nursing process: 5-step process gail ladwig, rn, msn, chtp mosby items and derived items © 2011 by...

Nursing Process: 5-Step ProcessNursing Process: 5-Step Process

Gail Ladwig, RN, MSN, CHTPGail Ladwig, RN, MSN, CHTP

Mosby items and derived items © 2011 by Mosby, Inc., an affiliate of Elsevier Inc.Mosby items and derived items © 2011 by Mosby, Inc., an affiliate of Elsevier Inc.

22Mosby items and derived items © 2011 by Mosby, Inc., an affiliate of Elsevier Inc.Mosby items and derived items © 2011 by Mosby, Inc., an affiliate of Elsevier Inc.

Nursing Process: DefinitionNursing Process: Definition

An organizing framework for professional An organizing framework for professional nursing practicenursing practice

Used in nursing to identify and treat the Used in nursing to identify and treat the nursing diagnoses (problems) of a client nursing diagnoses (problems) of a client


Critical Thinking and the NPCritical Thinking and the NP

Decision making for and with the clientDecision making for and with the client The nurse processes and interprets the The nurse processes and interprets the

information that is gathered while performing information that is gathered while performing the steps of the nursing process.the steps of the nursing process.


Nursing Process: QuoteNursing Process: QuoteCaring is major part of the processCaring is major part of the process

““Caring is essential to curing and pervades all Caring is essential to curing and pervades all efforts to help an individual recover after an efforts to help an individual recover after an illness and be curedillness and be cured”” (Leninger, 1996) (Leninger, 1996)


Nursing Process: QuoteNursing Process: Quote

According to Leninger (1996), According to Leninger (1996), ““Caring is the Caring is the most important and central focus of nursingmost important and central focus of nursing””


Nursing Process: QuoteNursing Process: Quote

Watson and Ray (1988) advocate that Watson and Ray (1988) advocate that ““we first we first love and care for ourselves, so as a beginning love and care for ourselves, so as a beginning nurse you are to believe in yourself, identify your nurse you are to believe in yourself, identify your strengths, and put your abilities to work.strengths, and put your abilities to work.””


Nursing Process: 5 StepsNursing Process: 5 Steps

Use the acronym ADPIEUse the acronym ADPIE1.1. AAssessmentssessment2.2. DDiagnosisiagnosis3.3. PPlanlan4.4. IImplementationmplementation5.5. EEvaluationvaluation


Step OneStep One

AssessmentAssessment


AssessmentAssessment

Initial step of the nursing processInitial step of the nursing process Collection of information about the clientCollection of information about the client Holistic and detailedHolistic and detailed Supports critical thinkingSupports critical thinking Determines problems and strengthsDetermines problems and strengths Ongoing during all phases of nursing processOngoing during all phases of nursing process


Step One: AssessmentStep One: AssessmentMethodMethod

Assess the client: perform a thorough Assess the client: perform a thorough holistic nursing assessmentholistic nursing assessment Use the format adopted by the facility or Use the format adopted by the facility or

educational institutioneducational institution• Nursing assessments may be based on conceptual Nursing assessments may be based on conceptual

models: Gordonmodels: Gordon’’s functional health patterns, s functional health patterns, OremOrem’’s self-care model, or Roys self-care model, or Roy’’s adaptation models adaptation model


Assessment Assessment Sources of InformationSources of Information

Nursing assessment/heath history: clientNursing assessment/heath history: client Physical assessment: clientPhysical assessment: client Medical recordsMedical records Diagnostic test resultsDiagnostic test results Health team membersHealth team members Significant others if appropriateSignificant others if appropriate


Obtain an Accurate Health History:Obtain an Accurate Health History:Sample QuestionsSample Questions

Ask open-ended questions: Ask open-ended questions: ““Describe what you are feeling.Describe what you are feeling.”” ““Tell me about these symptoms?Tell me about these symptoms?”” ““How does it affect your daily routine?How does it affect your daily routine?”” ““What can we help you with?What can we help you with?””


Physical AssessmentPhysical Assessment Perform a thorough physical assessmentPerform a thorough physical assessment

Medical model: head to toe Medical model: head to toe oror body system body system Carefully assess each area for normal and Carefully assess each area for normal and

abnormal findingsabnormal findings Inspect, auscultate, palpate, and percussInspect, auscultate, palpate, and percuss


Critical ThinkingCritical Thinking Look for normal and abnormal findingsLook for normal and abnormal findings Validate the data with the clientValidate the data with the client

ValidationValidation• ““This is what I have noticed.This is what I have noticed.””• ““Does this describe how you feel?Does this describe how you feel?””• ““Tell me more.Tell me more.””• ““What can I do to help?What can I do to help?””


