nursing process
a process nurses use to evaluate and select the best actions to meet desired goals
critical thinking skills needed for clinical decisions
- reasoning
- intellect
- creativity
- inquiry
- reflection
- intuition
behaviors to improve critical thinking skills
- intellect: build clinical knowledge and skills; cluster cues r/t a pattern
- creativity: brainstorming; what other approaches might facilitate success; finding solutions to unique problems
- inquiry: ask questions about nursing practice; make changes in practice based on evidence and innovative ways of doing things better
5 phases of the nursing process
- assessment
- nursing diagnosis
- planning
- implementation
- evaluation
assessment (nursing process)
gathering info to determine what the problem is using patient’s past medical hx, nursing assessment/vitals, or diagnostic studies
subjective
patient shares/says/reports
“pain level/nausea/blurred vision”
objective
data you can perceive and often measureable
“bowel sounds are hyperactive/skin is warm and dry”
nursing diagnosis
stating the specific problem that needs to be addressed
-provides a basis for selection of nursing interventions to achieve outcomes for which the nurse is accountable
why do we write a nursing diagnosis?
helps distinguish the nurse’s focus from the physician’s focus
Focus of the nursing diagnosis
human responses
Focus of the medical diagnosis
disease process/pathophysiology
“ineffective airway clearance”
nursing diagnosis
“pneumonia”
medical diagnosis
how to write a nursing diagnosis
- what is the problem? (dx)
- what is causing the problem? (related to…)
- defining characteristics of the problem…(as manifested by…)
Two types of nursing diagnosis
- risk for
- actual
2 parts of “Risk for” diagnosis
- dx: risk for aspiration
- related to left side weakness and impaired swallowing
3 parts of “actual” diagnosis
- dx: impaired gas exchange
- related to alveolar congestion
- as manifested by crackles auscultated in lower lobes, increased work of breathing, respiration rate of 26, SpO2 of 90% on 4L per nasal cannula
planning (nursing process)
- identify and prioritize goals
- describe observable patient responses to be achieved through independent and collaborative interventions
good goals must have…
- subject
- action verb
- performance criteria
- target time and date
- special conditions
good goals are…
- measurable
- realistic and attainable
- do not interfere with other therapies
- appropriate for patient’s level of growth and development
- realistic time frame
short term goals
few hrs to few days
long term goals
1 wk to several mths
goals have specific
date and time
implementation
- giving solutions to resolve the problem
- details of the plan of action
