The Nursing Process

Use critical thinking and reasoning skills within the framework of the nursing process to plan the delivery of safe and effective nursing care.

Critical Thinking

What is Critical Thinking?

"…is the active, organized, cognitive process used to carefully examine one's thinking and the thinking of others."

John Chaffee

Critical Thinking involves the use of the mind in forming conclusions, making decisions, drawing inferences and reflecting.

Critical Thinking Activities

Nursing Process Definition

The dynamic, systematic problem solving method, which uses critical thinking to plan and provide individualized care for patients in all states of wellness and illness.

A critical thinking process nurses use to apply research to the care and promotion of health throughout the lifespan, in any setting.

The nursing process is a systematic method of providing care to patients. It is:

  • Dynamic and creative
  • Although there are 5 steps, it is not a linear process, you will move back and forth between the steps as you critically think about a problem.
  • It improves communication and promotes independent thinking

Five Steps of the Nursing Process

Compare the Nursing Process to the Scientific Method

Nursing is similar to science in that it tests decisions based off of observations and evidence.

Scientific Method Nursing Process
Recognize a problem,
collect supporting data		 Step 1-Assessment- Gathering and examining data, clustering data, validating data
Identify solutions Step 2-Nursing Diagnosis- Analyzing data to identify strengths and problems
Plan solutions Step 3-Planning- Setting Goals and developing a plan of action
Test the solution Step 4- Implementing- Putting the plan into action
Evaluate the solution Step 5- Evaluation- Determining if the plan worked, if nursing care given was effective

Contrast the practice of Nursing and the practice of Medicine

Suppose a patient has been diagnosed with breast cancer. Here are the different ways Medicine and Nursing would approach the situation:

Medicine Nursing
Goal: To eliminate or correct the disease state or pathology Goal: To focus on the human response to the disease state or pathology
Example: Malignant tumor Example: Fear, body image disturbance, pain, anticipatory grieving
Purpose: to identify cell type and extent of involvement Purpose: to identify how the patient will respond to and deal with the cancer diagnosis
Interventions: Aimed at treatment, medications, surgery needed to eliminate or treat the cancer Interventions: Aimed at promoting and restoring optimal health and well-being while the patient is undergoing medical or surgical treatment

Step One: Assessment

Purpose

To gather data about the patient that can be used in diagnosing, identifying outcomes, planning and implementing care.

Data can come from various sources, and be categorized as subjective, or objective.

Process

Performing a health assessment is similar to the nursing process.

  1. Collection of Data
  2. Compare data with norms
  3. Analyze findings
  4. State Nursing Diagnosis(es)
  5. Prioritize Nursing Diagnosis
  6. Formulate careplan

Sources of Data

  • Primary sources: Come directly from the patient
    (Interview, Observation, Physical Examination)
  • Secondary sources: Come from elsewhere
    (Family Members, reports, charts, health care team)

Types of Assessment Data

Subjective Data

What the patient reports is subjective. For example: “I feel nauseated.”

The main way you will collect subjective data is by interviewing the patient. During the interview, you will obtain biographical data, which is usually collected by admitting clerks or other support staff. You will ask about the history of present illness, past medical or surgical history, and family history.

Feelings, perceptions, and concerns are best gathered during the interview, but could be gathered at any point in the nursing process.

Guidelines for Collecting an Interview and Health History

 

Step Two: Diagnosis

Definition

"a clinical judgment about individual, family or community responses to actual or potential health problems or life processes."

NANDA-I (North American Nursing Diagnosis Association-International)

Nursing Diagnoses
vs. Medical Diagnoses

A Nursing Diagnosis identifies situations where the nurse is qualified to treat.
It focuses on the client's responses to problems.

Types of Nursing Diagnoses

Parts of a Diagnosis

Diagnostic Label

The problem or label is the patient’s response to an actual or possible health problem. The North American Nursing Diagnosis Association (NANDA) is the official organization responsible for developing the system of naming and classifying nursing diagnoses. NANDA uses Gordon’s Functional Health Patterns to organize the label.

Each diagnostic label describes the essence of the problem in as few words as possible.