Critical ThinkingCritical Thinking (Continued)(Continued)Using the assessment informationUsing the assessment information

Organize the informationOrganize the information Identify patterns in the assessment (highlight or Identify patterns in the assessment (highlight or

underline problems)underline problems) Make a list of all problems and potential problemsMake a list of all problems and potential problems Group like problems togetherGroup like problems together Make initial inferences or impressionsMake initial inferences or impressions Prioritize the problemsPrioritize the problems

• Use MaslowUse Maslow’’s hierarchys hierarchy Record and report the informationRecord and report the information


Immediate ReportingImmediate Reportingof Assessment Informationof Assessment Information

Report and record information that requires Report and record information that requires immediate action.immediate action. Some examplesSome examples

• Sharp unrelenting painSharp unrelenting pain• Vital signs greatly deviated from normalVital signs greatly deviated from normal• Change in level of consciousnessChange in level of consciousness

When in doubt, report.When in doubt, report.

Be prepared to immediately follow Be prepared to immediately follow instructions that are given.instructions that are given.


DocumentationDocumentation

Record all information obtained from the Record all information obtained from the health history and physical assessment.health history and physical assessment.

Many institutions use computers for this Many institutions use computers for this purpose.purpose.


ConfidentialityConfidentiality Share only information that is of benefit to the Share only information that is of benefit to the

nursing and medical team for planning care.nursing and medical team for planning care. Always keep in mind that HIPAA laws must be Always keep in mind that HIPAA laws must be

followed. followed. Keep notes safe.Keep notes safe.

Do not leave at site of interview.Do not leave at site of interview.


ConfidentialityConfidentiality (Continued)(Continued)

ClientClient’’s name should appear only on agency s name should appear only on agency documents (do not put client's name on any documents (do not put client's name on any notes used for classroom work).notes used for classroom work).

Follow Health Insurance Portability and Follow Health Insurance Portability and Accountability Act (HIPAA) guidelines regarding Accountability Act (HIPAA) guidelines regarding client confidentiality.client confidentiality.


Step TwoStep Two

Nursing DiagnosisNursing Diagnosis


Nursing DiagnosisNursing Diagnosis

Clinical judgmentClinical judgment Individual, family, or communityIndividual, family, or community Response to actual or potential health Response to actual or potential health

problems or life processesproblems or life processes Basis for outcomes and interventionsBasis for outcomes and interventions The nurse is accountable.The nurse is accountable.

(NANDA-I [NANDA-International], 2009)(NANDA-I [NANDA-International], 2009)


Nursing Diagnosis ListNursing Diagnosis List

Select the appropriate nursing diagnosis for Select the appropriate nursing diagnosis for the client from NANDA-Ithe client from NANDA-I’’s approved list.s approved list.

Nursing Diagnoses: Definitions and Nursing Diagnoses: Definitions and Classification 2009Classification 2009

List of 203 List of 203 ““approved nursing diagnosesapproved nursing diagnoses””


Critical ThinkingCritical Thinkingand Nursing Diagnosisand Nursing Diagnosis

Based on assessment informationBased on assessment information Information is analyzed (Questions to Ask)Information is analyzed (Questions to Ask)

Can a change occur with a nursing intervention?Can a change occur with a nursing intervention? Does it fit the NANDA-I definition?Does it fit the NANDA-I definition? Are the defining characteristics in the Are the defining characteristics in the

assessment?assessment?


Make a Nursing Diagnostic Make a Nursing Diagnostic Statement: PESStatement: PES

Problem/nursing diagnosisProblem/nursing diagnosis Etiology/related to statementEtiology/related to statement Signs and symptoms/defining characteristicsSigns and symptoms/defining characteristics


Nursing Diagnosis: Critical Nursing Diagnosis: Critical ThinkingThinking

Does the selected diagnosis fit the NANDA Does the selected diagnosis fit the NANDA definition?definition?

Are the defining characteristics in the Are the defining characteristics in the assessment?assessment?


Document Selected Nursing Document Selected Nursing Diagnosis on Nursing Plan of CareDiagnosis on Nursing Plan of Care


Step ThreeStep Three

PlanningPlanning


PlanningPlanning

Step done after the nursing diagnosis is Step done after the nursing diagnosis is determineddetermined

This step consists of writing measurable This step consists of writing measurable client outcomes and nursing interventions to client outcomes and nursing interventions to accomplish the outcomes.accomplish the outcomes.

