Nursing Proces
Use the guidelines for writing nursing diagnoses when developing diagnostic statements.
**Know these terms and refer to this section in the book, pp 368-380 Problem The purpose of the problem statement is to describe the health state or health problem of the patient as clearly and concisely as possible. Because this section of the nursing diagnosis identifies what is unhealthy about the patient and what the patient would like to change in his or her health status, it suggests patient outcomes. NANDA-I recommends the use of quantifiers or descriptors to limit or specify the meaning of a problem statement. For example, the descriptor "anticipatory" placed before the concept "grieving" clarifies the nursing diagnosis for a pregnant couple informed prenatally that their child will most likely be stillborn and who are already grieving the death of their child. Some common descriptors are listed in Table 15-4. Etiology: The etiology identifies the physiologic, psychological, sociologic, spiritual, and environmental factors believed to be related to the problem as either a cause or a contributing factor. Because the etiology identifies the factors that maintain the unhealthy patient state and prevent the desired change, the etiology directs nursing intervention. Unless the etiology is correctly identified, nursing actions might be inefficient and ineffective. For example, a diabetic patient who is frequently admitted to the hospital with hyperglycemia and who has a poor history of dietary and pharmacologic management is diagnosed to be noncompliant. Mistakenly assuming that the noncompliance is related to a knowledge deficit, the nurse channels all nursing activities and energies into teaching the patient how to manage the diabetes. However, this would be useless if the noncompliance were actually a result of the patient's decreased will to live, an etiology that would necessitate a different group of nursing interventions. Defining Characteristics: The subjective and objective data that signal the existence of the actual or possible health problem are the third component of the nursing diagnosis. NANDA-I has identified defining characteristics for each accepted nursing diagnosis; familiarity with these characteristics helps nurses recognize clusters of significant data. It is important to remember that the defining characteristics are part of assessment. Although they are written last in the formal diagnosis, they are considered first. Table 15-3 defines the components of a nursing diagnosis statement and shows how they affect patient outcomes, nursing measures, and evaluation. Table 15-5 (on page 376) shows a NANDA-I diagnosis and all of its components. Other examples of sample nursing diagnosis statements are found throughout the book. Guidelines for Writing Nursing Diagnoses: Remember these guidelines to ensure that your diagnostic statements are correctly written. Phrase the nursing diagnosis (DX) as a patient problem or alteration in health state rather than as a patient need. Check to make sure that the patient problem precedes the etiology and that the two are linked by the phrase "related to" (R/T). Consider when at-risk populations or associated conditions should be identified. Defining characteristics, when included in the nursing diagnosis, should follow the etiology and be linked by the phrase "as manifested by" or "as evidenced by" (AEB). Write in legally advisable terms. Use nonjudgmental language. Be sure the problem statement indicates what is unhealthy about the patient or what the patient wants to change (enhance). Avoid using defining characteristics, medical diagnoses, or something that cannot be changed in the problem statement. Reread the diagnosis to make sure that the problem statement suggests patient outcomes and that the etiology will direct the selection of nursing measures. See Table 15-6 (on page 376) for key terms.
Evaluate the patient's achievement of four types of outcomes specified in the plan of care.
-Cognitive Outcome -Psychomotor Outcome -Affective Outcome -Physiologic Outcome Box 18-3
Differentiate between objective and subjective data.
-There are two types of data: subjective and objective. Subjective data are information perceived only by the affected person; these data cannot be perceived or verified by another person. Examples of subjective data are feeling nervous, nauseated, or chilly, and experiencing pain. Subjective data also are called symptoms or covert data. TABLE 14-1 Models for Organizing or Clustering Data -Objective data are observable and measurable data that can be seen, heard, felt, or measured by someone other than the person experiencing them. Objective data observed by one person can be verified by another person observing the same patient. Examples of objective data are an elevated temperature reading (e.g., 101°F), skin that is moist, and refusal to look at or eat food. Objective data also are called signs or overt data. Table 14-2 compares subjective and objective data.
Describe the risks and responsibilities of delegating nursing interventions.
17-4 Table
Define and describe the purpose of four types of nursing assessments.
