Nursing Process Part 1

PPN 102
Week 4
 1. Discuss the five steps of the NP:
• Discuss the rationale for using it to plan care.
• Compare the NP and a written nursing care plan.
• Discuss the links that integrate each step of a nursing care plan.

2. Discuss the relationship between the NP, critical thinking and clinical
judgment

3.Compare NP and NCSBN Clinical Judgement

Objectives 4. Discuss the diagnostic reasoning process

• Outline the principles of diagnostic reasoning.
• Summarize the types and risks of diagnostic errors.
• Identify the steps for diagnostic reasoning.
• Use diagnostic reasoning to identify strengths.

5. Differentiate Nursing diagnoses from collaborative problems

• Develop and write Diagnostic Statements (3-part statements-2-part format )
• Actual nursing diagnoses
• Potential and At-risk nursing diagnosis
• Health Promotion
• Wellness Diagnosis
 COMPARE
The Nursing Process with the written nursing care plan
The Nursing Process (NP)

“The Nursing Process incorporates general (scientific method,

problem solving, and decision making) and specific critical
4
thinking competencies (diagnostic reasoning, inference and
clinical decision making)….. in a manner that focuses on a
particular patient’s unique needs”
(Potter & Perry, 2019, p.181)

“The Nursing Process is a systematic and rational method of

planning and providing patient care organized around a series of
phases that facilitates evidence-informed, and ethical nursing
Gregory, et al, 2015
practice”
The nursing process … 5

• assists nurses in their critical thinking

• provides a guideline for data
collection and care planning
• helps organize nurses’ work
• assists with documentation of clients’
needs and plan of care
The nursing process is NOT: 6

• A conceptual framework
• A theory or theoretical framework
• A model of care
• A standard for the profession
Steps of the Nursing Process 7

1 2 3 4 5
Assessment: The nurse Diagnosis: The nurse Planning: The nurse Implementation: The Evaluation: The nurse
gathers & analyzes identifies the client’s prioritizes proposed nurse carries out the care looks at achievement of
information to understand response to health strategies and plan. outcomes to determine
the client’s health status. problems within the interventions and creates whether or not the
domain of nursing. a client-centred care plan, interventions have been
identifying expected effective.
outcomes. • Potter and Perry, 2019, pp. 188
Nursing Care Plan (NCP)

• Written care plans, nursing card-filing systems, standardized care

plans, or computerized care plans
• Includes: Nursing Diagnosis, Expected Outcomes, Specific Nursing
Interventions
• Any nurse should be able to identify a client’s clinical needs and
situation based on the care plan
• NCP allows for communication, continuity and coordination of
nursing care-information exchange
Nursing Care Plan - Example
Comparing the NP and the NCP 10

Look at the Nursing Process (NP) and the NP Care Plan

(NCP). Address the following questions:

• Are there links between each step of the Nursing

Process? If yes, describe them.
• What are the similarities and differences between
the NP and the NCP?
• How might you use the NCP in your clinical
placement?
 COMPARE
The Nursing Process with the Clinical Judgment Model and Critical Thinking
NP, Critical Thinking and Clinical Judgment
NP and Critical Thinking

 Critical thinking influences observations made.

 NP focuses on a client’s needs using general and
specific critical thinking competencies.
 Critical thinking allows us to see what is high,
intermediate and low priority for client.
 Uses research, evidence and experience to choose
appropriate interventions.
 Reflect on client responses to intervention(s) using
clear and measurable indicators.

13
The NCSBN Clinical
Judgement Measurement
Model (NCJMM)

•https://www.ncsbn.org/

NURSING PROCESS
Form Hypotheses

Recognize Cues Analyze Cues

Identify relevant and important Organizing and linking the recognized cues to
information from different sources the client’s clinical presentation.
(e.g. medical histpry, vital signs) • What client conditions are consistent with
• What information is the cues?
• Are there cues that support or
relevant/irrelevant?
contraindicate a particular condition?
• What information is most important? • Why is a particular cue or subset of cues of
• What is of immediate concern? concern?
• What other information would help establish
Do not connect cues with hypotheses the significance of a cue or set of cues?
just yet! Consider multiple things that could be
ASSESSMENT happening. NURSING DIAGNOSIS
 Refine Hypotheses

