Nursing Process
Assessment Types
-Initial assessment -Focused assessment -Time lapsed reassessment( maybe a yearly check or recheck after meds administered. ) -Emergency assessment: if someone is ABCs or heat attack, bleeding heavily for example.
2.Establish Goals and Expected Outcomes
-Provide guidelines for nursing interventions -establish evaluation criteria to measure the effectiveness of the nursing care plan -Goal: broad statement describing the desired change. Two types- long & short -Outcome: detailed, specific statement that describes the methods through which the goal will be achieved.
Evaluation: how well did the interventions workout?
-the last phase of the nursing process. It follows implementation of the plan of care It's the judgement of the effectiveness of nursing care to meet client goals based on the client's behavioral responses
Case Study: Judy Jones
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Other types of nursing diagnoses
1.Actual Nursing Diagnosis- (diagnostic label & etiology) 2.Risk for: Nursing Diagnosis- (diagnostic label & etiology ...where you expect that risk to come from)" risk for pain, risk for poor airway clearance, etc. 3.Wellness Nursing Diagnosis- different, one part statement "readiness for enhanced spiritual well-being. 4.Possible Nursing Diagnosis- it raises awareness to keep eye on.Includes diagnostic label but not sure where it is coming from. 5.Collaborative Health Problems- Diagnosis where you aer working with the Dr. ex: electrolyte imbalance need a medical order so collaborative.
Implementation: what will the nurse do for this patient?
1.Consists of Doing & Documenting the activities that are the specific nursing actions needed to carry out the interventions or nursing orders. 2.The first three nursing process phases(assessing, diagnosing, and planning) provide the basis for nursing action performed during implementing step. 3.In turn, the implementing phase, provide the actual nursing activities and client responses that are examined in the final phase, the evaluating phase.
Planning: What can or should be done for this Patient?
1.Est. client goal/outcomes 2.Work w/ client to prevent, reduce, resolve problem 3.Determine related nursing interventions (actions) that are most likely to assist client in achieving goal. This is about improving quality of life for your pt. This is about what your pt needs to do to improve their health status or better cope with illness.
What are the elements of planning in the nursing process?
1.Establish priorities 2.Write client goals/outcomes 3.Develop an evaluative strategy 4.Select nursing interventions 5.Communicate the plan
1.Prioritizing Nursing Diagnoses
1.HighPriority: Dx- Ineffective breathing pattern --> Nursing Implications: assess breathing sounds, monitor vital signs, reposition client, encourage IS/TCDB 2.MediumPriority: Dx- risk of impaired skin integrity--->Comprehensive skin assess, keep skin clean/dry, turn reposition client on specified schedule 3.LowPriority: Dx- Ineffective Coping--> assist to identify problems, encourage keeping daily journal, teach client strategies for expressing feelings. *ABCs are always first!
4.Specify- Nursing Interventions
1.Once the goals have been mutually agreed on by the nurse and client, the nurse should use a decision-making process to select the appropriate nursing interventions. 2. Nursing interventions are treatment, based upon clinical judgement and knowledge that a nurse performs to enhance patient/client outcomes.
3.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
Problem solving and the Nursing Process
1.Trial and error problem solving- testing several solns until one is found that works for that particular problem. Not efficient for nursing. 2.Scientific problem solving- systematic, 7-step process, used most correctly in a scientific controlled research setting, but is closely related to problem solving in healthcare. 3.Intuitive problem solving- a direct understanding of a situation based on a background of experience, knowledge and skill that makes expert decision making possible. Critical thinking in nursing has several facets: logical, scientific & evidence-based & clinical reasoning that is both creative and intuitive.
Nursing Process formalized
1950s-1970sThe nursing process was formalized and described. AssessPlanImplementEvaluate --> AssessDiagnosePlanImplementEvaluate
Benefits of the Nursing Process
For Patient: achieves for pt, scientifically based, holistic, individualized care; the opportunity to work collaboratively w/ nurse; & continuity of care. For the nurse: Achieve a clear, efficient, and cost effective plan of action by which the entire nursing team can achieve best results for pt; the satisfaction that they are making a difference in the lives of pts.; the opportunity to grow professionally as they evaluate the effectiveness of interventions and variables that contribute pos/neg to pt's achievement of valued outcomes.
Relationship of Evaluation to the Nursing Process
It is the last part of the circle, but it just goes back around to assessment->data analysis->planning -> implementation-> evaluation again! until health of pt established.
What are the essential skills necessary in assessment?
Observation Interviewing Physical exam techniques Intuition What you observe (data you collect) and the subjective data (what the pt says) Intuition comes from experience and knowledge
Nursing Process is Holistic
Physical Emotional Psychosocial Developmental Spiritual Being This is a personalized holistic approach involving the patient as a whole, individually. Inso doing you look also at the environment of the individual...their family interactions and other aspects of their environment.
Implement safe care
Provide teaching, support and comfort to enhance the effectiveness of nursing care plans. Be holistic, view the client as a whole Respect the dignity of the client and enhance the client's self-esteem Encourage client to participate actively in implementing the nursing intervention
Nursing Assessment Purpose & Activity assoc.
Purpose: Make a judgement about the patient's health status, ability to manage his or her own healthcare, and need for nursing. Activities of Assessment: 1.Establishes a Data Base (DB): Nursing hx Physical assessment Review of pt record & nursing Lit. Consult w/ pt's support ppl & health care professionals 2.Continuously update DB 3.Validate DB checking accuracy, dbl checking 4.Communicate Data: Documenting Data
Evaluation can be considered
Re-Assessment
Problem List
Set of symptoms and observations about the patient that answer the question "why does he need a nurse?" but not in standard nursing language. Nursing Diagnosis has a standard language focused on altered states of health.
