mne 204 (2)

8/4/2019 MNE 204 (2)

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Hannah Melissa Ilagan, RN

Michelle M. Luceno, RN

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The nursing process is an organized sequence of problem- solving steps used to identify and tomanage the health problems of clients.

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Characteristics:

Within the legal scope of nursing Based on knowledge Planned Client- centered Goal- directed Prioritized Dynamic

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Assessment 1. Collect data2. Organize data

Evaluation1. Monitor the client

outcomes2. Resolve, continue,

revise the current planof care

Diagnosis 1. Analyze data

2. Identify nx dx andcollaborativeproblems

Planning1. Prioritize problems2. Identify measurable outcomes3. Select nursing diagnosis4. Document the plan of care

Implementation1. Carry out the nursing

orders2. Document the nursing

care and clientresponses

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The first step in the nursing process, is thesystematic collection of facts, or data.

Begins with the nurse’s first contact with a clientand continues as long as a need for healthcare exists.

During assessment, the nurse collects informationto determine areas of abnormal function, risk factorsthat contribute to health problems, and client’sstrengths.

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Sources for Data

1. Primary- Client

2. Secondary- Client’s family, reports, testresults, information in current and past medical

records, discussions with other healthcare workers.

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Types of Assessments

Data Base Assessment Focus AssessmentObtained on admission Complied through subsequent care

Consists of predetermined questionsand systematic head-to-toeexamination

Consists of UNSTRUCTUREDquestions and collection of physicalassessments

Performed once Repeated each shift or more often

Suggests possible problems Rules out or confirms problemsFindings documented on anadmission assessment form

Finding documented on a checklist orin progress notes

Time- consuming; may take 1 hr ormore

Completed in a brief amount of time( about 15 mins)

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Types of Assessments

Data Base Assessment Focus AssessmentSupplies a broad, comprehensive

volume of data

Collects limited data

Provide breadth for futurecomparisons

Adds depth to the initial data base

Reflects the client’s condition onentering the health care system

Provides comparative trends forevaluating the client’s response to

treatment

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Organization of Data- Organization involves grouping related

information.

- Data organized into small groups is more easyto analyze and takes on more significance than when

the nurse considers each fact separately or examinesthe entire group at once.

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the 2nd step, is the identification of health- relatedproblems

Diagnosis results from analyzing the collected dataand determining whether they suggest normal orabnormal findings

NURSING DIAGNOSIS- is a health issue that can beprevented, reduced, resolved, or enhanced throughindependent nursing measures.

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TYPE EXPLANATION AND EXAMPLEActual Diagnosis A problem that currently exists. Impaired Mobility related

to pain as evidenced by limited range of motion, reluctanceto move

Risk Diagnosis A problem the client is uniquely at risk for developing. Risk for deficient fluid volume related to persistent vomiting

Possible Diagnosis A problem may be present, but requires more datacollection to rule out or confirm its existence. PossibleParental Role Conflict related to impending divorce

Syndrome Diagnosis Cluster of problems predicted to be present because of anevent or situation. Rape Trauma Syndrome and DisuseSyndrome

Wellness Diagnosis A health-related problem with which a healthy personobtains nursing assistance to maintain or perform at a

higher level. Potential for Enhanced Breastfeeding

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DIAGNOSTIC STATEMENTS Contains 3 parts:

1. Name of the health- related issue or problem asidentified in the NANDA list

2. Etiology3. Signs and Symptoms

*the name of nx dx –(related to)- etiology,(manifested by ) signs and symptoms

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Different types of diagnoses have different stems

Potential diagnoses are prefaced with the term “ risk

for ”, as in Risk for Impaired Skin Integrity related toinactivity.

The word “ possible” is used in a diagnostic

statement to indicate uncertainty- example, PossibleSexual Dysfunction related to anxiety

Wellness Diagnosis – prefaced with phrase “Potential

for enhanced”

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Collaborative Problems are physiologiccomplications whose treatment requires both nurseand physician prescribed interventions.

Nursing

Diagnoses

Collaborative Medical

Problems Diagnoses

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is a deliberative, systematic phase of the nursingprocess that involves decision-making and problem

solving.

In planning, the nurse refers to the client’sassessment data and diagnostic statements for

direction in formulating the client’s goals anddesigning the nursing interventions required toprevent, reduce, or eliminate the client’s healthproblems.