Prioritize Hypotheses Generate Solutions

• Evaluating and ranking • Identifying expected outcomes and using

hypotheses according to hypotheses to define a set of interventions for
the expected outcomes.
priority (urgency, likelihood,
risk, difficulty, time, etc.) • What are the desirable outcomes?
• What interventions can achieve those outcomes?
• Which explanations are
more/less likely? • What should be avoided?
NURSING DIAGNOSIS • Focus on goals and multiple potential
• Which possible explanations interventions – not just the best one – that
are the most serious? connects to those goals. Potential solutions
could include collecting additional information.
PLANNING
https://www.ncsbn.org/
Evaluation

Take Action Evaluate Outcomes

• Implementing the solution(s) that • Comparing observed outcomes

addresses the highest priorities. against expected outcomes
• Which intervention or combination of • What signs point to
interventions is most appropriate? improving/declining/unchanged
status?
• How should the interventions be
accomplished? (performed, requested, • Were the interventions effective?
administered, communicated, taught, • Would other interventions have
documented, etc.)? been more effective?
IMPLEMENTATION EVALUATION
https://www.ncsbn.org/
 STEPS
Of the Nursing Process: Assessment (Recognize Cues)
Assessment 19

• a nurse gathers information in order to understand the client’s

unique situation.
• date are gathered, often using a specific data collection tool (NCP)
or other framework
• goal = to “solve the puzzle” – to put all the pieces together until
they form a clear picture of the client’s situation
Assessment Data 20

SOURCES
TYPE
Primary Sources:
● Client • Subjective
Secondary Sources: • Objective
● Family and significant
others
● Health care team
Tertiary Sources:
● Medical records
● Literature
Potter and Perry, 2024, p. 189
● Nurse’s experience
Methods of Data Collection 21

• Interview
• Nursing health history
• Physical examination

Potter and Perry, 2024, p.192

 Holistic/Comprehensive Assessment vs. a
Problem Based Assessment 22

A holistic/comprehensive A problem-based assessment

assessment
 Sometimes a client will present with an initial health
problem
 Draws on a detailed database  You then observe, ask questions about the nature of
that included all spheres of the problem and listen for cues.
human functioning (physical,  As you collect data, you will begin to categorize
psychological, spiritual, “cues”, make “inferences” about the data, and
identify emerging patterns.
socio-cultural)
 You will start to see patterns of information that
point to some sort of conclusion about the nature of
the problem
 STEPS
Of the Nursing Process: Nursing Diagnosis (Analyze Cues, Prioritize Hypotheses)
Diagnostic Reasoning

• A process that enables an observer to assign meaning and classify

phenomena in clinical situations by integrating observations and
critical thinking
• Clinical inference – the process of drawing conclusions from
related pieces of evidence. An inference involves forming patterns
of information from data before making a diagnosis
• Use patient data you gather to logically explain a clinical
judgement

(Potter & Perry, 2019, p. 197, Potter & Perry, 2023, p. 90)
 Diagnostic Reasoning in Clinical Judgment

Diagnostic reasoning, the process of analyzing health data and drawing

conclusions to identify diagnoses, is based on the scientific method. It
has four major components:
(1) attending to initially available cues;
(2) formulating diagnostic hypotheses;
(3) gathering data relative to the tentative hypotheses; and
(4) evaluating each hypothesis with the new data collected, thus
arriving at a final diagnosis.
*A cue is a piece of information, a sign or symptom, or a piece of laboratory data. A hypothesis is a
tentative explanation for a cue or a set of cues that can be used as a basis for further investigation .

Jarvis 2024
Diagnostic Reasoning

Data Validation
Data Analysis and Interpretation
Validation is the act of “double
• Data clustering: organize assessment data
checking” or verifying that data
into meaningful clusters to help recognize
(cues) to confirm that they accurate significant cues/problems
or factual
• Recognize patterns in data which indicate
• Validate assessment data before you a current or potential problem
begin to analyze and interpret it • Interpret: use inferential reasoning (attach
• This avoids incorrect inferences meaning to clinical data)
• Data validation compares data to • Compare current data to the client’s
another source (patient; textbook; normal values or set of standard norms
other nurses and health care team • Look for interrelationships
P&P, 2024,p.194: Kozier & Erb , 2017, p.412
members) • Make a reasoned conclusion
 Forming a Nursing Diagnosis
(Diagnostic Reasoning)