Initial Assessment- The initial assessment is performed shortly after the patient is admitted to a health care facility or service. Most institutions have policies specifying the time interval within which this assessment must be completed. The purpose of this assessment is to establish a complete database for problem identification and care planning. The nurse collects data concerning all aspects of the patient's health, establishing priorities for ongoing focused assessments and creating a reference baseline for future comparison. See Figure 14-2 for a sample of an initial assessment in an electronic medical record. For an example of a handwritten admission database, see Figure 14-3 (on pages 340-341). Focused Assessment- In a focused assessment, the nurse gathers data about a specific problem that has already been identified. Helpful questions include: What are your signs and symptoms? When did they start? Were you doing anything different than usual when they started? What makes your symptoms better? Worse? Are you taking any remedies (medical or natural) for your symptoms? A focused assessment may be done during the initial assessment if the patient's health problems surface, but it is routinely part of ongoing data collection. Another purpose of the focused assessment is to identify new or overlooked problems. Quick priority assessments (QPAs) are short, focused, prioritized assessments you do to gain the most important information you need to have first. They are important because they can "flag" existing problems and risks (Alfaro, 2014, p. 50). Emergency Assessment- When a patient presents with a physiologic or psychological crisis, the nurse performs an emergency assessment to identify life-threatening problems. A long-term care facility resident who begins choking in the dining room, a bleeding patient brought to the emergency department with a stab wound, an unresponsive patient in the rehabilitation unit, and a factory worker threatening violence are all candidates for an emergency assessment. In the first example, the source of the choking is assessed; in the second, the blood loss and wound characteristics; in the third, airway, breathing, and circulation; and in the fourth, the potential for immediate harm. Time-Lapsed Assessment- The time-lapsed assessment is scheduled to compare a patient's current status to the baseline data obtained earlier. Most patients in residential settings and those receiving nursing care over longer periods of time, such as homebound patients with visiting nurses, are scheduled for periodic time-lapsed assessments to reassess their health status and to make necessary revisions in the care plan. This assessment can be comprehensive or focused.
Explain the relationship between nursing assessment and medical assessment.
Medical assessments target data pointing to pathologic conditions, whereas nursing assessments focus on the patient's responses to health problems. The findings from a nursing assessment may contribute to the identification of a medical diagnosis, the unique focus of nursing assessments is on the patient's responses to actual or potential health problems. Nurses manage collaborative problems using physician-prescribed and nurse interventions to minimize the complications of the event.
Describe evaluation, its purpose, and its relation to the other steps in the nursing process.
Nurse and patient together measure how well the patient has achieved the outcomes specified in the plan of care. The purpose of evaluation is to allow the patient's achievement of expected outcomes to direct future nurse-patient interactions. When the nurse needs to modify the care plan, the nurse reviews each preceding step of the nursing process. In the fifth step of the nursing process, evaluating, the nurse and patient together measure how well the patient has achieved the outcomes specified in the care plan. When evaluating patient outcome achievement, the nurse identifies factors that contribute to the patient's ability to achieve expected outcomes and, when necessary, modifies the care plan The five classic elements of evaluation are: 1-Identifying evaluative criteria and standards (what you are looking for when you evaluate—i.e., expected patient outcomes) 2-Collecting data to determine whether these criteria and standards are met 3-Interpreting and summarizing findings 4-Documenting your judgment 5-Terminating, continuing, or modifying the plan
Develop a plan of nursing care with properly constructed outcomes and related nursing interventions.
Nursing care plan: a written guide to direct the efforts of the nursing team as they work with the patient to meet health goals; specifies prioritized nursing diagnosis, patient goals, and nursing orders (Fundamentals of Nursing pg 385). After the nurse collects and interprets patient data, identifying patient strengths and health problems, it is time to plan for nursing actions. During the outcome identification and planning steps of the nursing process, the nurse works in partnership with the patient and family to: Establish priorities Identify and write expected patient outcomes Select evidence-based nursing interventions Communicate the nursing care plan A formal care plan allows nurses to: -Individualize care that maximizes outcome achievement -Set priorities -Facilitate communication among nursing personnel and their colleagues -Promote continuity of high-quality, cost-effective care -Coordinate care -Evaluate the patient's response to nursing care -Create a record that can be used for evaluation, research, reimbursement, and legal purposes -Promote the nurse's professional development Example found on page 409 box 16-7
Differentiate nurse-initiated interventions, physician-initiated interventions, and collaborative interventions.
