Nursing fundamentals: the nursing process (ati)

how do nurses obtain objective data?

"nurses feel, see, hear, and smell objective data through observation or physical assessment of the client"

nursing planning

- the establishment of client goals/outcomes - working with the client to prevent, reduce, or resolve problems -to determine related nursing interventions that are most likely to assist client in achieving goals -this about improving the quality of life for your patient - this is about what the patient needs to do to improve their health status or better cope with illness.

questions to consider-evaluation

1. " did the client meet the planned outcomes?" 2. "were the nursing interventions appropriate and effective?" 3. "should i modify the outcomes or interventions?"

what is involved in collecting data effectively?

1. ask appropriate questions 2. listen carefully to responses 3. develop good head to toe assessment skills 4. employ critical thinking and clinical judgment 5. recognize the need to collect data prior to interventions

five steps of the nursing process

1. assessment/data collection 2. analysis 3. planning 4. implementation 5. evaluation

examples of ethical/ legal skills

1. being trusted to act in ways that advance the interests of the patients 2.using technical equipment with sufficient competence and ease to achieve goals with minimal distress to patients 3. acting as an effective patient advocate.

nursing care plan

1. client centered 2. includes assessment data (subjective and objective); goals/outcomes;interventions;rationale; evaluation

activities involved in nursing assessment

1. collect data 2. validate data 3. organize 4. documenting data

nursing process-implementation

1. doing and documenting 2. the first three process phases-support implementation 3. the implementing phase, provides the actual nursing activities and client responses that are evaluated for effectiveness

what does planning involve?

1. establish priorities and outcomes that can be measured and evaluated 2. these priorities and outcomes are what directs selection of interventions 3. three types of planning 4. develop plan of care based on assessment 5. planning is continuous; obtain new info and evaluate responses to care; modify plan of care if necessary 6. discharge planning 7. nurses select priorities, determine outcomes, and select interventions

purpose of nursing assessment

1. establishes a data base 2. continuously updates the data base 3. validates data 4. communicates data

evaluation-nursing process

1. follows implementation 2. its the judgment of the effectiveness of nursing care to meet client goals based on the clients behavioral responses.

therapeutic interventions

1. includes measures nurses take to minimize risk and to respond to unplanned events, such as observation of unsafe practice, a change in a status, or the emergence of a life threatening situation.

factors that can lead to a lack of goal achievement

1. incomplete database 2. unrealistic client outcomes 3. nonspecific nursing interventions 4. inadequate time for the client to achieve the outcomes.

diagnosis-problem list

1. inflammation and distortion of tissues, ductal spasm 2. inability to ingest/absorb adequate nutrients, food intolerance 3.medically restricted intake, NG 4. pain 5. nausea, vomiting & anorexia 6. insufficient familiarity with condition, lack of information, misinterpretations 7. decreased lung expansion and ineffective cough 8. decreased energy/fatigue 9. altered coagulation and bleeding

evaluation

1. nurses evaluate the patients response to the interventions and form a clinical judgment about the extent to which the patient has met the goals/outcomes that were set

methods of data collection

1. observation 2. interviews 3. medical history 4. comprehensive or focused physical exam 5. diagnostic and laboratory reports 6. collaboration

characteristics of a critical thinker

1. open to all points of view 2. resisting "easy" answers to pt problems 3. thinking "outside the box"

guidelines for writing outcomes

1. outcomes are derived from only one nursing diagnosis 2. show a direct resolution of the problem statement in the nursing diagnosis 3. identify long term and short term outcomes

roles of nurse during implementation

1. perform nursing actions 2. delegate tasks 3. supervise other health staff 4. document the care and the patients responses.

steps of scientific problem solving

1. problem identification 2. data collection 3. hypothesis formulation 4. plan of action 5. hypothesis testing 6. interpretation of results 7. evaluation

what does implementation involve?

