Nursing Process Unit III

NURS 2210Nancy Pares, RN, MSN

Metro Community College

RN Role in developing nursing dx

• First used in 1953, but not implemented until 1974

• Currently five steps– Assessment, diagnosis, outcome identification,

implementation, evaluation

• Emphasis on professionalism, accountability, multiculturalism and scientific method of problem solving

Comparison of nursing vs medical model

medical• Focuses on illness, injury or

disease process

• Remains constant until cured

• Identifies conditions that can be treated by qualifying healthcare practitioner

nursing• Focus on responses to

actual or potential diseases

• Changes as client condition changes

• Identifies situations in which the nurse is qualified to intervene

Assessment Step 1

• Collection of data, organizing data, validating data, identifying patterns, recording data

• Primary source• Secondary source• Subjective vs objective

Types of nursing diagnosis• Actual– Problem exists

• Risk– Factors are present to cause problem

• Possible– Problem could arise unless preventative action

taken

• Wellness– ‘potential for enhanced…’; expressed desire

Developing Nursing dx- Step 2

• What are the problems?• What are causes? Risk factors?• Could a problem occur if prevention not

taken?• What data is needed to answer these

questions?• If more than one problem…which is priority?

Planning- Step 3

• List priority of nursing dx– Use critical thinking- what needs attention first?

• Long and short term goals are written– SMART

• Specific interventions are developed• Plan of care is recorded

Implementation- Step 4

• Communicate with team to solve complex problems

• Accurately report data and clues• RN needs to know what can be delegated• Is there a need to alter the intervention?

Evaluation- Step 5

• Was the goal met? Why not?– Assessment incomplete– Goal not SMART– Goal not appropriate for individual client

Maslow’s Priority of Care

• Physiologic• Safety and security• Love and belonging• Self esteem• Self actualization

Delegation decision tree• Are there rules and laws in place supporting the rules of

delegation?• Is the task within the scope of practice• Has there been an assessment of the client needs• Is the person being delegated tasks competent• Does the ability of the caregiver match the needs of the client• Can the task be completed without nursing judgment• Is the result of the task predictable• Can the task be safely performed according to directions• Can the task be completed without repeat assessment• Is the appropriate supervision available

NCLEX questions LPN –cannot:

• Do new admission assessments• Give IV push meds• Write nursing diagnosis• Do complex skills• Care for clinically unstable clients• Care for clients with acute conditions

NCLEX– UAP/CNA

• Lowest level of skill• Least complicated task• Most stable• Look for client with chronic illness

Client care needs

• The nursing dx, ‘alteration in skin integrity R/T immobility as manifested by Stage 1 pressure ulcer on coccyx ‘ is what type of nursing dx?

• 1. Risk• 2. Possible• 3. Wellness• 4. Actual

• Which of the following is an accurate summary of the difference between medical and nursing dx.?

• 1. Nursing dx determined by med dx• 2. Med dx can be treated by nurse• 3. Nursing dx reflects a human response to

actual problem• 4. Only physicians can treat a pathophysiology.

• Client will ambulate 20 ft with walker twice a day. Which phase of nursing process is this?

• 1. assessment• 2. planning• 3. implementing• 4. evaluation

• An example of an independent nursing intervention is:

• 1. admin IV fluids for client with nutritional impairment

• 2. turning and repositioning q 2 hr• 3. ordering chest xray for client with

breathing problem• 4. reviewing lab values and reordering tests

for abnormal values.

• Using aseptic techniques, a nurse demonstrates insulin preparation to a client. This is an example of which phase of nursing process?

• When a task is delegated, the role of the nurse is to

• 1. validate the skill level of the care provider• 2. assume the task was completed as

expected• 3. allow the care provider independence• 4. review care provider notes

• You determine that the client has not met an expected outcome..What action do you take?

• 1. call a meeting of team• 2. ask the client why the goal was not

accomplished• 3. call for a nursing consultation• 4. review and revise the care plan

• A nursing audit is used to evaluate

• 1. the nursing process• 2. institutional standards• 3. quality of nursing care• 4. client outcomes and goal achievement

• The purpose of evaluation is• 1. determine whether problems are resolved• 2. determine if the nurse developed outcome

criteria for the client• 3. select appropriate goals and objectives• 4. develop a time frame for completing the

nurse client relationship.