSN, EdD 41 Effects Of Immobility Loss of appetite (anorexia) Negative calcium balance Calcium extracted from bone Cannot be adequately replaced Urinary tract calculi (stones)


Effects of Immobility :Barbara Dries, RN, MSN, EdD 42 Effects of Immobility Effects on motor function Atrophy Contractures Osteoporosis Joint pain and stiffness Decubitus ulcers


Slide 43:Barbara Dries, RN, MSN, EdD 43


Prevention :Barbara Dries, RN, MSN, EdD 44 Prevention Mobilize


Activity :Barbara Dries, RN, MSN, EdD 45 Activity


Website :Barbara Dries, RN, MSN, EdD 46 Website Valuable NCLEX practice questions and case studies www.prenhall.com/kozier Click on correlating chapter