Nursing Interventions and Client Care

Unit 1: Nursing Process

• Nursing process is a dynamic and modified form of the scientific method used in nursing to assess client needs and create a course of action to address and solve patient problems.
• It is an organized sequence of problem-solving steps for identifying and managing health problems of clients.
• It is an accepted practice established by the American Nurses Association.

Objectives

• Define nursing process
• Describe purposes of nursing process
• Identify components of the nursing process
• Discuss requirements for effective use of the nursing process
• Describe the functional health approach to the nursing process

Purpose Of Nursing Process

• Identify a client's health status and actual or potential health care problems or needs
• Establish plans to meet the identified needs
• Deliver specific nursing interventions to meet those needs
• Provide individualized, holistic, effective, and efficient client care

Components Of Nursing Process

• Assessment (data collection)
• Nursing diagnosis
• Planning
• Implementation
• Evaluation

Components of Nursing Process (Diagram)

• The nursing process utilizes the following steps
• Assessment
• Nursing diagnosis
• Planning
• Implementation
• Evaluation
• Steps remain the same
• Applications and results are different

Characteristics of Nursing Process

• Cyclic
• Dynamic nature
• Client centeredness
• Focus on problem solving and decision making
• Interpersonal and collaborative style
• Universal applicability
• Use of critical thinking and clinical reasoning

1. Assessment

• It involves collection, organizing, validating, and documenting data (information).
• Types of assessment are:
  • Initial nursing assessment
  • Problem-focused assessment
  • Emergency assessment
  • Time-lapsed reassessment
• The ultimate purpose of assessment is data collection

1. Initial nursing assessment:

• Performed within specified time after admission.
• To establish a complete database for problem identification.
• Example: Nursing admission assessment

2. Problem-focused assessment:

• To determine the status of a specific problem identified in an earlier assessment.
• Example: hourly checking of vital signs of a fever patient

3. Emergency assessment:

• During emergency situation to identify any life-threatening situation.
• Example: Rapid assessment of an individual's airway, breathing status, and circulation during a cardiac arrest.

4. Time-lapsed reassessment:

• Several months after initial assessment.
• To compare the client's current health status with the data previously obtained.

Components Of Assessment

• Collection of data
• Organize data
• Validate data
• Document data

1. Collection of data

• The process of gathering information about a client's health status, including health history, physical examination, results of lab and diagnostic tests, and material contributed by other health personnel

1. Subjective data

• Also referred to as symptoms or covert information.
• Clear only to the person affected and can be described only by that person.
• Examples: itching, pain, and feelings of worry

2. Objective data

• Also referred to as signs or overt information.
• Detectable by an observer or can be measured or tested against an accepted standard.
• Obtained by observation or physical examination.
• Examples: discoloration of skin or a blood pressure reading

Sources of Data

• Primary: Direct source of information (client)
• Secondary: Indirect source of information (family members, health professionals, records, lab/diagnostic results)

Methods Of Data Collection

• Interview
• Auscultation
• Percussion
• Palpation
• Observation

2. Diagnosis

• The process of defining a patient's response to health conditions/life processes, or to a vulnerability for a human response.
• The official NANDA definition of a nursing diagnosis is: "a clinical judgment concerning a human response to health conditions, life processes, or a vulnerability for that response, by an individual, family, group, or community."
• Diagnosing is to:
  • Analyze data.
  • Identify health problems, risks, and strengths
  • Formulate diagnostic statement.

Status of the Nursing Diagnoses

• Actual: Client problem is present at the time of assessment
• Health Promotion: Client's readiness to improve health
• Risk: Client is at risk of developing a problem unless nurses intervene.
• Possible: Suspected problem for which data is insufficient to validate
• Syndrome: Cluster of diagnoses

1. Actual Diagnosis Examples

• Ineffective breathing pattern
• Anxiety

2. Health Promotion Diagnosis Examples

• Readiness for Enhanced Nutrition

3. Risk Nursing Diagnosis Examples

• Risk for Infection

4. Wellness Nursing Diagnosis Examples

• Family coping: potential for growth related to unexpected birth of twins.

Components of a Nursing Diagnosis

• The problem statement (diagnostic label)
• The etiology (related factors & risk factors)
• Signs & Symptoms (defining characteristics)

1. Problem Statement (Diagnostic Label) Examples

• Deficient Knowledge (Medications)
• Deficient Knowledge (Dietary Adjustments)
• Activity intolerance
• Constipation

2. Etiology or Contributing Factors

• Factors that influence client's response to a health problem
• Example: Activity intolerance related to generalized weakness or obesity or sedentary lifestyle.

3. Defining Characteristics (S/S)

• Cluster of signs and symptoms that indicate a particular health problem.
• Example: Fluid volume deficit related to decreased oral intake ,manifested by dry skin and mucus membranes.

The Diagnostic Process

• Analyzing data
• Identifying health problems, risks and strengths
• Formulating diagnostic statements

Formulating Diagnostic Statements

• Basic two-part statements (PE format)
• Problem (P) - statement of the patient's response
• Etiology (E) - factors contributing to the response
• Example: Activity intolerance related to generalized weakness or obesity
• Basic three-part statements (PES format) Problem (P)- statement of the patient's response Etiology (E)- factors contributing to the response Signs & Symptoms (S)- evidence of the problem

Difference between Nursing Diagnosis & Medical Diagnosis

• Nursing Diagnosis: Statement of nursing judgment; focused on patient responses; addresses conditions nurses are licensed to treat; describes patient's physical, sociocultural, psychological and spiritual responses to illness or a health problem;
• Medical Diagnosis: Statement of medical judgment; focused on disease processes; addresses conditions only physicians can treat; describes a patient's response or specific patho-physiological responses to illness.