These outcomes and interventions are These outcomes and interventions are designed to change the clientdesigned to change the client’’s nursing s nursing diagnosis/problem.diagnosis/problem.


Planning Steps: Planning Steps: Outcomes, InterventionsOutcomes, Interventions

Write measurable client outcomes.Write measurable client outcomes. Identify nursing interventions to accomplish Identify nursing interventions to accomplish

the outcomes.the outcomes.


Planning: Critical ThinkingPlanning: Critical ThinkingOutcomes and InterventionsOutcomes and Interventions

OutcomesOutcomes What does the client hope to accomplish?What does the client hope to accomplish? How should these client outcomes be prioritized?How should these client outcomes be prioritized? How will the outcomes be measured?How will the outcomes be measured? How long will it take?How long will it take?

InterventionsInterventions What nursing interventions can the nurse do to help the What nursing interventions can the nurse do to help the

client with satisfactory outcomes?client with satisfactory outcomes? Who will assist the client?Who will assist the client?

• The nurse?The nurse?• Ancillary personnel?Ancillary personnel?


Definition: NOC (Nursing Outcome Definition: NOC (Nursing Outcome Classification) Classification)

Standardized LanguageStandardized Language An individual, family, or community state, An individual, family, or community state,

behavior, or perception that is measured along a behavior, or perception that is measured along a continuum in response to nursing intervention(s)continuum in response to nursing intervention(s)

The outcomes are variable concepts that can be The outcomes are variable concepts that can be measured along a continuum.measured along a continuum.

Outcomes are stated as concepts that reflect a Outcomes are stated as concepts that reflect a patient, family caregiver, family, or community patient, family caregiver, family, or community actual state rather than expected goals.actual state rather than expected goals.(Moorhead, 2004)(Moorhead, 2004)


Planning: OutcomesPlanning: Outcomes

Set client-centered short-term and long-term Set client-centered short-term and long-term goals/outcomes.goals/outcomes.

Prioritize by what is most important.Prioritize by what is most important. Use MaslowUse Maslow’’s hierarchy.s hierarchy.


Outcomes: Critical Thinking and Outcomes: Critical Thinking and OutcomesOutcomes

QuestionsQuestions Does it come from the nursing diagnosis?Does it come from the nursing diagnosis? Is it measurable?Is it measurable? Does the client agree to it?Does the client agree to it? Is it realistic?Is it realistic? Is it attainable?Is it attainable? Is there a time frame?Is there a time frame? Does it provide direction for care?Does it provide direction for care?


Document Selected Outcomes Document Selected Outcomes on Nursing Plan of Careon Nursing Plan of Care


NICNIC (Nursing Intervention Classification) (Nursing Intervention Classification) The nursing interventions classification (NIC) is The nursing interventions classification (NIC) is

a comprehensive, standardized language a comprehensive, standardized language describing treatments that nurses perform in all describing treatments that nurses perform in all settings and in all specialties .settings and in all specialties .

The classification includes both physiological The classification includes both physiological and psychosocial interventions and covers all and psychosocial interventions and covers all nursing specialties.nursing specialties.(Bulechek, Butcher, McCloskey Dochterman (Bulechek, Butcher, McCloskey Dochterman 2004)2004)


Interventions:Interventions:How to Select Appropriate OnesHow to Select Appropriate Ones

Criteria for interventionsCriteria for interventions Activity done for and with clientActivity done for and with client Accomplishes outcomesAccomplishes outcomes Removes or reduces related factors that Removes or reduces related factors that

contributed to the nursing diagnosiscontributed to the nursing diagnosis IndividualizedIndividualized Specific/safeSpecific/safe


InterventionsInterventions (Continued)(Continued)

Road map to guide nursing careRoad map to guide nursing care The more clearly a nurse writes an The more clearly a nurse writes an

intervention, the easier it will be to complete intervention, the easier it will be to complete the journey and arrive at the destination of the journey and arrive at the destination of successful client outcomes .successful client outcomes .


Evidence-BasedEvidence-BasedNursing InterventionsNursing Interventions

A set of interventions or guidelines that have A set of interventions or guidelines that have been shown to be effective in helping clientsbeen shown to be effective in helping clients

EBN looks at standard protocol and determines EBN looks at standard protocol and determines if the protocol is effective based on gathered if the protocol is effective based on gathered evidence.evidence.


PlanningPlanningInterventions: Critical ThinkingInterventions: Critical Thinking

Questions to askQuestions to ask ASKASK

What nursing interventions can the nurse do to help the client What nursing interventions can the nurse do to help the client with satisfactory outcomes?with satisfactory outcomes?

