Unit 5 Yoost Ch. 5 Introduction to the Nursing Process

All short- and long-term goals must be:

(1) patient focused, (2) realistic, and (3) measurable.

A two-part health-promotion nursing diagnostic statement contains

(1) the nursing diagnostic label and (2) defining characteristics. -It always begins with the words Readiness for Enhanced.

A two-part risk nursing diagnostic statement contains only

(1) the patient's identified need or problem (i.e., NANDA-I nursing diagnostic label) and (2) factors indicating vulnerability (i.e., risk factors).

Three-part nursing diagnosis statements include

(1) the patient's identified need or problem (i.e., NANDA-I nursing diagnostic label), (2) the etiology or underlying cause (i.e., related to [r/ t]), and (3) signs and symptoms (i.e., as evidenced by [AEB] or as manifested by [AMB]).

Nursing Process Step 4 - Implementation

Interventions -Independent -Dependent -Collaborative Care -Direct -Indirect Documentation NIC Care Plans -Clinical pathways -Protocols -Standing orders

(NOC)

The Nursing Outcomes Classification

NIC provides:

nurses with multidisciplinary interventions linked to specific NANDA-I- accepted nursing diagnoses and the NOC. -Using NIC as a reference, the nurse remains responsible for customizing and implementing appropriate interventions for each specific patient.

The Nursing Outcomes Classification (NOC) is:

one resource for outcome identification.

r/ t

related to

The patient's health care team members may include:

several nurses the primary care provider medical or surgical specialists respiratory therapists a dietician a physical therapist occupational, music, or art therapists a spiritual adviser; and social workers. -The patient's primary nurse is often the central figure in coordinating collaborative care.

etiology

the cause, set of causes, or manner of causation of a disease or condition

Actual nursing diagnoses are written with ______, whereas risk nursing diagnoses and health-promotion nursing diagnoses contain _________.

three parts; only two parts

PES

(problem, etiology, symptoms) -used to remind nursing students of how to structure an actual nursing diagnosis statement.

LO 5.4 Describe the steps in the nursing process:

*During the assessment step of the nursing process, patient care data are gathered. *In the diagnosis step, patient data are analyzed to identify patient problems and then are stated as specific nursing diagnoses. *During the third step of the nursing process, planning, the nurse prioritizes the nursing diagnoses and identifies goals with specific outcome identification. *The implementation step includes initiating specific nursing interventions designed to help achieve established goals. *During the evaluation step, the nurse determines goal attainment, the effectiveness of interventions, and whether the plan of care should be discontinued, continued, or revised.

Subjective data

-(i.e., symptoms) -spoken -Patients' feelings about a situation -comments about how they are feeling -Data shared by a source verbally -most often gathered during a patient interview or health history -typically documented in the patient's medical record as direct quotations

Objective data

-Data collected from medical records, laboratory, and diagnostic test results, or physical assessments - consist of observable information that the nurse gathers on the basis of what can be seen, measured, or tested -collected by the nurse during physical assessment, which includes inspection, palpation, percussion, and auscultation, or during direct patient care

Historical Development of the Nursing Process

-first used by Lydia Hall in 1955 -late 1950s and early 1960s: used to define the steps used for decision making while initiating and providing patient care. -1973: American Nurses Association (ANA) identified five specific steps of the nursing process in its Standards of Clinical Practice (1991).

Steps of the Nursing Process Each step of the nursing process— assessment, diagnosis, planning, implementation, and evaluation (ADPIE)— has a unique purpose.

1. During the assessment step, patient care data are gathered through observation, interviews, and physical assessment. 2. In the diagnosis step, patient data are analyzed, validated, and clustered to identify patient problems. Each problem is then stated in standardized language as a specific nursing diagnosis to provide greater clarity and universal understanding by all care providers. 3. During the planning step of the nursing process, the nurse prioritizes the nursing diagnoses and identifies short- and long-term goals that are realistic, measurable, and patient focused, with specific outcome identification for evaluation purposes. 4. The implementation step includes initiating specific nursing interventions and treatments designed to help the patient achieve established goals or outcomes. 5. In the evaluation step, the nurse determines whether the patient's goals are met, examines the effectiveness of interventions, and decides whether the plan of care should be discontinued, continued, or revised.