Nursing intervention: any treatment, based on clinical judgment and knowledge, that a nurse performs to enhance patient outcomes. Derived from nursing diagnosis. Nurse-initiated interventions do not require a health care provider's (or other team member's) order. Physician-initiated intervention: dependent nursing actions, involving carrying out physician-prescribed orders. EX- Physician examining patient brought to the emergency room after an accident. Physicians might ask the nurse to administer medicine and schedule the patient for radiographs. BOTH the physician and the nurse are legally responsible for the intervention. Collaborative interventions: Nurses also carry out treatments initiated by other providers such as pharmacists, respiratory therapists, or physician assistants EX- Nurses caring for a patient after a motor vehicle accident may eventually implement interventions written by a physical therapist, occupational therapist, or other member of the health care team.
Identify five sources of patient data useful to the nurse.
Page 347: Patient, family and significant others, patient record, medical history, physical examination, progress notes, consultations, reports of lab + other diagnostic studies, reports of therapies by other health care professionals, nursing and other health care literature 1. Patient 2. Family and significant others 3. Patient record 4. Assessment technology 5. Other health care professionals
Describe the four steps involved in data interpretation and analysis.
Page: 366 -Recognizing significant data: comparing data to standards: Sorting out healthy patient responses from those that are not healthy is not as clear-cut as it may seem. To avoid erroneously labeling selected patient health patterns as unhealthy (diagnostic error) while failing to detect an actual unhealthy behavior, nurses must be familiar with comparative standards to be used in data interpretation and analysis. A standard, or a norm, is a generally accepted rule, measure, pattern, or model to which data can be compared in the same class or category. For example, when determining the significance of a patient's blood pressure reading, appropriate standards include normative values for the patient's age group, race, and illness category. The patient's own normal range, if known, is an important standard. A pressure of 150/90 mm Hg may be high for someone whose pressure normally is 120/70 mm Hg, but it may be normal for a person with hypertension. Examples of how standards can be used to identify significant cues include the following (Gordon, 1994): -Recognizing patterns or clusters: A data cluster is a grouping of patient data or cues that point to the existence of a health problem. Nursing diagnoses should always be derived from clusters of significant data rather than from a single cue. The danger of deriving a nursing diagnosis from a single cue is illustrated in the following example. Diagnosing a woman recovering from gallbladder surgery with Ineffective Coping solely on the basis of tears may misinterpret the patient's crying, which may be a healthy release of emotion. If the same patient begins to exhibit a cluster of significant cues, such as refusing to eat, preferring bed rest to scheduled ambulation, and reporting increasing discomfort, an unhealthy pattern is emerging. -Identifying strengths and problems: The next step in analyzing data is to determine the patient's strengths and problems. It also helps to determine whether the patient agrees with the nurse's identification of strengths and problems and is motivated to work toward problem resolution. If you recall the situation described in the Reflective Practice box on p. 361, you'll understand how important it is to create a partnership with the patient and family in order to respect the patient's priorities. -Identifying potential complications Patients may experience many complications related to their diagnoses, medications or treatment regimens, or invasive diagnostic studies. While new to nursing, you can more easily prevent potential complications—or at least make sure that they are detected early and managed well—if you research the potential complications associated with your patient's diagnoses, diagnostics, and treatment, and if you report all abnormal data. For example, slurred speech, changes in skin color or moistness, inability to move an extremity or abnormal movement, and changes in levels of consciousness may all be indications of serious and life-threatening complications (Alfaro-LeFevre, 2014). Remember, if you are unsure about the significance of data, always confer with someone more experienced. -Reaching conclusions The nurse reaches one of four basic conclusions after interpreting and analyzing the patient data. Different nursing responses result from each conclusion: No Problem No nursing response is indicated. Reinforce the patient's health habits and patterns. Initiate health promotion activities to prevent disease or illness or to promote a higher level of wellness. Wellness diagnosis might be indicated. Possible Problem Collect more data to confirm or disprove a suspected problem. Actual or Potential Nursing Diagnosis or Problem or Issue Begin planning, implementing, and evaluating care designed to prevent, reduce, or resolve the problem. If unable to treat the problem because the patient denies the problem and refuses treatment, make sure that the patient understands the possible outcomes of this stance.