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TYPES OF PLANNING Initial planning- the nurse who performs the

admission assessment usually develops the initialcomprehensive plan of care.- this nurse has the benefit of the client’s body

language as well as some intuitive kinds of

information that are not available solely from thewritten database.

- planning should be initiated as soon aspossible after the initial asessment.

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TYPES OF PLANNING Ongoing planning- is done by all nurses who

work with the client. As nurse obtain new info andevaluate the client responses to care, they canindividualize the initial care plan further.

-It also occurs at the beginning of a shift as thenurse plans the care to be given that day.

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Using ongoing assessment data, the nurse

carries out daily planning for the ff purposes:

1. to determine whether the client’s health status haschanged2. To set priorities for the client’s care during the shift 3. to decide which problems to focus on during the

shift4. To coordinate the nurse’s activities so that morethan one problem can be addressed at each clientcontact.

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Formats of NCPs The care plan is often organized into four columns orcategories:I. Student Care Plansa. Nursing diagnosisb. Goals/ Desired outcomesc. Nursing ordersd. Evaluation

(e.) Rationale

II. Computerized Care plans- nurses access the client’s storedcare plan from a centrally located terminal at the nurses

station or from terminals in client rooms.

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Guidelines for writing NCPs: 1. Date and sign the plan2. Use category headings

3. Use standardized medical or English symbols andkey words rather than complete sentences tocommunicate your ideas. (e.g. Turn and repositionq2h)

4. Be specific. (working shifts)5. Refer to procedure books or other sources of

information rather than including all the steps on awritten plan.( e.g. see unit procedure book for

tracheostomy care.

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Guidelines for writing NCPs:6. Tailor the plan to the unique characteristics of the

client by ensuring that the client’s choices, such as

preferences about the times of care and themethods used, are included.7. Ensure that the plan contains interventions for

ongoing assessment of the client. (e.g. Inspect

incision q8h)8. Ensure that the NCP incorporates preventive and

health maintenance aspects as well as restorativeones. (e.g. Provide active ROM exercises to

affected limbs)

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Guidelines for writing NCPs:9. Include collaborative and coordination activities in

the plan. (e.g. Ask a physical about ROM exercises)

10. Include plans for the client’s discharge and homecare needs. (e.g. ask to make arrangements withthe CHN, social worker)

SETTING PRIORITIES The process of establishing a preferential sequence for

addressing nursing diagnoses and interventions.

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ESTABLISHING CLIENT OUTCOMES AND GOALS In terms of observable client responses, what thenurse hopes to achieve by implementing the nursing

interventions.

SELECTING NURSING INTERVENTIONS a. Independent interventions- those activities that

nurses are licensed to initiate on the basis of theirknowledge and skills.

b. Dependent interventions- activities that are carriedout under the physician’s orders or supervision, or

according to specified routines.

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WRITING NURSING ORDERSAre instructions for the specific individualized activitiesthe nurse performs to help the client meet established

health care goals.DATE

ACTIONVERB

CONTENTAREA

TIMEELEMENT

SIGNATURE

Are datedwhen they are

written andreviewedregularly atintervals thatdepend on theindividual’s

needs.

Starts theorder andmust beprecise.

The what andthe where ondthe order.

Answerswhen, howlong, or howoften thenursing actionis to occur.

The signatureof the nurseprescribingthe ordershows thenurse’saccountabilityand has legal

significance.

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consists of doing and documenting the activitiesthat are the specific nursing actions needed to carryout the interventions.

The nurse delegates the nursing activities for theinterventions that were developed in the planning stepand then concludes the implementing step by

recording nursing activities and the resulting clientresponses.

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To implement the care plan successfully, nursesneed cognitive, interpersonal, and technical skills.

Cognitive skills- include problem solving, decisionmaking, critical thinking, and creativity.

Interpersonal skills-all of the activities, verbal and

nonverbal, people use when interacting directly withone another.

Technical skills- hands on skills.

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Process:

1. Reassessing the client

2. Determining the nurse’s need for assistance 3. Implementing the nursing interventions4. Supervising the delegated care5. Documenting nursing activities.

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is a planned, ongoing, purposeful activity in whichclients and health care professionals determine:

a. The client’s progress toward achievement of goals/outcomes

b. the effectiveness of the nursing care plan.

An important aspect because conclusions drawnfrom the evaluation determine whether thenursing interventions should be terminated,continued, or changed.

mne 204 (2)

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