Ch. 4: The Nursing Process and Pharmacology:

3 Types of Nursing Actions

- Dependent - Interdependent - Independent

Collaborative Problems

- Different from nursing diagnoses when the intervention used is to prevent or treat a problem and is worded with potential complication in the diagnosis

Pharmacology Nursing Process: Assessment

- Obtain Drug History - Relies on 3 sources

Phases of Planning

- Setting priorities - Developing measurable goal/outcome statements - Formulating nursing interventions - Formulating anticipated therapeutic outcomes

Primary Sources

- Subjective data: produced by patient - Objective data: observations nurse makes

Three Reasoning for Obtaining a Drug History

- To evaluate need for medication - To obtain current and past use of over-the-counter medication - To identify problems related to drug therapy

Phases of Planning - Priority Setting

- identify problems and prioritize which ones are more important and must be attended to first, depending on patient needs - use Maslow's Hierarchy of Needs

Five Types of Nursing Diagnosis - Risk/high-risk

- patient may be more susceptible to a particular problem Components: 1. the diagnostic label from the NANDA-I-approved list 2. the risk factors that make the individual or group more susceptible to the development of the problem

Assessment

- starts when pt. is admitted until pt. is discharged - Physical examination - Nursing history - Medication history - Diagnostic test results

3 Types of Sources

Primary Secondary Tertiary

Tertiary Sources

literature to provide background information, diagnostic tests, diet

Anticipated Therapeutic and Expected Outcome Statements

outcome statements measured along the continuum of care developed to document effectiveness of care delivered

Five Types of Nursing Diagnoses

- Actual - Risk/High Risk - Possible - Health Promotion and Wellness - Syndrome

The Nursing Process

- Foundation for the clinical practice of nursing - provides framework for consistent nursing actions

Evidence-Based Practice

- Goal is to improve patient outcomes by implementing best practices evolved from scientific studies - Uses best care practices to improve patient outcomes - Evidence-based practice uses research to impact nursing practice changes; the interventions used in the research findings can be implemented into care plans

Formats of Data-Collection

- Head-to-Toe Assessment - Body Systems Assessment - Gordon's Functional Health Patterns Model

Nursing Interventions Classification (NIC)

comprehensive, research-based, standardized classification of interventions that nurses perform

Focused Assessment

process of collecting additional data specific to a patient or family that validates a suggested problem or nursing diagnosis

Nursing Diagnosis.

refers to the patient's ability to function in ADLs; it identifies the patient's response to the illness

Secondary Sources

relatives, significant others, medical records, lab reports

Nursing Outcome Classification (NOC)

standardized classification system of patient outcomes - includes definition, list of indicators used to evaluate patient status in relation to outcome, target outcome rating, place to ID source of data, and 5-point Likert scale to measure pt. status and short list of references

Critical Pathway (integrated care plans, care maps, clinical maps)

standardized, automated care plans integrating standards, interventions, goals, and outcomes

Five Types of Nursing Diagnosis - Possible

suspected problems requiring additional data

Nursing Care Plan

written or computer-generated document that evolves from the planning process

Holistic Care Needs

•See Figure 4-1 in the text (p. 38).

Pharmacology Nursing Process: Nursing Diagnosis

- Nursing diagnoses often can be formulated based on the patient's drug therapy - Most commonly associated with drug treatment for a disease or adverse effects from drug therapy Situations: 1. Pathophysiologic 2. Treatment related 3. Personal 4. Environmental 5. Maturational

Pharmacology Nursing Process: Evaluation

- assesses the patient's response to the medications prescribed - observes for signs and symptoms of recurring illness - evaluates for therapeutic effects or the development of adverse effects of the medication - determines the patient's ability to receive patient education and to self-administer medications - notes the potential for compliance

Five Types of Nursing Diagnosis - Actual

- based on human responses and supported by defining characteristics Components: 1. patient problem statement summarizing issue 2. contributing factors or cause 3. defining characteristics (signs/symptoms)

Phases of Planning: - Measurable Goal and Outcome Statements

- write short- and long-term goals for the patient to be followed when providing care - Starts with an action verb followed by behavior or behaviors to be performed by patient of patient's family - The patient will know how to take their medications by the end of the day.

How to Differentiate Nursing Diagnosis from Medical

1. Conditions of nursing diagnoses can be identified by nursing assessment methods. 2. Nursing treatments or methods of risk-factor reduction can resolve the condition . 3. Nurses assume accountability for outcomes within the scope of nursing practice. 4. Nurses assume responsibility for the research required to clearly identify the defining characteristics and causative factors of conditions described by nursing diagnoses. 5. Nurses engage in improving methods of treatment and treatment outcomes for conditions described by nursing diagnoses.