1. problem solving 2. clinical judgment 3. critical thinking to select and implement appropriate interventions 4. use nursing knowledge, priorities of care, and planned outcomes to promote, maintain and restore health. 5. use interpersonal skills and technical skills

establish goals and expected outcomes

1. provide guidelines for nursing interventions 2. establish evaluation criteria to measure the effectiveness of the nursing care plan 3. goal- broad statement describing the desired change 4. outcome- detailed, specific statement that described the methods through which the goal will be achieved

implementing safe care

1. provide teaching, support, and comfort 2. keep a holistic view of the client 3. respect the dignity of the client 4. encourage client to participate

role of documenting in the nursing process

1. pt record is the chief means of communication between the members of the interdisciplinary team 2. nursing action not documented is an action not performed 3. content of the pt report and documentation helps establish nursing priorities

what does analysis requires the nurse to do ..?

1. recognize patterns or trends 2. compare the data with expected standards or reference pages 3. arrive at conclusions to guid nursing care

what does subjective data include?

1. symptoms 2. patients feelings 3. patients perceptions 4. description of health status

traits that help nurses develop the attitudes and dispositions to think critically

1. thinking independently 2. being intellectually humble 3. being curious and persevering

nursing interventions

1. use a decision making process to select appropriate nursing interventions 2. nursing interventions are treatment, based upon clinical judgment and knowledge that a nurse performs to enhance patient/client outcomes

what three things does the nurse do during assessment?

1. validate 2. interpret 3. cluster data

cases in which the nursing process is applicable

1. when nurses work with patients who are able to participate in their care 2. when families are supportive and wish to participate in care 3. when patients are totally dependent on the nurse for care.

roles of the provider-plan of care

1.carries out the plan of care 2. collects data 3. modifies the plan of care 4. documents care

how the nurse and patient work together to accomplish the tasks of the nursing process

Determining the need for nursing care: The nursing process provides a framework that enables the nurse to systematically collect patient data and clearly identify patient strengths and problems. b. Planning and implementing the care: The nursing process helps the nurse and patient develop a holistic plan of individualized care that speci- fies both the desired patient goals and the nursing actions most likely to assist the patient to meet those goals and execute the plan of care. c. Evaluating the results of the nursing care: The nursing process provides for evaluation of the plan of care in terms of patient goal achievement.

nursing diagnosis vs. medical diagnosis

ND- focus on unhealthy responses to health and illness; describe the problems treated by nurses within the scope of nursing practice; may change from day to day as the patient's responses change. MD- identify diseases; describe problems for which the physician directs the primary treatment; remains the same for as long as the disease is present

implementation

Nurses base the care they provide on the assessment data, analysis, and the plan of care they developed in the previous steps.

(q&a#3) A nursing instructor is reviewing which actions nurses can initiate w/out a provider's prescription w/ a group og nursing students. The student should identify which of the following interventions as nurse-initiated?

Pg.55 ati C. show a client how to use pregressive muscle relaxation D. perform daily bath after evening meal E. reposition the patient every 2 hours to reduce pressure ulcer risk

three patient benefits of using the nursing process correctly

Scientifically based, holistic, individualized care The opportunity to work collaboratively with nurses Continuity of care

goals of nursing process

The goals of the nursing process are to help the nurse manage each patient's care scientifically, holistically, and creatively to promote wellness, prevent disease or illness, restore health, and facilitate coping with altered functioning.

define nursing process

The nursing process is a systematic, patient centered, goal oriented method of caring that provides a framework for nursing practice.

what is the nursing process?

a cyclical, critical thinking process. it is dynamic, continuous, client-centered, problem-solving, and decision making framework that is foundational to the nursing practice.

example: implementing

a nurse assist a patient to achieve desired goals such as promoting wellness, preventing disease and illness, restoring health, or facilitating coping with altered functioning

three nursing benefits of using the nursing process correctly

a. Achievement of a clear and efficient plan of action by which the entire nursing team can achieve results for patients b. Satisfaction that the nurse is making an important difference in the lives of patients 3. opportunity to grow professionally when evaluating the effectiveness of interventions and variables that contribute positively or negatively to the patient's goal achievement

the group that legitimized the steps of the nursing process in 1973 by developing standards of practice to guid nursing practice

american nurses association for nursing practice

concept mapping

an instructional strategy that requires learners to identify, graphically display, and link key concepts.