Examples include:

  • Pain (acute)
  • Alteration in Tissue Perfusion
  • Alteration in Nutrition (less than Body Requirements)

 

Step Three: Planning

Purpose: to assist in planning client care that is individualized, realistic, measurable, and which promotes patient participation and involvement of support people. If the plan of care we develop is successful, then our expected outcome will be met.

Pyramid graph of Maslow's Heiararchy of Needs. High to Low: Self-Actualization, Esteem & Self Respect, Belongingness and affection, Safety & Security, and Physiologic needs.

Maslow's Heierarchy of Needs

Abraham Maslow’s Human Needs Theory (1968) places human needs into a hierarchy of motivation. All needs are steps toward self actualization. According to Maslow, a person must meet their basic (often physiologic) needs in order to step up to the next level. Nurses must prioritize their patient’s needs from the bottom up, and provide appropriate care that is individualized and based on mutually agreed upon goals. The patient is an active part of the planning process.

 

Step Four: Implementation

Purpose: to meet the patient’s identified needs which results in health promotion, prevention of illness, illness management, or health restoration. In this stage we will carry out the plan of care. It is the “action stage.”

Activities

  1. Reassess
  2. Set Priorities
  3. Perform Nursing Actions
  4. Record Nursing Actions

Types of Implementation Activities

Examples

  • Providing skilled nursing care, assessing, assisting with activities of daily living
  • Delivering skilled therapeutic interventions
  • Monitoring and surveillance of response to care
  • Teaching
  • Discharge planning
  • Supervising and coordinating nursing personnel

NOTE: all interventions must have scientific rationale.

Step Five: Evaluation

Purpose: to determine the client’s progress or lack of progress toward achievement of expected outcomes. It is a planned, purposeful nursing activity in which the patient participates.

Activities

  1. Review client goals/outcomes
  2. Collect data
  3. Determine goal/outcome attainment
  4. Revise/modify nursing care plan

In this step the nurse evaluates the patient’s progress toward meeting the identified outcome identified in Step Three. The nursing actions are formulated to lead the nurse to meeting the outcome. Now we are determining whether the plan of care lead to the behavior identified in that outcome.

Evaluation can be ongoing, that is the nurse can evaluate as the care is being given, or is can be performed at specified times. Evaluation continues until the goal is met. To determine goal achievement, evaluate outcomes, patient’s condition and movement toward short and long term goals.

Outcomes

The evaluative statement has 2 parts: the conclusion and the supporting information.

What Went Wrong?

If the goal is not met, what went wrong? Ask yourself:

  • Were the outcomes realistic and appropriate?
  • Was the outcome mutually agreed upon with the patient and nurse?
  • Did the patient value the outcome?
  • Have all the interventions that were identified been carried out and in the timeframe specified?
  • What variables may have affected achievement of the outcomes?
  • Were there changes to the patient’s condition?
  • When you review the nursing interventions, will the implementing of these interventions lead to meeting the patient outcome?

Evidence Based Practice

Evidence based practice does not rely on intuition, unsystematic observations, or pathophysiologic rationale, it emphasizes the use of research and evidence to guide clinical decision making. Evidence based practice combines the current research-based evidence with clinical expertise and patient preferences to make a decision about a specific patient.

Infographic showing that Improved Patient Outcomes result from Expertise, Evidence, and Expectations working together.

Research vs. Tradition

Nursing care that is based only on statements such as “This is the way it has always been done,” or “I have been working here for 15 years and I know that this way is the best” are not sufficient in today’s health care environment.

For example, 30 years ago, when a patient had a pressure ulcer, a heat lamp was often used to “dry out” the wound and promote healing. Why did we do this? There was no scientific rationale for it, but it seemed to work most of the time. We now know that a moist environment accelerates wound healing, and we found this out through research.

Regulatory Agencies

Evidence based practice assures that the best and current nursing care is being given to patients and families. Regulatory agencies, such as Joint Commission use standards that call for health care providers to implement best practices based on research evidence.

Market Demand

Third party payers are increasingly looking at paying for only health care interventions that have known effectiveness supported by scientific evidence. Even patients and families are using the Internet to seek information about the best treatments that have been tested in clinical trials.

The Process of Evidence-Based Practice

The American Journal of Nursing described the EBP process in the 2010 article Evidence Based Practice: Step by Step. The Seven Steps of Evidence Based Practice.

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