The Five Steps of the Nursing Process-Unit 1

planning

(in five-step nursing process) a category of nursing behavior in which a strategy is designed to achieve the goals of care for an individual patient, as established in assessing and analyzing. Planning includes developing and modifying a care plan for the patient, cooperating with other personnel, and recording relevant information.

evaluating

(in five-step nursing process) a category of nursing behavior in which the extent to which the established goals of care have been met is determined and recorded. To make this judgment, the nurse estimates the degree of success in meeting the goals, evaluates the implementation of nursing measures, investigates the patient's compliance with therapy, and records the patient's response to therapy. The nurse evaluates effects of the measures used, the need for change in goals of care, the accuracy of the implementation of nursing measures, and the need for change in the patient's environment or in the equipment or procedures used. The impact of the care or treatment on the patient, the patient's family, and the staff is evaluated; the accuracy of tests and measurements is checked; and the patient's and family's understanding of the information given them is evaluated.

The nursing diagnosis identifies an actual or potential problem or response to a problem.

Accurate identification of nursing diagnoses for patients results from carefully analyzing, validating, and clustering related patient subjective (symptoms) and objective (signs) data. If data collection is inaccurate or inadequate, or if data are not validated or clustered with related information, a patient may be misdiagnosed.

The evaluation phase loops back to which earlier phases of the nursing process when considering new data?

Assessment Diagnosis Planning

Assessment Definition

Assessment is the organized and ongoing appraisal of a patient's well-being.

Objective data example

Blood pressure reading and weight

What type of patient-centered care respects the input of family members and other members of the health care team?

Collaborative

What determines if an assessment is primary or secondary?

Data Source

Data Source

Data collection begins at the first direct or indirect encounter with a patient. The data source determines if it is primary or secondary.

Setting Goals

Depending on the patient's immediate and future needs, nurses need to establish short- and long-term goals. While short-term goals may be achieved in less than a week, long-term goals may extend over weeks or months. Setting short- and long-term goals helps create a structure, or a framework, within which nursing care takes place. And all goals should be patient-focused, realistic, and measurable.

Outcome Example

Diagnosing a patient with Activity Intolerance could have "Endurance" as a desired outcome classification (from the NOC), with indicators ranging from Uncompromised to Severely compromised activity. The nurse could then select patient interventions (from the NIC) related to "Exercise Therapy: Ambulation."

What questions should the nurse ask when evaluating the effectiveness of nursing interventions?

Did the patient meet the goals established during the planning phase? Should the plan of care be discontinued? Does the care plan need to be modified in response to patient changes?

subjective data example

Direct quotes describing patient feelings

Steps of the nursing process serve which purpose?

Enable organization of patient care Ensure comprehensive patient care Facilitate evaluation of patient care

What is the fifth step of the nursing process that includes a decision point on whether to discontinue, continue, or revise the plan of care?

Evaluation

Evaluation Definition

Evaluation focuses on the patient's response to nursing interventions and goal or outcome attainment.

What is the primary purpose for documenting nursing interventions?

Facilitate communication

A nurse is creating a care plan and wants to put direct care items before indirect care items. Which of these is in the correct order?

Help the patient ambulate, and then order occupational therapy to come.

What type of patient assessment takes into account factors such as the patient's physical, psychological, emotional, environmental, cultural, and spiritual health?

Holistic

Identifying Outcomes

Identifying outcomes as a specific aspect of the nursing process was added by ANA in 1991. It involves listing behaviors or observable actions that indicate attainment of a goal. Interventions to help patients meet goals are identified by the nurse during the planning step.

Planning Definition

In the planning step of the nursing process, the nurse prioritizes a patient's various nursing diagnoses, establishes short- and long-term goals, chooses outcome indicators, and identifies interventions to address patient goals. The order in which nursing diagnoses are addressed depends on factors such as the severity of symptoms and the patient's preference.

Nursing care can be categorized as direct or indirect, depending on the nursing ___________.

Interventions

What is the most important aspect of a patient-centered care plan?