ex. a nurse consults with a patient's support people and other healthcare professionals to learn more about a patients problem

assessing

ex. a nurse performs an initial pt interview

assessing

ex. a nurse reviews a patient's past medical records

assessing

critical thinking

can be intuitive, logical, or both

ex. nurse understands the need for palpating the lungs of a patient with pneumonia

cognitive competencies

time-lapsed reassessment

comparison of client's current status to baseline obtained previously, detection of changes in all functional health problems after an expected period of time has passed -several months(3,6,9 months or more) between assessment

ex. a nurse identifies the strengths a patient with cancer possesses

diagnosing

nursing diagnosis - components

diagnostic label RT etiology AEB defining characteristics

documentation

documentation is essential. it should focus on facts and should be very descriptive.

when do you collect subjective data (symptoms)?

during the nursing history

when is objective data (signs) obtained?

during the physical assessment

ex. a nurse carefully fills out an incident report documenting a fall

ethical/legal competencies

ex. a nurse decides whether to continue, modify, or terminate the healthcare plan

evaluating

ex. a nurse sits down with the healthcare team halfway through treatment of a patient to see how effective the treatment has been

evaluating

ex. a nurse weighs a patient after three weeks to determine whether his/her new diet has been effective

evaluating

prioritize nursing process

high - ineffective breathing pattern medium- risk for impaired skin integrity low-ineffective coping

emergency assessment

identification of life threatening situation-anytime

ex. a home care nurse helps the physical therapist exercise the pt limbs

implementing

ex. nurse analyzes data to determine what health problems might exist

implementing

ex. nurse documents respiratory care performed on a patient

implementing

initial assessment

initial identification of normal function, functional status, and collection of data concerning actual or potential dysfunction. Baseline for reference and future comparison. within the specified time frame after admission to a hospital, nursing home, or ambulatory healthcare center

ex. a nurse conducts a patient interview in such a way that the patient relaxes and "opens up" to her

interpersonal competencies

three important ideas that must be linked together during clinical planning

medical diagnosis, nursing diagnosis, all pertinent clinical data

whistle blower

nurse who reports his/her employer's violation of law to law enforcement agencies outside the employer's facilities

critical thinking process

nurses who use the critical thinking process must identify alternative decisions and reach a conclusion

(q&a#4) During evaluation, the nurse must gather information about the client to...?

pg. 55 ati A. determine whether the clients outcomes have been met

(q&a #1) By the second post op day, a client has not achieved satisfactory pain relief. Based on this evaluation, what should the nurse do next according to the nursing process?

pg. 55 ati the nurse should reassess the client to determine why he has no achieved satisfactory pain relief. Various factors may be influencing the lack of pain relief.

(q&a#2) A nursing instructor is reviewing the steps of the nursing process with a group of students. The students should identify which of the following data as objective?

pg.55 ati A. RR of 22/min w/ even, unlabored respirations D. skin pink, warm, and dry E. urine output of 300 ml/8hr F. dressing clean, dry, and intact

nursing process- holistic

physical emotional psychosocial developmental spiritual being

ex. a home care nurse determines how much nursing care is needed by an elderly stroke patient living with her daughter

planning

ex. a nurse sets a goal for an obese teenager to lose 2lbs a week

planning

what did the ANA congress for nursing practice develop?

standards of practice to guide nursing performance

focus assessment

status determination of a specific problem identified during previous assessment. ongoing process, integrated with nursing care, a few minutes to a few hours between assessments.

ex. a nurse skillfully attaches a heart monitor to a patient

technical competencies

the nursing process is...

the nursing process is nursing practice in action

the nursing process is considered dynamic

there is a great deal of overlapping interaction between the five steps, each step flows into the next step

primary sources of data

this is what the patients tells the nurse (subjective) or what the nurse observes.

analysis

use of critical thinking to identify health status or problems, interpret, or monitor the collected data base, reach an appropriate nursing judgment about health status and coping mechanisms, and provide direction for nursing care.

secondary sources of data

what others tell the nurse based on what the client has told them (subjective; "she told me that her shoulder is sore every morning") and the objective data is obtained from another source such as, family, friends, health care professional, or records.

what does the evaluation determine?

whether or not to modify the plan of care