NURSING PROCESS
Systematic guide to patient-centered care
> involves critical thinking skills and data collection
1. Assessment
2. Diagnosis/Analysis
3. Planning
4. Implementation
5. Evaluation
*although the steps are ordered, nursing is not linear and care is both cyclic and bidirectional
DOCUMENT! DOCUMENT! DOCUMENT! If it wasn't documented, it wasn't done |
Assessment
explore the pt's viewpoint
> interview, physical examination, observation, functional assessment
> initial, focused, organized, emergent
> collect subjective & objective data
> pt demographics, past medical history, past surgical history
> utilize database: patient medical records, labs and diagnostic results
> gather info about pt's condition, vital signs and/or lab results
> risk assessment: identify any potential health problems
> inquire about related goals, experiences, values & expectation about healthcare system
> cluster cues, make inferences & identify patterns & problems
> must be: purposeful, prioritized, complete, systematic, factual, relevant, documented
collect, analyze, validate, communicate |
Diagnosis
Use clinical judgement; actual vs potential health problem, wellness
clarify exact nature of problem or risk to achieve overall outcome
> Identify how pt responds to health or life processes
> Identify factors contributes to problem; specific, critical and related
> Identify resources & strengths of pt
health problem prevented or resolved
> problem focused (actual)
> identify "at risk for" problems
> health promotion
- problem NANDA
- etiology "related to" or "r/t"
- symptoms "as evidenced by" or "AEB"
*use nursing standards to help determine nursing diagnosis |
Planning
Plan of care
Design of plan of care results in prevention, reduction, resolution of pt health problems
> Priorities: high, intermediate, low
> MASLOW: physiological, safety, love/belonging, esteem, self actualization
> SMART goals: Specific, Measurable, Attainable, Realistic, Timed
Steps
1. establish priorities and develop outcomes
- individualized
- culturally appropriate
2. identify and document expected outcomes
3. identify and select nursing interventions: integrate EBP and nursing standards
4. communicate and document care plan
Identify goals and criteria for success related to the pt's needs |
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Implementation
Implement the plan of care
Specify the nursing actions and interventions, who, what, when, how
> plans are carried out, safely and timely
> plans are evidence based
> coordinate care delivery
> provide health teaching and health promotion
> document implementation and any modifications |
Implementation (cont.)
Direct |
Indirect |
ADLS |
manage and collaboration |
physical care |
communicate nursing intervention |
lifesaving measures |
delegating |
counseling |
supervising |
pt teaching and education |
evaluating |
prevention |
medication administration; monitor for adverse effects |
Evaluation
Re-assessment of how well pt has achieved expected therapeutic outcomes
ongoing through nursing process
> resolve health problems
> prevent potentially new problems
> collect data
> maintain a healthy state/ health promotion
> document findings using clinical judgement
> terminate, continue, modify
*Include the pt and their family by interpreting and summarizing findings
if the goal(s) has not been met, reassessment and revision of plan of care |
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