NR416 Class 3 Nursing Process

Nursing Process, Clinical Judgment and Care Plan

Evaluate Outcomes

Generate Solutions

Take Action

Assessment

Diagnosis

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Two Types of Assessment Data

Recognize Cues

The first step of the Nursing Process is Assessment. Assessment is done initially and ongoing throughout the plan and implementation of care.

What assessment data is relevant/irrelevant?

What assessment data is most important?

Objective

Everything else

What the patient says

Subjective

Assessment

What assessment data is of immediate concern?

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Maslow’s Hierarchy of Needs

Nursing Diagnostic Statement (PES format)

The nursing diagnosis is the nurse’s clinical judgment about the patient's response, not pathology. Consider the disease process causing these assessment findings, and think about what is the patient’s response to the disease.

• The most basic needs are those necessary to support life. The ABCs (Airway, Breathing, Circulation). These are ALWAYS a priority when planning care.
• Breathing is the most basic physiological need in Maslow’s Hierarchy
• Physiologic (Survival) Needs: Food, fluids, oxygen, elimination, warmth, physical comfort.
• Safety is next up on the hierarchy

Diagnosis

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Based on the assessment and diagnosis, the nurse sets measurable and achievable short- and long-range goals for this patient that might include moving from bed to chair at least three times per day; maintaining adequate nutrition by eating smaller, more frequent meals; resolving conflict through counseling, or managing pain through adequate medication. Assessment data, diagnosis, and goals are written in the patient’s care plan so that nurses as well as other health professionals caring for the patient have access to it.

• What are the desirable Outcomes (goals) for the patient during your shift? What is the Plan to achieve those outcomes?

• Formulate a SMART goal in collaboration with the patient.

Generate Solutions

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Take Action with Interventions: Interventions are aimed at the etiology in the nursing diagnostic statement in order to address the underlying cause.

Which interventions are most appropriate to meet the outcomes?

Include both collaborative and nurse-initiated interventions.

Are the interventions evidence based? Need support from Lippincott.

List the interventions in order of priority.

Take Action

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Both the patient’s status and the effectiveness of the nursing care must be continuously evaluated, and the care plan modified as needed.

What was the patient’s response to the interventions?

What signs point to improving/declining/unchanged status?

How did you evaluate the response?

Were the interventions effective?

Evaluate Outcomes

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