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Providing Patient-Centered Care Through the Nursing Process

Chapter 11

Copyright © 2014, 2009 by Mosby, Inc., an imprint of Elsevier Inc.

Historical Perspective

Copyright © 2014, 2009 by Mosby, Inc., an imprint of Elsevier Inc.2

1955 Lydia Hall introduced observation, administration of

care, and validation.1958-1961

Orlando introduced three-step nursing process: assessment, planning, and evaluation.

1967 Yura and Walsh developed four-step nursing process:

assessment, planning, implementation, and evaluation.

Historical Perspective (Cont'd)


1973 ANA added a fifth item to the nursing process:

diagnosis. 1991

ANA introduced outcome identification.Today

The six steps of the nursing process are assessment, diagnosis, outcome identification, planning, implementation, and evaluation.

Nursing’s problem-solving method combines the art and science of nursing.

Nursing Process


Excellent critical thinking skill Leads to good clinical judgment Crucial in providing nursing care for patients with

complex health conditionsRN responsible for creating an individualized

plan of care using the nursing processNursing’s method of critical thinking focused

on solving patient problems

Nursing Process (Cont'd)


Assessment First step Involves the collection of both objective and subjective

data about an individual, family, or community Examines five realms: physiological, psychological,

social, cultural, and spiritual Nurse observes the patient and the surrounding

situation, interviews both primary and secondary sources, examines the patient from head to toe in a systematic manner, and interprets laboratory data



Assessment Objective data

Information that is observed and leaves little room for interpretation

Facts that can be measured and verified Examples: vital signs, size and location of a wound, color

of drainage Subjective data

Information experienced and described only by the patient

Cannot be verified as to its characteristics or easily quantified

Examples: feelings and experiences of the patient’s pain, fear, nausea, and uneasiness



Assessment Data collection methods

Interview Observation Physical assessment

Inspection, auscultation, palpation, and percussion



Assessment Data collection methods

Gordon’s Functional Health Patterns Proposed 11 categories of functional health patterns

that make a systematic and standardized approach possible

Virginia Henderson Identified 14 needs of the individual Holistic approach assesses the biological,

psychological, sociocultural, and spiritual needs of the individual



Assessment Organization of data collection

Must be organized in a clear, systematic manner that permits logical progression of the data

Validating assessment data Validating, or verifying, assessment data necessary to

ensure accuracy

Nursing ProcessQuestion 1


A nurse collected the following data. Which data are subjective?

1. Patient breathes 14 times a minute. 2. Patient has a dime-sized wound on the left leg.3. Patient’s sputum is rust colored.4. Patient is nauseated.

answer


11

. Patient is nauseated. Examples of subjective data include such feelings and experiences as the patient's pain, fear, nausea, and uneasiness.

1.Examples of objective data are vital signs, size and location of a wound, color of drainage, or any assessment that does not require personal perspective or opinion to document.

2.Examples of objective data are vital signs, size and location of a wound, color of drainage, or any assessment that does not require personal perspective or opinion to document.

3.Examples of objective data are vital signs, size and location of a wound, color of drainage, or any assessment that does not require personal perspective or opinion to document



Diagnosis Clustering of cues, or data points, gathered in

assessment helps define care priorities and associated “problems,” or nursing diagnoses.

Every nursing diagnosis must be substantiated by identifying criteria (defining characteristics).

Diagnosis may be actual, potential, or wellness. Use PES format.

Problem (NANDA-I diagnostic label) related to Etiology (cause) as evidenced by Signs and symptoms (defining characteristics)

Nursing diagnosis may be written: “Spiritual distress related to death of husband as evidenced by tearfulness and subjective comment, “Why did God let this happen?”



Diagnosis Collaborative problems are problems that require

collaborative interventions with the physician and the health care team.

With collaborative problems, nurses monitor the patient to detect changes in status or for the onset of complications.


Copyright © 2014, 2009 by Mosby, Inc., an imprint of Elsevier Inc. 14

Diagnosis Ackley and Ladwig (2014) suggest five steps to

formulate a nursing diagnosis.1. Highlight or underline the relevant symptoms.2. Make a short list of the symptoms.3. Cluster similar symptoms.4. Analyze or interpret the symptoms.5. Select a nursing diagnosis label that fits with the

appropriate related factors and defining characteristics (p. 3).



Diagnosis Prioritizing

When prioritizing nursing diagnoses, the most critical problems receive the highest priority.

Using Maslow’s hierarchy of needs, importance is first given to physical needs.

Safety is also a priority.



Outcome identification Immediate, intermediate, and long-term goals are

identified with the patient and family. Outcomes are specific, realistic, and measurable and

written in positive, patient-centered terms. Every diagnosis is associated with specific,

individualized expected outcomes. Outcomes must be measurable and clearly

communicated, along with signs of attainment or nonattainment and dates and times for evaluation. Patient’s pain will decrease to ≤2 on a 0 to 10 pain scale

by (a certain date).



Outcome identification Nursing Outcomes Classification (NOC)

330 NOC outcomes, grouped into 31 classes and 7 domains

1. Functional health2. Physiologic health3. Psychosocial health4. Health knowledge and behavior5. Perceived health6. Family health7. Community health

Defines outcomes that focus on patient, identifies risk adjustment factors, and provides measures for comprehensive outcomes that respond to nursing intervention; can be used by nurses in all settings



Planning Includes goals and outcomes and planning

interventions; plan of care developed Includes identifying interventions needed for the

patient to regain a level of independence Establishment of outcome priority is a planning

mechanism Involves mapping out specific, individualized nursing

actions that aim to achieve the desired outcomes associated with the nursing diagnoses

Critical pathway and care mapping



Planning Nursing Interventions Classification (NIC)

Contains 542 nursing interventions, grouped into 30 classes and 7 domains Basic; physiological; behavioral Safety Family; community Health systems

Each intervention coded and linked with NANDA-I nursing diagnoses Example: Performing prompt and comprehensive

assessment and management of pain including location, characteristics, onset and duration, frequency, quality, intensity, and precipitating factors



Implementation Carrying out of the plan of care Requiring a multidisciplinary approach RNs serving as gatekeepers; responsible for

Delegating and coordinating care Implementing advanced interventions Evaluating and updating plan of care and associated

outcome priorities Engaging in and documenting patient/family education Documenting care Retaining full accountability that plan of care is carried

out in a sensitive and effective manner



Evaluation This is the process of examining the effectiveness of

the plan of care and adjusting it to ultimately meet the needs of the patient.

Outcome achievement is part of evaluation. Assessment and evaluation occur simultaneously and

continually. RNs interpret the data and adjust the plan of care to

best meet the patient’s needs. The plan of care may require no changes if the

patient’s condition is progressing as expected.

Nursing Process Question 2


A nurse is developing an individual care plan for the patient. Which step of the nursing process is the nurse using?

1. Planning2. Implementation3. Evaluation4. Assessment

answer


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1. Planning. The plan of care, developed during the planning phase of the nursing process, includes the process of identifying the interventions needed for the patient to regain a level of independence at or higher than he or she had before admission into the health care setting.

2. Implementation, the carrying out of the plan of care, requires a multidisciplinary approach.

3. Evaluation is the process of examining the effectiveness of the plan of care and adjusting it to ultimately meet the needs of the patient.

4. Assessment is the first step of the nursing process and involves gathering objective and subjective data.

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