The Nursing Process
Elizabeth
Bruderle
Villanova
University
The Nursing Process
In 1980, The American Nurses’ Association
(ANA) defined nursing as:
The
diagnosis and treatment of HUMAN RESPONSES
to
actual or potential health problems
Introduction
A problem-solving method
Systematic, goal-directed, flexible, rational approach
Ensures consistent, continuous, quality nursing care
Provides a basis for
professional accountability
Input of nurse and patient/family critical
The Steps of the Nursing Process
are cyclic, overlapping and interrelated:
Assess
Diagnose
Evaluate
Plan
Implement
Step One of the Nursing Process:
Assessment: the most critical step
Answers the questions: “What is happening?”
(actual problem), or
“What could
happen?” (potential problem)
Involves collecting, organizing,
and analyzing information/data about the patient
Results in Nursing Diagnoses
Two parts: Data collection &
Data analysis
1. Data Collection: A Holistic Approach
Types of data
Subjective: “symptoms”
that the patient describes; e.g. “I can’t do anything for myself”
Objective: signs that can be observed, measured, and
verified; e.g. swollen joints
Sources of data
Primary: the patient; is always the best source
Secondary: everything/everybody else
Methods of Data Collection
Observation
Requires practice and skill
Systematic, head-to-toe (cephalocaudal)
Results in objective, factual
information
Document exactly what
you observe
e.g. “Yawned frequently, had dark circles under eyes”
NOT “Patient seems tired”
Observation results in a General
Survey
The General Survey: a
brief description of patient’s appearance and behavior.
64 year old, well groomed
African-American male in acute distress. Awake, alert, and oriented.
Approximately 6’, 170lbs. Hair sparse and gray, eyes brown. Sitting on side of
bed, holding siderail for support. Verbal responses coherent but halting.
Methods of data collection
Interview
Structured form of communicationPurpose: to provide care specific to this
individual’s needs and problems
Focus: patient’s perceptions
Nurse must: explain purpose of interview, provide comfort and privacy,
ensure confidentialityResult: A comprehensive Health History
Components of the Health History
Demographic data
CC: chief complaint
HPI: history of present illness
PMH: past medical history
FMH: family medical history (genogram)
ROS: review of systems
Psychosocial history
Methods of Data Collection
Examination
Inspect
Palpate
Percuss
Auscultate
Nurse must: explain
what you are doing, provide
privacy, and ask permission before you touch the patient
2. Data Analysis
Data review
Are data accurate and
complete?
Data interpretation
What are the patient’s
actual and/or potential problems?
Develop
a problem list based on the data
Prioritize
the patient’s problems
Step Two of the Nursing Process
Nursing Diagnosis:
a statement that describes a
specific human response to an actual or potential health problem that requires nursing
intervention
Written in P E format
P = Problem:
use North American Nursing Diagnosis Association (NANDA) category
[due to or related to]
E = Etiology: cause
of the problem
The Patient
A
Holistic-Physical-Emotional-Psychosocial-Developmental-Spiritual Being
Data Base
Medical Diagnosis Nursing
Diagnosis
Rheumatoid Arthritis Self-care
deficit:bathing, related to joint stiffness
Step Three of the Nursing Process
Plan: to provide
consistent, contiuous care that will meet the patient’s unique needs.
Includes Patient Goals & Nursing Orders
Patient Goals: describe the desired result of nursing care
What will the patient (or
part of the patient) do to resolve or lessen the problem identified in the
nursing diagnosis?
By when will this be accomplished?
Patient Goals are directly related to the patient’s problem as
stated in the nursing diagnosis:
One goal should describe resolution
of the problem
Additional
goals should describe steps that contribute to problem resolution
Patient Goals can be long term or short term
Patient Goals are:
Focused on the patient
Clear and Concise
Observable, Measurable, Realistic:
how much? how far? how long? how well?
Written with a specific time
frame: by when should the goal be accomplished?
Determined by the nurse and the
patient
Mr. H. will perform entire
bath unassisted by 4-4-01
Nursing Orders
Describe
what the nurse will do to help the patient achieve the goals.
Nursing Orders must:
Focus on nursing actions
Describe when and how the nurse will perform
nursing actions
Include the date & be signed by the nurse 3/30/01
The nurse will assist Mr. H. with bathing qAM until he is
able to bathe independently. E. Bruderle, RN
Step Four of the Nursing Process
Implement: Carry out
the care plan
Reassess
the patient
Validate
that the care plan is accurate
Carry out nurses’ orders
Document
on patient’s chart
Step Five of the Nursing Process
Evaluate: Compare
the patient’s current status with the stated Patient Goals
Were the goals achieved? Why
not?
Review
the nursing process
Problem: “I can’t do anything for myself”
Nursing Diagnosis: Self care deficit: bathing, related to joint
stiffness
Patient Goal (resolution): Mr. H. will perform entire bath
unassisted by 4-4-00.
Patient Goal (contributory): Mr. H. will bathe his upper body
unassisted by 4-1-00.
Nursing order: 3/30/01 The nurse will assist Mr. H. with bathing q
AM until he is able to bathe independently. E.Bruderle RN Evaluation:
Was Mr.. H. able to bathe unassisted by 4-4-00?