Who will assist the client? The nurse? Ancillary personnel?Who will assist the client? The nurse? Ancillary personnel? What equipment is needed?What equipment is needed? How long will the intervention take?How long will the intervention take? How often should the intervention be done?How often should the intervention be done? What is the evidence to support its effectiveness?What is the evidence to support its effectiveness?


Document Interventions on Nursing Document Interventions on Nursing Plan of CarePlan of Care


Step FourStep Four

ImplementationImplementation


ImplementationImplementationACTIONACTION

Initiation of the nursing care plan Initiation of the nursing care plan Performing the nursing interventionsPerforming the nursing interventions Delegation of appropriate nursing Delegation of appropriate nursing

interventionsinterventions Using skillsUsing skills

PsychomotorPsychomotor InterpersonalInterpersonal CognitiveCognitive

Performing continuous assessmentPerforming continuous assessment


Implementation: Critical ThinkingImplementation: Critical ThinkingASKASK

How did the client tolerate the intervention?How did the client tolerate the intervention? Were there any identified problems?Were there any identified problems? Was any additional equipment needed? Was any additional equipment needed? Was the time frame appropriate?Was the time frame appropriate? Were the appropriate personnel involved?Were the appropriate personnel involved?


Report Report and and

DocumentDocument


Step FiveStep FiveEvaluationEvaluation


EvaluationEvaluation Although evaluation is listed as the last phase Although evaluation is listed as the last phase

of the nursing process, it is actually an of the nursing process, it is actually an integral part of each phase and something integral part of each phase and something that is done continually.that is done continually.

ClientClient’’s outcomes are evaluated to see if they s outcomes are evaluated to see if they are satisfactory.are satisfactory.

If the outcomes were not satisfactory, then If the outcomes were not satisfactory, then the nursing process is begun again with the nursing process is begun again with assessment to determine the reason why the assessment to determine the reason why the outcomes were not satisfactory.outcomes were not satisfactory.


Evaluation: Critical ThinkingEvaluation: Critical ThinkingASKASK

Check the client outcomes.Check the client outcomes. Were the outcomes satisfactory?Were the outcomes satisfactory? Is an additional assessment needed?Is an additional assessment needed? Were the outcomes realistic?Were the outcomes realistic? Was the right nursing diagnosis selected?Was the right nursing diagnosis selected? Does the nursing care plan need to be Does the nursing care plan need to be

modified?modified?


Evaluation: Critical ThinkingEvaluation: Critical Thinking (Continued)(Continued)

When using EBN, it is at this point that it is When using EBN, it is at this point that it is determined whether the practice that was determined whether the practice that was followed was effective.followed was effective.

Necessary revisions may be made at this Necessary revisions may be made at this time.time.


SummarySummary

ReviewReview Steps of the nursing process (ADPIE)Steps of the nursing process (ADPIE)

AssessmentAssessment DiagnosisDiagnosis PlanningPlanning ImplementationImplementation EvaluationEvaluation


Final ReminderFinal Reminder

Document and report.Document and report. ““If you didnIf you didn’’t chart it, you didnt chart it, you didn’’t do it.t do it.””


Good JobGood Job

You have mastered the nursing process.You have mastered the nursing process. You have delivered safe, effective care to You have delivered safe, effective care to

your client.your client.

Be proud of your work and profession. Be proud of your work and profession.


ReferencesReferences Bulechek G, Butcher H, McCloskey Bulechek G, Butcher H, McCloskey

Dochterman J: Dochterman J: Nursing intervention Nursing intervention classification (NIC)classification (NIC), ed 5., St. Louis, Mosby, , ed 5., St. Louis, Mosby, 2008.2008.

Leininger M: Culture care theory, research, and Leininger M: Culture care theory, research, and practice. practice. Nurs Sci QNurs Sci Q 9(2): 71 – 78, 1996. 9(2): 71 – 78, 1996.

Moorhead S, Johnson M, Maas M et al: Moorhead S, Johnson M, Maas M et al: Nursing outcomes classification (NOC)Nursing outcomes classification (NOC), ed , ed 4., St. Louis, Mosby, 2008.4., St. Louis, Mosby, 2008.

Watson J, Ray M (Eds.): Watson J, Ray M (Eds.): The ethics of care The ethics of care and the ethics of cure: Synthesis in chronicityand the ethics of cure: Synthesis in chronicity. . New York, NLN, 1998. New York, NLN, 1998.

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