• The nurse further analyzes and synthesizes information and comes

to specific conclusions
• The nurse identifies areas of positive functioning, where there
may be a risk of problems and where there are actual problems.
• The strengths you identify are invaluable when planning effective
interventions
• The problems or needs that you identify are the basis for the plan
of care
Sources of Error

• Errors in data collection

• Errors in interpretation and analysis of data
• Errors in clustering data
• Errors in diagnostic statements
 Nursing Diagnosis
• “A clinical judgment about individual, family or community
responses to actual and potential health problems or life
processes that is within the domain of nursing” (NANDA, cited in
P & P, 2019, p. 196)
• “ Provides the basis for selecting nursing interventions to
achieve outcomes for which the nurse is accountable”
• Focuses on the actual or potential response to health problem
rather than on the physiological event, complication or disease

( P & P, 2024, p. 196)

Nursing vs Medical Diagnoses

“The identification of a disease condition on the

basis of a specific evaluation of physical signs,
symptoms, the client’s medical history, and the
results of diagnostic tests and procedures”

(P & P, 2024, p. 196)

Collaborative Problems

“Actual or potential physiological complications

that nurses monitor to detect the onset of
changes in a client’s status” (Carpenito-Moyet
cited in P & P, 2024, p. 196)
• Nurses work in collaboration with other health
care team members to manage the problems
 Differentiating ND from Collaborative
Problems

P&P, 2019, p198

https://nurseslabs.com/nursing-diagnosis
 NANDA
(North American Nursing Diagnosis Association International)

• A taxonomy of nursing diagnosis (see P&P, 2019, p. 196-199)

• Each diagnosis is made up of two parts
• Diagnostic label
• Statement of related facts. Statements may be actual, risk,
health promotion or wellness diagnoses
• Visit http://www.nanda.org
 Types of 1. Actual Nursing Diagnosis

Nursing
2. Risk Nursing Diagnosis
3. Health Promotion Nursing Diagnosis
Diagnosis 4. Wellness Nursing Diagnosis
Formulating Nursing Diagnostic Statements

• Two parts:
• LABEL related to RELATED FACTORS
• For example:
• DEFICIENT KNOWLEDGE related to LACK OF EXPOSURE
TO INSTRUCTION
• RISK FOR INFECTION related to SURGICAL INCISION
Diagnostic Statements (cont)

Label
• Describes patient/client response to health condition
• Will include descriptors to strengthen meaning (e.g., impaired,
decreased)
Related Factors
• Etiology or ‘cause’ of the patient response
• What nursing actions will target or address
Actual Nursing Diagnosis

• Response to health conditions or life processes that exist in an

individual, family or community
• Defining characteristics (signs/symptoms) that cluster in patterns
of related cues
• Selection of an actual diagnosis indicates that there is sufficient
assessment data available to establish the nursing diagnosis
• i.e. Acute pain
Risk Nursing Diagnosis

• Human responses to health conditions or life processes that will

possibly develop in a vulnerable individual, family or community
• Include: Physiological, psychological, psychosocial, familial,
lifestyle and environmental factors that increase the client’s
vulnerability to, or likelihood of, developing the condition
• E.g. risk for infection
Health Promotion Nursing Diagnosis

• A clinical judgement of a person’s, family’s or community’s

motivation and desire to increase well-being and actualize human
health potential, as expressed in their readiness to enhance
specific health behaviours (i.e. nutrition, exercise)
• Can be used in any state of health
• Does not reflect current states of wellness
• E.g. Lack of knowledge about diabetic diet
Wellness Nursing Diagnosis

• Describes levels of wellness that can be enhanced

• A clinical judgement that can be enhanced from a specific level of
wellness to a higher level of wellness
• Nurses select this ND when a client wishes to or has achieved an
optimal level of health
• i.e. Readiness for enhanced coping related to successful cancer
treatment
Related factors: Examples

Activity Intolerance related to:

• Inactivity secondary to sedentary lifestyle

• Lack of motivation
• Increased metabolic demands secondary to assistive
device (walker) and increased stress
• Decreased muscle strength and flexibility
Points to Remember

• Identify a client response, not a medical diagnosis

• Use clear language that states the problem/need or use a
NANDA dx statement
• Identify a treatable etiology, not a chronic problem
• Identify a client’s problem, not the nurse’s
• Avoid legally suspect or judgmental statements
• Refer to only one problem/need per statement
Next Week
Nursing Process Part 2