TimbySmith Introductory MedicalSurgical Nursing 11e Chapter 3 The

Nursing Process • Systematic method to plan and implement care to achieve desired outcomes • Problem-solving techniques and scientific process • Framework for nursing care in all healthcare settings • Nurse practice acts include nursing process in nursing definition. • Organized structure of nursing curricula • Basis for National Council Licensure Examination (NCLEX) Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins

Steps of Nursing Process • Nursing process – Five steps • Assessment—collects data • Diagnosis (analysis)—defines problems/needs • Planning—establishes outcomes to achieve goals • Implementation—plans into action • Evaluation—responses to care Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins

Nursing Process—(cont. ) Systematic method to plan and implement care to achieve desired outcomes

Nursing Process—(cont. ) • Assessment – Purpose: collect information • Determines abnormal function and risk factors as well as client strengths – Obtains data about client’s health and illness – Client database • Medical and nursing history, physical examination, and diagnostic studies Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins

Nursing Process—(cont. ) • Nursing diagnosis – Purpose: analyzes data and defines health problems – LPN/LVN reports information. • Actual and potential health problems – RNs examine and analyze data to formulate nursing diagnoses. – NANDA—classification system for problems and diagnoses Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins

Nursing Diagnostic Statement • Nursing diagnosis—(cont. ) – Three parts • Name/label of the problem • Cause of the problem • Signs and symptoms Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins

Nursing Diagnosis • Four types • Actual—identify existing problems Example: Urinary Retention or Anxiety • Health promotion—client’s motivation and behavior Example: Ineffective Health Maintenance • Risk—potential problems Example: Risk for Impaired Skin Integrity • Syndrome—specific diagnoses Example: Disuse Syndrome Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins

Question Your patient has a diagnosis of rheumatoid arthritis. While making the patient’s plan of care, which nursing diagnosis would be most applicable to this patient? A) Self-Care Deficit related to fatigue and joint stiffness B) Urinary Retention related to narcotic pain medication C) Risk for Depression related to inactivity D) Fluid Volume Deficit related to nausea Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins

Answer A) Self-Care Deficit related to fatigue and joint stiffness Rationale: Actual nursing diagnoses identify existing problems and are derived from data gathered by assessing the client. Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins

Nursing Process—(cont. ) • Planning – Purpose: setting priorities, defining desired outcomes (goals), determining interventions, and recording plan of care • Encourage client and family participation. – Establishing priorities • Maslow’s hierarchy of needs • Five levels: physiologic, safety and security, love and belonging, esteem and self-esteem needs, self-actualization Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins

Question Maslow proposed five levels of need and grouped them according to motivation. Which client need is of primary importance? A) Breathing easy B) Being safe from falling C) Liking the nurse D) Recognizing surroundings Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins

Answer A) Breathing easy Rationale: The first-level needs, sometimes called baseline survival needs, have the highest priority. These activities, such as eating, breathing, and drinking, sustain life. Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins

Nursing Process—(cont. ) • Nursing expected outcomes – Outcomes: specific, realistic, and measurable – Client-centered outcomes; developed with client and family and healthcare providers • Derived from nursing diagnosis – Achievable with client’s available resources – Time estimate for achievement; short- or long-term – Direction for continuity of care Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins

Question A patient comes to the emergency department complaining of severe chest pain. The nurse asks the patient questions and takes vital signs. Which step of the nursing process is the nurse demonstrating? A) Assessing B) Diagnosing C) Planning D) Implementing Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins

Answer A) Assessing Rationale: Assessing is the step in which nurses assess the patient to determine the need for nursing care. When assessing, the nurse systematically collects patient data. Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins

Nursing Process—(cont. ) • Interventions – Purpose: actions for achieving outcomes – Written as nursing orders • Specific and compatible with medical orders – Documentation functions • Communicates care • Shows trends in client status • Creates legal document • Supplies validation for reimbursement Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins

Nursing Process—(cont. ) • Evaluation – Purpose: assessment and review of care and client’s response to care • Compare actual outcome to expected outcome. – Conclusions: outcomes are met or not met • Outcome achieved; problem solved; nursing orders discontinued • Outcome is not met; plan of care continued or revised. Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins

Nursing Process—(cont. ) • Evaluation—(cont. ) – Outcome is not achieved; plan requires reevaluation – Reasons • Unrealistic expectations • Incorrect diagnosis of problem • Development of additional problems • Ineffective nursing measure • Premature target date Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins

Question What phase of the nursing process is the nurse in when he determines a medication is effective and documents this in the medication record? A) Analysis B) Evaluation C) Assessment D) Data Collection Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins

Answer B) Evaluation Rationale: Evaluation allows the nurse to determine the patient’s response to the nursing interventions and the extent to which the goal has been achieved. Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins

Nursing Process and Critical Thinking • Critical thinking – Intentional, contemplative, and outcome-directed thinking – Guided by standards, based on nursing process, identifies key problems, applies logic, calls for strategies, and constant reevaluation – Makes nurses efficient and effective – Scientific problem solving in a systematic, clientcentered, outcome-based thinking Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins

Question Which of the following is a true statement about critical thinking in nursing? A) It involves purposeful, outcome-directed thinking. B) It shows outcomes for client care. C) It makes judgments based on assessment data. D) It provides justification for actions. Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins

Answer A) It involves purposeful, outcome-directed thinking. Rationale: Critical thinking assists nurses to identify client problems and develop and implement plans of care with a logical, purposeful, and outcome-based method. Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins

Nursing Process and Critical Thinking— (cont. ) • Concept care mapping – Links important ideas – Organizes data – Considers all client’s problems as a whole – Steps of nursing process • Shows interrelationships • Dependent on assessment skills Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins