Chapter 11

1. Providing Patient-Centered Care
Through the Nursing Process
Chapter 11
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Elsevier Inc.

2. Historical Perspective
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 1955
 Lydia Hall introduced observation, administration of care, and
validation.
 1958-1961
 Orlando introduced three-step nursing process: assessment,
planning, and evaluation.
 1967
 Yura and Walsh developed four-step nursing process:
assessment, planning, implementation, and evaluation.

3. Historical Perspective (Cont'd)
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 1973
 ANA added a fifth item to the nursing process: diagnosis.
 1991
 ANA introduced outcome identification.
 Today
 The six steps of the nursing process are assessment, diagnosis,
outcome identification, planning, implementation, and
evaluation.
 Nursing’s problem-solving method combines the art and
science of nursing.

4. Nursing Process
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 Excellent critical thinking skill
 Leads to good clinical judgment
 Crucial in providing nursing care for patients with complex
health conditions
 RN responsible for creating an individualized plan of
care using the nursing process
 Nursing’s method of critical thinking focused on
solving patient problems

5. Nursing Process (Cont'd)
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 Assessment
 First step
 Involves the collection of both objective and subjective data
about an individual, family, or community
 Examines five realms: physiological, psychological, social,
cultural, and spiritual
 Nurse observes the patient and the surrounding situation,
interviews both primary and secondary sources, examines the
patient from head to toe in a systematic manner, and
interprets laboratory data

6. Nursing Process (Cont'd)
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 Assessment
 Objective data
 Information that is observed and leaves little room for
interpretation
 Facts that can be measured and verified
 Examples: vital signs, size and location of a wound, color of
drainage
 Subjective data
 Information experienced and described only by the patient
 Cannot be verified as to its characteristics or easily quantified
 Examples: feelings and experiences of the patient’s pain, fear,
nausea, and uneasiness

7. Nursing Process (Cont'd)
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 Assessment
 Data collection methods
 Interview
 Observation
 Physical assessment
 Inspection, auscultation, palpation, and percussion

8. Nursing Process (Cont'd)
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 Assessment
 Data collection methods
 Gordon’s Functional Health Patterns
 Proposed 11 categories of functional health patterns that make a
systematic and standardized approach possible
 Virginia Henderson
 Identified 14 needs of the individual
 Holistic approach assesses the biological, psychological,
sociocultural, and spiritual needs of the individual

9. Nursing Process (Cont'd)
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 Assessment
 Organization of data collection
 Must be organized in a clear, systematic manner that permits
logical progression of the data
 Validating assessment data
 Validating, or verifying, assessment data necessary to ensure
accuracy

10. Nursing Process
Question 1
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A nurse collected the following data. Which data are
subjective?
1. Patient breathes 14 times a minute.
2. Patient has a dime-sized wound on the left leg.
3. Patient’s sputum is rust colored.
4. Patient is nauseated.

11. answer
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 . Patient is nauseated. Examples of subjective data include
such feelings and experiences as the patient's pain, fear,
nausea, and uneasiness.
1. Examples of objective data are vital signs, size and location of
a wound, color of drainage, or any assessment that does not
require personal perspective or opinion to document.
2.Examples of objective data are vital signs, size and location of
a wound, color of drainage, or any assessment that does not
require personal perspective or opinion to document.
3.Examples of objective data are vital signs, size and location of
a wound, color of drainage, or any assessment that does not
require personal perspective or opinion to document

12. Nursing Process (Cont'd)
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 Diagnosis
 Clustering of cues, or data points, gathered in assessment
helps define care priorities and associated “problems,” or
nursing diagnoses.
 Every nursing diagnosis must be substantiated by
identifying criteria (defining characteristics).
 Diagnosis may be actual, potential, or wellness.
 Use PES format.
 Problem (NANDA-I diagnostic label) related to
 Etiology (cause) as evidenced by
 Signs and symptoms (defining characteristics)
 Nursing diagnosis may be written: “Spiritual distress
related to death of husband as evidenced by tearfulness
and subjective comment, “Why did God let this happen?”

13. Nursing Process (Cont'd)
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 Diagnosis
 Collaborative problems are problems that require collaborative
interventions with the physician and the health care team.
 With collaborative problems, nurses monitor the patient to
detect changes in status or for the onset of complications.