Describe how patient goals/expected outcomes and nursing orders are derived from nursing diagnoses.
The purpose of evaluation is to allow the patients achievement of expected outcomes to direct future nurse-patient interactions (Ch. 15 PP). From the problem statement you get the goals, outcomes, objectives. Etiology we get our interventions. Patient goals/expected outcomes- nursing orders are derived from nursing Dx. Cognitive- describing increases in Pt knowledge or intellectual behaviors. Psycho motor- describes pts. achievements of new skills. Affective- describes changes in pt values, beliefs and attitudes. Adding patient family support into the outcome is imperative in establishing priorities for a better outcome. Key points at the end of the chapter Measurable outcome - The pt or part of the pt Verb- The action the pt will perform Condition- Circuntance in which the outcome will be achieved. Performance- Expected pt behavior, measurable terms Target- when the patient is expected to achieved outcome.
Identify five types of nursing diagnoses and the parts included in each type.
Types of Nursing Diagnoses NANDA-I describes three types of nursing diagnoses: problem focused, risk, and health promotion. Problem-Focused Nursing Diagnoses A problem-focused nursing diagnosis is a clinical judgment concerning an undesirable human response to a health condition/life process that exists in an individual, family, group, or community. This type of nursing diagnosis has four components: label, definition, defining characteristics, and related factor. Risk Nursing Diagnoses A risk nursing diagnosis is a clinical judgment concerning the vulnerability of an individual, family, group, or community for developing an undesirable human response to health conditions/life processes. Health Promotion Nursing Diagnoses A health promotion nursing diagnosis is a clinical judgment concerning motivation and desire to increase well-being and to actualize human health potential. These responses are expressed by a readiness to enhance specific health behaviors, and can be used in any health state. Health promotion responses may exist in an individual, family, group, or community. NANDA-I also recognizes syndromes. A syndrome is a clinical judgment concerning a specific cluster of nursing diagnoses that occur together and are best addressed together and through similar interventions. Chronic pain syndrome is an example (2018, pp. 35-36).
Explain why reassessment after nursing intervention is important.
When a patient does not follow the plan of care despite your best efforts, it is time to reassess strategy. The first objective is to identify why the patient is not following the therapy. One possibility is that the plan of care may not be right for this patient. Common reasons for noncompliance include: -Lack of family support -Lack of understanding about the benefits of compliance -Low value attached to outcomes or related interventions -Adverse physical or emotional effects of treatment (such as pain and fatigue) -Inability to afford treatment -Limited access to treatment
Use the patient's response to the plan of care to modify the plan as needed.
When evaluation reveals that the patient has made little or no progress toward outcome achievement, the nurse needs to reevaluate each preceding step of the nursing process to try to identify the contributing factors causing problems with the care plan. New assessment data may need to be collected, diagnoses may be added or altered, outcomes may need to be modified or rewritten, nursing orders may be changed, or evaluation may be targeted more frequently. The Nursing Process ADPIE Assessment: Assess-Man Diagnosis: Diagnostic Computer- Maslow Hierarchy Planning: Planning for Treatment Realistic Individualized to the Patient Timed Implementation Evaluation A- No Unrine 8 hours Distended bladder "I need relief" D- Impaired uninary elimination P- (5 things for plan: subject:person, verb, why, goal) Pt will empty bladder, distention will go down by 1400 after fowley catheter I- inserted catheter (do), Assessed bladder (assess), Educated on procedure (teach) E- goal met
Describe the term nursing diagnosis, distinguishing it from a collaborative problem and a medical diagnosis.
nursing diagnosis: actual or potential health problem that an independent nursing intervention can prevent or resolve (actual problem is present; possible problem may be present, but more data are needed to confirm or disconfirm the problem; and potential problem may occur); defining characteristics are present as risk factors collaborative problem: actual or potential health problem that may occur from complications of disease, diagnostic studies, or the treatment regimen; the nurse works together with other members of the health care team toward its resolution medical diagnosis: statement about a specific disease process using terminology from a well-developed classification system accepted by the medical profession