Five steps of the Nursing Process:

1. assessment, 2. diagnosis, 3. planning, 4. implementation, and 5. evaluation

Interventions may be ____, ____, or ____ nursing actions requiring ____ or ____ nursing care.

=independent, dependent, or collaborative =direct or indirect

Characteristics of the Nursing Process

Analytical Dynamic Organized Outcome Oriented Collaborative Adaptable

Nursing Process Step 5 - Evaluation

Care Plan Evaluation -Patient goal/outcome attainment? -Continue? -Revise/adapt? -Discontinue?

Clinical Pathways, Protocols, and Standing Orders

Clinical pathways, protocols, and standing orders often impact interventions carried out in the implementation phase of the nursing process.

collaborative care

Coordinated, team-based patient care

implementation

Initiation of appropriate interventions designed to meet the unique needs of each patient.

Definition of the Nursing Process

Critical thinking using the nursing process allows nurses to collect essential patient data, articulate the specific needs of individual patients, and effectively communicate those needs, realistic goals, and customized interventions with members of the health care team.

Nursing Process Step 1 - Assessment:

Data Collection -Primary Data -Patient interview -Secondary Data -Subjective Data -Symptoms -Health History -Objective Data -Signs -Physical examination -lab results -Diagnostic test results

short- and long-term goals

Establishing short- and long-term goals to address nursing diagnoses involves discussion with the patient and often requires collaboration with family members and other members of the health care team

evaluation

Examination of goal or outcome attainment by focusing on the patient and the

nursing diagnosis

Identification of an actual or potential problem or response to a problem.

Medical diagnoses vs. nursing diagnoses

Medical diagnoses are labels for diseases, whereas nursing diagnoses describe a response to an actual or potential problem or life process.

NANDA-I

NANDA International, Inc., formerly North American Nursing Diagnosis Association.

a holistic approach to patient care.

Nurses assess the state of a patient's physical, psychological, emotional, environmental, cultural, and spiritual health to gain a better understanding of his or her overall condition.

(NIC).

Nursing Interventions Classification -One method of determining interventions to meet patient outcome goals

outcome identification

Observable behaviors or actions that indicate attainment of a goal. -added by the ANA in 1991 as a specific aspect of the nursing process,

planning

Phase of the nursing process during which the nurse prioritizes a patient's nursing diagnoses, establishes short- and long-term goals, chooses outcome indicators, and identifies interventions to address patient goals.

Nursing Process Step 3 - Planning

Prioritize Nursing Diagnoses Personalize Care Plans -Short-term goals (STGs) -Long-term goals (LTGs) Outcome Identification NOC

LO 5.2 Describe the historical development and significance of the nursing process:

The five primary steps of the nursing process were clearly identified by the early 1960s and have remained virtually unchanged since then, with only the addition of a subcategory to planning, outcome identification, in the early 1990s. -Professional nursing practice in all types of settings is based on the nursing process. It is used to assess individuals, families, and communities; diagnose needs; plan attainable goals; implement specific interventions; and evaluate degrees of goal attainment.

LO 5.1 Define the nursing process:

The nursing process is the scientific method through which professional nurses systematically identify and address actual or potential patient problems. -Critical thinking, using the nursing process, allows nurses to collect essential patient data, articulate the specific needs of individual patients, and effectively communicate those needs, establish realistic goals, and customize interventions with members of the health care team.

LO 5.3 Articulate the characteristics of the nursing process:

The nursing process requires nurses to think critically. It is dynamic, organized, and collaborative, and it is universally adaptable to various types of health care settings.

assessment :

The organized and ongoing appraisal of a patient's well-being.

