THE NURSING PROCESS
Includes 5 steps:
3. Planning and outcome identification
A series of steps that lead to
accomplishing some goal or purpose.
A systematic method for providing
care to clients.
Provides individualized, holistic,
effective and efficient client care.
Clients of all ages and in any care
The first step in the nursing process.
Includes systematic collection,
interpretation, and documentation of
To organize a database regarding a
client’s physical, psychosocial, and
To identify health-promoting
behaviors and actual and/or potential
TYPES OF ASSESSMENT
Focused–limited to a particular
need or health care concern.
monitoring of specific problems.
SOURCES OF DATA
Primary source–client or the major
provider of information about a client.
Secondary source–sources of data
other than client and include family
members, other health care providers,
and medical records.
TYPES OF DATA
Subjective data–data from client’s
point of view, and include perceptions,
feelings, and concerns. Collected by
Objective data–observable and
measurable, obtained through both
physical examination and the results
of lab and diagnostic testing.
VALIDATING THE DATA
omissions, and incorrect inferences
ORGANIZING THE DATA
Data must be organized.
Data clustering is the process of
putting the data together in order
to identify areas of the client’s
problems and strengths.
INTERPRETING THE DATA
Organizing data in clusters helps to
recognize patterns of response or
Distinguish between relevant, irrelevant.
Determine whether and where there are
gaps in the data.
Identify patterns of cause and effect.
DOCUMENTING THE DATA
The nurse must decide which data
should be immediately reported and
which data can just be recorded.
It is essential for accurate and
complete recording of assessment
data to communicate information to
other health care team members.
Second step in the nursing process.
Clinical judgment about individual,
family, or community response to
actual or potential health
Provides the basis for client care
through the remaining steps.
Clients have both nursing and medical
A medical diagnosis is a clinical
judgment by the physician that
identifies or determines a specific
disease, condition, or pathological
Part one–problem statement or
diagnostic label describing the client’s
response to actual or risk health
problem or wellness condition.
Part two–etiology or the related
cause or contributor to the problem.
Linked by the term related to (r/t).
Part one–diagnostic label.
Part three–defining characteristics, or
signs and symptoms, subjective and
objective data, or clinical
Third part linked to the first two by
the term as evidenced by (AEB).
Actual nursing diagnosis–indicates
that problem exists.
Risk nursing diagnosis–indicates that
specific risk factors are present.
Wellness nursing diagnosis–client’s
statement of desire to attain a higher
level of wellness in some area of
Third step of the nursing process.
Includes establishing guidelines for
the proposed course of nursing action
and developing the client’s plan of
Initial planning–developing a
preliminary plan of care.
Ongoing planning–updating the
client’s plan of care.
Discharge planning–anticipating and
planning for the client’s needs after
PLANNING INVOLVES …
Prioritizing the nursing diagnoses.
Identifying and writing client-centered
long- and short-term goals and
Identifying specific nursing
Recording the entire nursing care plan
in the client’s record.
Actions performed by nurse to help
client achieve results specified by
goals and expected outcomes.
Refer directly to the related factors or
the risk factors in nursing diagnoses.
Are stated in specific terms.
Independent–initiated by the nurse
do not require an order.
Interdependent–implemented in a
collaborative manner by nurse in
conjunction with other health care
Dependent–requires an order.
THE NURSING CARE PLAN
Written guide of strategies to be
implemented to help client achieve
Begins on the day of admission and
continues until discharge.
Fourth step in the nursing process.
The performance of the nursing
interventions identified during the
ORDERS FOR INTERVENTIONS
Specific order–for individual client.
intervention written, approved, and
signed by a physician, kept on file to
be used in predictable situations.
Protocol–series of standing orders or
Fifth step in the nursing process.
Determines whether client goals have
been met, partially met, or not met.
Ongoing evaluation is essential for the
nursing process to be implemented
THE NURSING PROCESS
AND CRITICAL THINKING
Critical thinkers ask questions,
identify assumptions, evaluate
evidence, examine alternatives, and
seek to understand various points of
Critical thinking can be learned.
Any printed or written record of
Recording and reporting are the
major ways health care providers
The client’s medical record is a legal
document of all activities regarding
PURPOSES OF DOCUMENTATION
Practice and legal standards
Documentation confirms the care
provided to the client and clearly
outlines all important information
regarding the client.
The legal aspects of documentation
Writing legible and neat
Spelling and grammar properly used
Authorized abbreviations used
Time-sequenced factual and
State Nursing Practice Acts
Joint Commission on Accreditation of
Healthcare Organizations (JCAHO)
The federal government requires
monitoring and evaluation of quality,
appropriateness of care provided.
Documentation of intensity of services
and severity of illness reviewed.
Failure to document can result in
Health care students use medical
record as tool to learn about disease
processes, nursing diagnoses,
complications and interventions.
Students can enhance critical-thinking
skills by examining the records and
following health care team’s plan of
The client’s medical record is used
by researchers to determine whether
a client meets the research criteria
for a study.
Documentation can also indicate a
need for research.
Method of evaluating the quality of
Treatment interventions and responses
PRINCIPLES OF EFFECTIVE
1. Document accurately, completely,
and objectively, including any errors.
2. Note date and time.
3. Use appropriate forms.
4. Identify the client.
5. Write in ink.
6. Use standard abbreviations.
PRINCIPLES OF EFFECTIVE
7. Spell correctly.
8. Write legibly.
9. Correct errors properly.
10.Write on every line.
12.Sign each entry.
SYSTEMS OF DOCUMENTATION
Traditional method of nursing
Chronologic account in paragraphs
describing client status, interventions
and treatments, and client’s response.
The most flexible system.
Usable in any clinical setting.
Narrative recording by each
member of the health care team on
SOAP, SOAPI, AND SOAPIER
S: subjective data
O: objective data
A: assessment data
System using a column format to
chart Data, Action, and Response
CHARTING BY EXCEPTION
Only significant findings (exceptions)
are documented in a narrative form.
Presumes that unless documented
otherwise, all standardized protocols
have been met and no further
documentation is needed.
Reduces time taken, increases
Stores, retrieves information quickly.
Improves communication among
health care departments.
Confidentiality and costs can be
Also known as Care Maps.
Comprehensive pre-printed standard
plan reflecting ideal course of
treatment for diagnosis or procedure,
especially with relatively predictable
Additional forms are needed to
complement the pathway.
NURSE’S PROGRESS NOTES
Document client’s condition,
problems, complaints, interventions,
and client’s response to
Include MAR, vital signs records,
flow sheets, and intake and output
Client status on admission and
Brief summary of the client’s care
Intervention and education outcomes
Resolved and unresolved problems
Client instructions about medications,
diet, food-drug interactions, activity,
treatments, follow-up, and other
FOR SHIFT REPORT
Name, room and
bed, age, gender
Diagnostic tests or
performed in past
24 hours (results if
General status, any
New or changed
IV fluid amounts,
last PRN medication
Date and time
Order as given by the physician
Signature beginning with t.o.
Physician must countersign
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