14. Nursing Process (Cont'd)
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 Diagnosis
 Ackley and Ladwig (2014) suggest five steps to formulate a
nursing diagnosis.
1. Highlight or underline the relevant symptoms.
2. Make a short list of the symptoms.
3. Cluster similar symptoms.
4. Analyze or interpret the symptoms.
5. Select a nursing diagnosis label that fits with the appropriate
related factors and defining characteristics (p. 3).

15. Nursing Process (Cont'd)
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 Diagnosis
 Prioritizing
 When prioritizing nursing diagnoses, the most critical problems
receive the highest priority.
 Using Maslow’s hierarchy of needs, importance is first given to
physical needs.
 Safety is also a priority.

16. Nursing Process (Cont'd)
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 Outcome identification
 Immediate, intermediate, and long-term goals are identified
with the patient and family.
 Outcomes are specific, realistic, and measurable and written in
positive, patient-centered terms.
 Every diagnosis is associated with specific, individualized
expected outcomes.
 Outcomes must be measurable and clearly communicated,
along with signs of attainment or nonattainment and dates and
times for evaluation.
 Patient’s pain will decrease to ≤2 on a 0 to 10 pain scale by (a
certain date).

17. Nursing Process (Cont'd)
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 Outcome identification
 Nursing Outcomes Classification (NOC)
 330 NOC outcomes, grouped into 31 classes and 7 domains
1. Functional health
2. Physiologic health
3. Psychosocial health
4. Health knowledge and behavior
5. Perceived health
6. Family health
7. Community health
 Defines outcomes that focus on patient, identifies risk adjustment
factors, and provides measures for comprehensive outcomes that
respond to nursing intervention; can be used by nurses in all
settings

18. Nursing Process (Cont'd)
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 Planning
 Includes goals and outcomes and planning interventions; plan
of care developed
 Includes identifying interventions needed for the patient to
regain a level of independence
 Establishment of outcome priority is a planning mechanism
 Involves mapping out specific, individualized nursing actions
that aim to achieve the desired outcomes associated with the
nursing diagnoses
 Critical pathway and care mapping

19. Nursing Process (Cont'd)
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 Planning
 Nursing Interventions Classification (NIC)
 Contains 542 nursing interventions, grouped into 30 classes and 7
domains
 Basic; physiological; behavioral
 Safety
 Family; community
 Health systems
 Each intervention coded and linked with NANDA-I nursing
diagnoses
 Example: Performing prompt and comprehensive assessment
and management of pain including location, characteristics,
onset and duration, frequency, quality, intensity, and
precipitating factors

20. Nursing Process (Cont'd)
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 Implementation
 Carrying out of the plan of care
 Requiring a multidisciplinary approach
 RNs serving as gatekeepers; responsible for
 Delegating and coordinating care
 Implementing advanced interventions
 Evaluating and updating plan of care and associated outcome
priorities
 Engaging in and documenting patient/family education
 Documenting care
 Retaining full accountability that plan of care is carried out in a
sensitive and effective manner

21. Nursing Process (Cont'd)
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 Evaluation
 This is the process of examining the effectiveness of the plan of
care and adjusting it to ultimately meet the needs of the
patient.
 Outcome achievement is part of evaluation.
 Assessment and evaluation occur simultaneously and
continually.
 RNs interpret the data and adjust the plan of care to best meet
the patient’s needs.
 The plan of care may require no changes if the patient’s
condition is progressing as expected.

22. Nursing Process Question 2
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A nurse is developing an individual care plan for the
patient. Which step of the nursing process is the nurse
using?
1. Planning
2. Implementation
3. Evaluation
4. Assessment

23. answer
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 1. Planning. The plan of care, developed during the
planning phase of the nursing process, includes the
process of identifying the interventions needed for the
patient to regain a level of independence at or higher than
he or she had before admission into the health care
setting.
 2. Implementation, the carrying out of the plan of care,
requires a multidisciplinary approach.
 3. Evaluation is the process of examining the
effectiveness of the plan of care and adjusting it to
ultimately meet the needs of the patient.
 4. Assessment is the first step of the nursing process and
involves gathering objective and subjective data.