Cyclic and Dynamic Nature of the Nursing Process

The steps of the nursing process are cyclic and dynamic; one aspect of care leads into and informs the next. It is crucial that the professional nurse continuously reassess the patient, revise care as needed, and evaluate whether the patient's goals are being met.

nursing process

The systematic method of critical thinking used by professional nurses to develop individualized plans of care and provide care for patients.

Secondary data

are collected from family members, friends, other health care professionals, or written sources such as medical records and test results. -Some nurses may subdivide secondary data to identify information as -indirect: if it is obtained from medical charts or a hand-off communication.

Clinical pathways, sometimes referred to as care pathways, care maps, or critical pathways,

are multidisciplinary resources designed to guide patient care.

Nursing Process Step 2 - Diagnosis

Types of Nursing Diagnoses -Actual -Risk -Heath-promotion

LO 5.5 Explain the significance of the cyclic and dynamic nature of the nursing process:

Use of the nursing process requires the professional nurse to continuously reassess patients, revise care as needed, and evaluate whether goals are being met. -As goals are met, portions of the nursing plan can be eliminated or discontinued. -Nursing care sometimes needs to be modified to meet previously unidentified needs. - The ongoing process of evaluating and adjusting intervention strategies requires nursing care that is based on current evidence-based practice.

by NANDA International, Inc. (NANDA-I),

a professional nursing organization that provides standardized language to identify patient problems and plan customized care.

RQ 9. A patient reports feeling tired and complains of not sleeping at night. What action should the nurse perform first? a. Identify reasons the patient is unable to sleep. b. Request medication to help the patient sleep. c. Tell the patient that sleep will come with relaxation. d. Notify the physician that the patient is restless and anxious.

a. Identify reasons the patient is unable to sleep. When a patient shares a concern, the first action by the nurse is to assess potential reasons for the patient's problem. Depending on the underlying reason for the patient's inability to sleep, the nurse may then want to administer prescribed sleep medication, teach the patient some relaxation techniques, or discuss patient behaviors with the primary care provider.

RQ 7. What should be the primary focus for nursing interventions? a. Patient needs b. Nurse concerns c. Physician priorities d. Patient's family requests

a. Patient needs Patient needs are always the primary focus of nursing interventions. Nursing concerns, physician priorities, and family requests can provide additional guidance in the development of a patient-centered plan of care.

RQ 6. Which statement is an appropriately written short-term goal? a. Patient will walk to the bathroom independently without falling within 2 days after surgery. b. Nurse will watch patient demonstrate proper insulin injection technique each morning. c. Patient's spouse will express satisfaction with patient's progress before discharge. d. Patient's incision will be well approximated each time it is assessed by the nurse.

a. Patient will walk to the bathroom independently without falling within 2 days after surgery. Goals are to be patient-focused, realistic, and measurable. Only the first goal meets these three criteria.

NANDA-I (2012) identifies three types of nursing diagnoses that nurses should use when developing plans of patient care.

actual, risk, health-promotion

Accurate charting helps to

alleviate omissions and repetition of care.

Standing orders

are written by physicians and list specific actions to be taken by a nurse or other health care provider when access to a physician is not possible or when care is common to a certain type of situation

Protocols

are written plans that can be generalized to groups of patients with the same or similar clinical needs that do not require a physician's order.

[AEB]

as evidenced by

[AMB]

as manifested by

RQ 4. What is the primary purpose of the nursing diagnosis? a. Resolving patient confusion b. Communicating patient needs c. Meeting accreditation requirements d. Articulating the nursing scope of practice

b. Communicating patient needs Each nursing diagnosis label identifies either a patient problem or need, which is its purpose. Resolving patient confusion, meeting accreditation requirements, and articulating the nurse's scope of practice are not related to the purpose of the nursing diagnostic process.

