NURSING PROCESS GUIDELINES
I. Assessment
A. Data Collection: What information does the nurse
need to know?
The patient is the primary source of
information.
Secondary sources of information include
the patient chart, family, and health team members.
The nurse gathers
subjective and objective data.
Subjective data is information the patient
tells the nurse during the nursing assessment. Subjective data can be called
symptoms.
Objective data
is information collected by using the sense. Information that can be seen by
observation (inspection), felt (palpation), heard (auscultation) (percussion),
or smelled. Objective data can be called signs.
B. Assessment Format
1. HEALTH HISTORY
BIOGRAPHICAL DATA
CHIEF COMPLAINT
PRESENT ILLNESS/HEALTH STATUS
PAST HISTORY
CURRENT HEALTH INFORMATION
FAMILY HISTORY
2. REVIEW OF SYSTEMS - BIO-PHYSICAL
INTEGUMENT
HEAD AND NECK
RESPIRATORY
CARDIOVASCULAR
GASTROINTESTINAL
MUSCULOSKELETAL
NEUROLOGICAL
GENITO-URINARY (MALE/FEMALE)
REPRODUCTIVE (MALE/FEMALE)
C. REVIEW OF SYSTEMS - PSYCHOSOCIAL
PSYCHOLOGICAL
SPIRITUAL
SOCIAL
DEVELOPMENTAL
II. Nursing Diagnosis: Refer to the
most current list of NANDA - Approved Nursing Diagnoses
A. According to NANDA (1990) Taxonomy I, nursing
diagnosis is defined as follows: "Nursing diagnosis is a clinical judgment
about individual, family, or community response to actual or potential health
problems/life processes. Nursing interventions to achieve outcomes for which
the nurse is accountable." (As cited in Carroll-Johnson, & Paquette,
1994, p.277).
B. Nursing Diagnostic Statement
The following components make up a three part diagnostic statement:
1. The nursing diagnostic statement (problem/title)
describes alterations in the patient's health status. Alterations cause
problems and untoward changes in the patient's ability to function.
2. The related factors (etiologists) are those factors
contributing to the existence of, or maintenance of, pathophysiological,
psychosocial, situational, developmental, cultural, and/or environmental. The
phrase "related to" (R/T) serves to connect the nursing diagnosis and
etiology statements.
3. The defining characteristics are a cluster of
subjective and objective signs and symptoms that represent a nursing diagnosis.
The defining characteristics, gathered during the assessment phase, provide
evidence that a health problem exists. The symptoms (subjective data) are
changes which the patient feels and expresses verbally to the nurse. The signs
(objective data) are observable changes in the patient's health status. Use the
phrase "as evidenced by" (AEB) to connect the etiology and defining
characteristic statement.
*Note: High risk nursing diagnoses denote the
presence of risk factors that may cause an actual health problem in the future.
A high risk nursing diagnosis is a two part statement: 1) High risk nursing
diagnosis, and 2) related factors (etiologies). There are no defining characteristics
for a high risk diagnosis.
Examples:
1. Pain (acute) R/T tissue trauma AEB verbal report of pain,
irritability, restlessness, and increased blood pressure and pulse.
2. High risk for infection R/T inadequate physical barriers.
C. Comprehensive list of nursing diagnoses in order of
priority (include actual and high risk). Identify the problem, related factors,
and defining characteristics pertinent to the patient. The ranking of nursing
diagnoses permits the nurse to arrange the patient's problems in order of their
importance and urgency. Maslow's hierarchy of needs (1968) assists the nurse in
ranking of nursing diagnoses. The five levels of hierarchy are: (1)
physiological, (2) safety and security, (3) love and belonging, (4)
self-esteem, and (5) self-actualization.
III. Planning
Characteristics of patient outcomes/goals:
- Patient-centered, i.e. "Patient wiill..."
- Specific and measurable
- One measurable verb
Examples of measurable verbs: Verbalize, Perform, Discuss, State,
Apply, Identify, List, Avoid, Explain, Demonstrate, Describe, Exhibit,
Ambulate, Report
Verbs to Avoid: Allow, Know, Learn, Understand, Have
- Realistic for the individual patient
situation
- Limited time frame: short term goals arre generally achievable within
approximately one week and long term goals may take several weeks or months to
be achieved. The target date/time for achievement should be identified, e.g. by
discharge or by 11/20/0__ .
Examples:
1.
Patient will rate pain as no greater than 0 or 1 on a 0-5 scale by 10/26.
2. Patient will remain free of infection as evidenced by temperature within
normal range, incision well-approximated and free of redness or drainage and
WBC within normal limits by 10/29.
IV. Implementation
A. Definition of Nursing Intervention: "Any treatment,
based upon clinical judgment and knowledge, that a nurse performs to enhance
patient/client outcomes. Nursing interventions include both direct and indirect
care; nurse-initiated physician-initiated, and other provider-initiated
treatments." (McCloskey & Bulchek, 1996, p. xvii).
B. Definition of Nursing Activities: "The specific
behaviors or actions that nurses do to implement an intervention and which
assist patients/clients to move toward a desired outcome." (McCloskey
& Bulchek, 1996, p. xvii).
C. Six Factors to be Considered when Choosing an
Intervention:
1. Desired Patient Outcomes
2. Characteristics of the Nursing Diagnosis
3. Research Base for the Intervention
4. Feasibility of Doing the Intervention
5. Acceptability to the Patient
6. Capability of the Nurse (McCloskey & Bulchek, 1996).
D. Procedure for Using the Nursing Interventions
Classification (NIC). (These guidelines refer to the text by McCloskey &
Bulchek, 1996)
1. Locate a selected nursing diagnosis in "Part Four: NIC Interventions
Linked to NANDA Diagnoses".
2. "Review boxed nursing interventions for consideration first as
the treatment of chose for resolution of a nursing diagnosis."
3. "Review other interventions in the suggested list because
these are considered most essential for resolution of the intervention."
4. "Review the additional suggestions for interventions, which may also be
used for resolution of the nursing diagnosis." (McCloskey & Bulchek,
1996, p.605).
5. After reviewing the interventions (2, 3, & 4 above), locate in
"Part Three: The Classification" those interventions you feel are
most appropriate for the patient.
6. Select the nursing activities deemed appropriate for a specific
patient. "A series of activities is necessary to implement an intervention."
(McCloskey & Bulchek, 1996, p. xvii). Individualize each
activity as needed. e.g. Activity - Monitor vital signs as appropriate vs.
Monitor BP, P, R, q 2 h, t q 4 h.
7. Write the intervention/s and accompanying activities in the
implementation column of the nursing process form. Draw a box around those
interventions that were "boxed" in the text (#2 above).
8. Provide rationale for each nursing activity. The rationale
identifies the principle on which the activity is based, i.e. why the activity
is expected to resolve the problem. (Sources utilized to determine rationale
should be cited.)
V. Evaluation
1. Address the achievement of each goal and include data to support the decision
about whether or not the goal was met. If a particular goal was not achieved,
identify factors that have prevented accomplishment of the goal.
2. Discuss any revisions you would suggest for this plan of care.
Nursing Process: Definition | Critical Thinking | Guidelines
Critical Thinking:
Characteristics | Skills, Elements,
Standards
Nursing Process: Assessment | Nursing Diagnosis | Planning | Implementation | Evaluation
John
Philip Tiongco, MD