Maslow's Hierarchy of Needs

5 Levels of Need: - Physiologic - Safety - Belonging - Self-esteem - Self Actualization

Nursing Diagnosis

A clinical judgment about individual, family, or community responses to actual or potential health problems/life processes (NANDA-I)

Steps of the Nursing Process

ADPIE - Assessment - Diagnosis - Planning - Implementation - Evaluation

Nursing Intervention or Implementation

carrying out the established plan of care

Pharmacology Nursing Process: Implementation

Dependent Nursing Actions: - follow medication orders of HCP Interdependent Nursing Actions: - Another qualified professional consulted for nursing doubts abt calculations, monitoring for adverse effects and establishment of nursing interventions - pharmacist: reviews drug order, prepares medications, sends to unit for storage Independent Nursing Actions: - verifies the drug order and assumes responsibility for the correct transcription of the drug order - formulates appropriate nursing diagnoses and actions to monitor for therapeutic effects and adverse effects of medications

Evaluation

Evaluated by comparison with: - goal statements - planned nursing actions - anticipated therapeutic outcomes - patient, family, and significant others who provide feedback and help determine goals

Gordon's Functional Health Patterns Model

Health Perception-Health Management Pattern Nutrition-Metabolic Pattern Elimination Pattern Activity-Exercise Pattern Cognitive-Perceptual Pattern Sleep-Rest Pattern Self-Perception-Self-Concept Pattern Role-Relationship Pattern Sexuality-Reproductive Pattern Coping-Stress Tolerance Pattern Value-Belief Pattern

Pharmacology Nursing Process: Planning

Must include: 1. ID therapeutic intent, why drug was prescribed and what symptoms will be relieved 2. ID common and adverse effects that can be alleviated or prevented by actions of nurse 3. ID recommended dosage and route of administration 4. scheduling of administration of medication based on HCP's orders and policies, review drug interations and food interactions 5. Teach patient to use Patient Self-Assessment Form 6. Provide Additional education about techniques of self-administration

Nursing Actions/Nursing Interventions

Nursing Actions: - counseling - teaching - providing comfort - coordinating - referring - communication skills - performing the actions ordered by HCP Nursing Interventions: - meeting the physical needs of the patient - providing for patient safety - monitoring for potential complications - assessing and evaluating to identify changes in the patient's needs

•Which piece of information obtained during a patient assessment is a subjective finding? a) Patient states, "I have pain in my abdomen." b) Temperature of 38.5º C c) 400 mL of clear, yellow urine d) Blood pressure of 116/74 mm Hg

a) Patient states, "I have pain in my abdomen." Rationale: A subjective finding is one which the nurse makes using physiologic parameters. A patient's report of pain is a subjective finding because people experience pain differently. An objective assessment is clearly measurable and consistently reportable.

Five Types of Nursing Diagnosis - Wellness

clinical judgment about a transition from one level to a higher level Component: 1. "Readiness for enhanced" followed by nursing diagnosis being applied to situation or group

How does a nursing diagnosis differ from a medical diagnosis? a) A nursing diagnosis concerns a disease that impairs physiologic function. b) A nursing diagnosis evaluates a patient's response to actual or potential health problems. c) A nursing diagnosis determines the rate of Medicare reimbursement. d) A nursing diagnosis does not consider potential future problems.

b) A nursing diagnosis evaluates a patient's response to actual or potential health problems. Rationale: A nursing diagnosis takes the form of a three-part statement relating to a patient's response to actual or potential health problems and life processes. It is constantly changing, whereas a medical diagnosis is frequently unchanged during a patient's hospitalization.

What is the foundation for the clinical practice of nursing? a) Assessment b) Nursing process c) Planning d) Evaluation e) Implementation

b) Nursing process Rationale: It takes all parameters of the nursing process, which include assessment, diagnosis, planning, implementation, and evaluation, to encompass the full care of a patient.

Five Types of Nursing Diagnosis - Syndrome

cluster signs and symptoms to predict certain circumstances or events

A clinical judgment that a person is more susceptible to a particular problem than others in the same situation is defined as which type of nursing diagnosis? a) Actual b) Wellness c) Risk/high risk d) Syndrome

c) Risk/high risk Rationale: A risk/high-risk nursing diagnosis is supported by risk factors that increase a patient's vulnerability beyond that of the same population. The patient can be at risk or at high risk for a particular problem.

•Which is an independent nursing action? a) Orders medications based on the patient's medical diagnosis b) Orders laboratory tests depending on the medications ordered c) Chooses an alternate route for medications if indicated d) Verifies the correct route of medication administration

d) Verifies the correct route of medication administration Rationale: Verification of the correct route of administration is an independent nursing action that is required as part of the "six rights" of administration. Ordering drugs or labs and changing a route of administration are not within the scope of practice for a nurse.

Nursing Order

describe how specific actions, including time intervals, will be implemented

Medical Diagnosis

diagnosis of a disease or disorder that impairs normal physiologic function

Nursing Action or Intervention Statements

list what nurse will do to achieve each goal that has been developed for each nursing

Core Measures

measures of care that are tracked to show how often hosptials and HCPs use the care recommendations ID'd by EBP

Interdependent Nursing Action

nurse implements cooperatively with other members of the healthcare team for restoring or maintaining the patient's health ex. monitoring a patient's heart rate and rhythm while the patient is receiving antidysrhythmic therapy

Independent Nursing Action

nursing actions that are not prescribed by a healthcare provider that a nurse can provide by virtue of the education and licensure ex. listening to a patient's lung sounds after a respiratory treatment and monitoring laboratory values

Dependent Nursing Action

performed by the nurse on the basis of the healthcare provider's orders ex. administering an antibiotic every 6 hours as ordered (but can still require the nurse's professional judgment

Planning

plans formulated to meet patient needs