RQ 5. On what premise is a nursing diagnosis identified for a patient? a. First impressions b. Nursing intuition c. Clustered data d. Medical diagnoses

c. Clustered data Nursing diagnoses emerge from groupings of clustered data collected during the assessment phase of the nursing process. The nurse documents the patient's medical diagnosis as one piece of data, which may be clustered with others to support a nursing diagnosis. Data collected from a nurse's intuition and first impressions may also be listed in the patient's assessment findings as long as they are objectively recorded without prejudice and are not judgmental in nature.

RQ 8. Which nursing action is critical before delegating interventions to another member of the health care team? a. Locate all members of the health care team. b. Notify the physician of potential complications. c. Know the scope of practice for the other team member. d. Call a meeting of the health care team to determine the needs of the patient.

c. Know the scope of practice for the other team member. Knowing the scope of practice of the other team member is critical to understanding what is appropriate and safe to delegate to that person. It is unnecessary to locate or meet with all members of the health care team prior to delegation. Physicians are already aware of potential complications related to patient care.

RQ 10. What action should the nurse take regarding a patient's plan of care if the patient appears to have met the short-term goal of urinating within 1 hour after surgery? a. Consult the surgeon to see if the clinical pathway is being followed. b. Discontinue the plan of care because the patient has met the established goal. c. Monitor patient urine output to evaluate the need for the current plan of care. d. Notify the patient that the goal has been attained and no further intervention is needed.

c. Monitor patient urine output to evaluate the need for the current plan of care. The nurse should evaluate the need to continue or discontinue a plan of care if a patient has met a short-term goal. It is unnecessary to consult the surgeon unless there is a concern. Discontinuing the care plan may be premature, and the decision needs to be evaluated before taking action. The patient's intake and output will continue to be monitored throughout hospitalization, not just for 1 hour after surgery.

RQ 1. What is the purpose of the nursing process? a. Providing patient-centered care b. Identifying members of the health care team c. Organizing the ways nurses think about patient care d. Facilitating communication among members of the health care team

c. Organizing the ways nurses think about patient care The nursing process is the methodology used to "think like a nurse." Providing patient-centered care and enhancing communication among health team members is facilitated through the use of care plans. Collaborating with rather than identifying members of the health care team is part of many plans of care.

Primary data

consist of information obtained directly from a patient.

RQ 3. An alert, oriented patient is admitted to the hospital with chest pain. Who is the best source of primary data on this patient? a. Family member b. Physician c. Another nurse d. Patient

d. Patient The nurse collects primary data directly from patients who are alert and oriented. Family members and other members of the health care team may provide secondary data on patients.

RQ 2. A patient comes to the emergency department complaining of nausea and vomiting. What should the nurse ask the patient about first? a. Family history of diabetes b. Medications the patient is taking c. Operations the patient has had in the past d. Severity and duration of the nausea and vomiting

d. Severity and duration of the nausea and vomiting In an emergent situation, the nurse initially focuses on the patient's chief complaint to determine its cause. Before initiating care, the nurse gathers information on the other topics.

short-term goals

goals that are achievable within an immediate time frame of less than approximately 1 week

long-term goals.

goals that will take more time to achieve— weeks to months

Nursing interventions, including collaborative care interventions, are:

identified by the nurse during the planning stage to help patients meet goals, outcome classifications, and outcome indicators (i.e., criteria that can be observed or measured).

Thinking like a nurse

is facilitated by nurses using the nursing process in the development of individualized patient plans of care.

Ethical, Legal, and Professional Practice *Documentation

• All health care professionals are required to document patient interventions they implement in a traditional or an electronic medical record. • Nurses must document the physical treatment and patient education that is provided. • Follow-up evaluation of interventions must be documented to help the health care team determine the effectiveness of treatments, activities, and prescribed medications. • Ethical and legal standards mandate that nurses chart or document only the interventions that they themselves implement.