Data Types: Subjective and Objective
Subjective data: what pt/family says Symptoms Client's feelings Statement Objective data: what I see/observe as nurse Signs/ overt clues Observations Standard assessment Laboratory and diagnostic testing
The nurse completes the implementation phase of the nursing process by recording the interventions and the client's responses in the nursing process notes.
TRUE
Nursing Process
The essence of critical thinking and clinical decisions in nursing
Diagnosis
Why does this patient need a nurse?
Question: What are the primary purposes of the evaluation phase of the Nursing Process
a. Examine the need for adjstments and changes to the plan of care c. Measurement: the extent to which client goals have been met
diaphoretic
profuse sweating
Name 5 categories of nursing interventions of the NIC Iowa Intervention Project
1. Physiologic 2. psychosocial 3. illness treatment 4. illness prevention 5. health promotion
5 Steps in Nursing Process Today
1. Assessment 2. Diagnosis 3. Outcome Indentification & Planning 4. Implementation 5. Evaluation
Necessary/appropriate parts of nursing diagnosis
1. Diagnostic label 2. Etiology (patho...) 3. Defining Characteristics (uses subj & object data as evidence... need at least on kind of evidence)
What are the unique characteristic of the Nursing Process?
1. Systematic- ordered sequence with each activity dependent on the accuracy of the activity that preceded it. 2.Dynamic- ever changing, steps overlap and flow 3. Interpersonal- Human interaction is at the heart of nursing. interact w/ pt & family 4. Outcome oriented/Goal-directed: Together the nurse and patient set goals, short & long-term for the health plan. 5. Universally applicable to any nursing situation
EXAMPLES OF NURSING DIAGNOSES
1.ACUTE PAIN related to inflammation and distortion of tissuesm ductal spasm; AEB, verbal reports, guarding/distraction behaviors and autonomic responses (specify changes in vital signs.) 2. IMBALANCED NUTRITION: less than body requirements related to inability to ingest/absorb adequate nutrients secondary to food intolerance/pain/nausea/vomiting,anorexia AEB, possibly evidenced by aversion to food/decreased intake and weight loss.
Examples of Nursing Diagnoses
3.Deficient Fluid volume related to vomiting/NG tube aspiration, medically restricted intake, altered coagulation and bleeding; AEB, changes in mentation, dizziness, syncope, cold clammy skin, decreased skin turgor, tachycardia, decreased Bp or hypotension, decreased pulse volume and pressure, decreased / concentrated urine, decreased Hemoglobin and Hematocrit, change in coagulation studies. 4. DEFICIENT KNOWLEDGE regarding patho-physiology, therapy choices, and self care needs may be related to insufficient familiarity with condition, lack of information, misinterpretation, AEB verbilization of concerns,questions, and recurrence of condition 5. INEFFECTIVE BREATHING PATTERN R/T decreased lung expansion decreased energy/fatigue, ineffective cough, secondary to pain and muscle weakness, AEB, fremitus, tachypnea, and decreased respiratory depth/vital capacity.
Assessment Data Nursing Diagnoses
DATA: pain, nausea, vomiting, diaphoresis Fever, Jaundice URQ abdominal pain Elevated WBC, Liver funcs, & amylase Ultrasound/other diagnostics NURSING DIAGNOSIS: (diagnostic label portion) Acute pain Imbalanced nutrition Deficient knowledge Ineffective breathing pattern Deficient fluid volume
Provider carries out the plan of care
Carries out the plan of Nursing Care or Setting your plans in motion and delegating responsibilities for each step. Continues data collection and modifies The Plan of Care as needed. Documents the care given
Blended skills and critical thinking
Cognitive and technical skills equip nurses to manage the clinical problems stemming from the patient's changing health or illness state. Interpersonal and ethical skills are essential for nurses concerned about the patient's broader well-being.
Nursing Process: Activity
Collect Data Validate Data Organize Data Documenting Data: saves time for others and gives you a frame of reference.
Objectives of Nursing Process
Compare 3 approaches to problem solving: Classical, Technology (counter clockwise), Scientific Method- starts with a THEORY developed by observation (Use the theory to make a prediction) -->This leads to PREDICTION (design an experiment to test prediction)-> perform EXPERIMENT --> OBSERVATION (create new of modify the theory)
Nursing Diagnosis comes from (1) a problem list...using standard lang. (2) clinical judgement of altered pt's response to actual or potential health condition/need.
NSg Dx: (diagnostic label) ________ related to (R/T)[etiology]...______ as evidenced by (AEB) [defining characteristics]...
Differentiating Nursing Dx from Medical Dx
NURSING Dx focuses on unhealthy responses to health and illness Medical Dx focuses on Identifying disease. NURSING Dx describes problems treated by nurses w/in the scope of independent nursing practice. Medical Dx describes problems for which the physician directs the primary tx. NURSING Dx may change from day to day as pt responses change. Medical Dx remains the same for as long as the disease is present.
Primary Purpose of the Nursing Process (Taylor p198)
The primary purpose of the nursing process is to help nurses manage each patient's care holistically, scientifically, and creatively.
5.Communicate- write the "plan of care"
client centered, step by step process Nursing Care Plan (slide) NANDA Nsg Dx: (Diagnostic label)_________________ R/T (etiology)_______________ AEB (defining characteristics)______________________ -------------------------------------------- Assmnt Goals/Otcmes Intvntns Ratnls Evals subj assmnt, for treatmnts, interventions education, objective etc.