Matching the patient's goals and relevant current status

Holistic Assessment

Nurses assess the state of a patient's physical, psychological, emotional, environmental, cultural, and spiritual health to gain a better understanding of his or her overall condition. This is known as a holistic approach to patient care.

What does the evaluation phase include?

Patient's achievement of short- and long-term goals.

Primary Data

Primary data are obtained directly from a patient.

Information received from the patient's family members, friends, or other nurses is what type of data?

Secondary Subjective

Secondary Data

Secondary data are collected from family members, friends, other healthcare professionals, and written sources, such as medical records and test results.

Why must nursing diagnoses include up-to-date diagnostic labels as determined by NANDA International?

Standardized language facilitates care recognized by all health care team members.

What types of care plans are used in implementation?

Standing orders that describe specific actions to be taken by a nurse General protocols that apply to patients with similar clinical needs. Care pathways that combine several areas of health care expertise.

Collaborative

Tasks coordinated with the health care team, such as respiratory therapy

Dependent

Tasks that require a provider's orders, such as administering medication

Independent

Tasks the nurse can perform without a provider's orders, such as raising the head of the bed to help a patient who is having trouble breathing

Planning

The development of a patient-centered care plan to address nursing diagnoses involves discussion with the patient and often requires collaboration with family members and other members of the healthcare team. This is also referred to as collaborative care. Nurses need to use critical thinking, creativity, expertise, and communication skills when developing a patient-centered care plan. The plan of care needs to be relevant to the patient's health status and goals, and the plan must be based on the latest evidence-based nursing practices.

implementation

a deliberate action performed to achieve a goal, such as carrying out a plan in caring for a patient. It is the fourth step, or phase, of the nursing process.

The Nursing Outcomes Classification (NOC)

a standardized classification of patient outcomes that evaluates the effects of interventions. The Nursing Interventions Classification (NIC) is a comprehensive classification of interventions that nurses perform on behalf of patients.

nursing diagnosis

a statement of a health problem or of a potential problem in the client's health status that a nurse is licensed and competent to treat. Four steps are required in the formulation of a nursing diagnosis. A data base is established by collecting information from all available sources, including interviews with the client and the client's family, a review of any existing records of the client's health, observation of the client's response to any alterations in health status, a physical assessment, and a conference or consultation with others concerned in the client's care. The data base is continually updated. The second step includes analysis of the client's responses to the problems, healthy or unhealthy, and classification of those responses as psychologic, physiologic, spiritual, or sociologic. The third step is the organization of the data so that a tentative diagnostic statement can be made that summarizes the pattern of problems discovered. The last step is confirmation of the sufficiency and accuracy of the data base by evaluation of the appropriateness of the diagnosis to nursing intervention and by the assurance that, given the same information, most other qualified practitioners would arrive at the same nursing diagnosis. In use, each diagnostic category has three parts: the term that concisely describes the problem, the probable cause of the problem, and the defining characteristics of the problem.

nursing assessment

an identification by a nurse of the needs, preferences, and abilities of a patient. Assessment includes an interview with and observation of a patient by the nurse and considers the symptoms and signs of the condition, the patient's verbal and nonverbal communication, the patient's medical and social history, and any other information available. Among the physical aspects assessed are vital signs, skin color and condition, motor and sensory nerve function, nutrition, rest, sleep, activity, elimination, and consciousness. Assessment is extremely important because it provides the scientific basis for a complete nursing care plan.

Indirect care

care performed on behalf of patients, such as ordering a special diet or arranging with a social worker to set up home care

Direct care

care performed on or with patients, such as giving an injection or helping a patient to ambulate

The nursing __________ identifies an actual or potential problem or response to a problem.

diagnosis

The nurse establishes the ____ of unlicensed health care team members as a crucial balance between collaboration and overlapping responsibilities.

scope of practice

When a patient reports feeling anxious, what is the subjective data called?

symptom

Nursing diagnoses are established and revised every three years by NANDA International, Inc. (NANDA-I)

which provides standardized language to identify patient problems and plan customized care.