4.Planning

• The nurse develops a detailed client care plan.
• The nurse and client collaboratively develop goals/desired outcomes and nursing strategies to prevent, reduce, or alleviate health problems.

Types Of Planning

• Initial Planning- occurs after initial assessment
• Ongoing Planning- occurs during the beginning of a shift
• Discharge Planning- anticipatory planning for needs after discharge

Planning process

• Prioritize problems/diagnosis
• Formulate goals/desired outcomes
• Select nursing interventions
• Write nursing interventions

1. Setting priorities

• Deciding which nursing diagnosis requires attention first (Maslow's hierarchy of needs)
• Examples: Air, food, water, security, and activity
• Physiologic needs receive highest priority

2. Establishing Client Goals/ Desired Outcomes

• Specific, measurable, attainable
• Example: Client will raise right arm to shoulder height by Frida

Types Of Goals

• Short-term goals
• Long-term goals

3. Nursing interventions

• Actions nurses take to achieve patient goals.
• Types of interventions are: Independent, Dependent, and Collaborative

Types of Nursing Interventions

• Independent- actions nurses are licensed to initiate
• Dependent- actions carried out under orders or supervision of a healthcare professional.
• Collaborative- actions carried out in collaboration with other health team members

4. Implementation

• The action phase of the nursing process, where nurses perform the planned interventions. Processing implementing:
• Reassessing the client
• Determining the nurse's need for assistance
• Implementing the nursing interventions
• Supervising the delegated care
• Documenting nursing activities

Evaluation

• A planned, ongoing, purposeful activity in which the nurse determines the client's progress toward the achievement of goals and the effectiveness of the plan.

2. Diagnosis (cont)

• Diagnosing is to:
• Analyze data
• Identify health problems, risks and strengths
• Formulate diagnostic statements

2. Diagnosis (cont)

• Status of nursing diagnosis:
• Actual diagnosis: Client problem that exists when assessed.
• Health promotion diagnosis, Risk diagnosis, Possible diagnosis, Syndrome diagnosis

3. Planning (cont)

• Planning involves 3 stages:
• Initial planning
• Ongoing planning
• Discharge planning

4.Implementation

• Implementation is the action phase
• Nurses are responsible to reassess the client, and determine whether the intervention needs assistance.

5. Evaluation

• Evaluation determines client progress towards goals and effectiveness of the plan.

Concept Of Values And Belief

• Values are important in nursing and healthcare as they under- pin all aspects of professional practice.

• Belief - assumptions about self, others in the world and how we expect things to be.

• Attitude- feelings toward a person, object or idea

• Relevant terms:

• Assumptions - beliefs considered obvious and correct.

• Honesty- virtuous moral character (integrity, truthfulness, straightforwardness)

• Code- system of principles

• Conduct- manner of acting, personal deportment, mode of action.

• Decision- choice or judgment.

• Environment- surroundings and influences

• Moral

• Attitudes

• Values transmission

• Learned from observation, parents, teachers, and influential people

• affected by family, sociocultural environment and peers.

• examples ( honesty, courage, and patience)

• Types of Beliefs:

• Commendatory beliefs-e.g. "I am a good writer."

• Existentialism-e.g. Belief in God

• Monotheism, Polytheism, Atheistic

• Types of Values

• Religious values

• Personal values

• Cultural values

• Humanistic Values

• Optimistic Values

• Democratic Values

• Motivational Values

• Rituals

• A ritual is a formalized predetermined set of symbolic actions performed in a certain environment.

• Factors influencing values:

• Family, environment, peers, culture

1. Assessment (cont)

• Examine the client from a physical perspective.

2. Planning (cont)

• Implement plans in a way that achieves client's goals and is consistent with their values.

3. Implementation (cont)

• Take into account their values and beliefs when implementing the plan.

Concept Of Pain

• Pain is a complex experience consisting of physiological and psychological responses to a noxious stimulus.
• A warning mechanism that protects organism against harmful stimulus or the threat of injury.
• Is subjective and difficult to quantify.

Types of pain:

• Acute pain - quickly appears, short duration (hours/days) associated with tissue damage
• Chronic pain - lasts longer than expected (months/years) often related to long-term diseases.

Theories of pain:

• Gate control theory - non-painful input closes "gates" to painful input (preventing it from getting to the brain)

Non-pharmacological interventions

• Massage
• Positioning
• Hot and cold treatment
• Transcutaneous Electrical Nerve Stimulation (TENS)
• Acupuncture
• Progressive muscle relaxation

Pharmacological Interventions

• Nonopioids- Mild to moderate pain (NSAIDs, paracetamol, aspirin)
• Compound analgesics- mild to moderate pain (combination of drugs with codeine + aspirin or paracetamol)
• Opioids- severe pain (morphine, oxycodone, codeine, tramadol, buprenorphine, fentanyl, diamorphine)
• Adjuvants- manage symptoms of neuropathic pain (tricyclic antidepressants, antiepileptic drugs)
• Topical analgesics- localized pain relief (rubefacients, topical NSAIDs, local anesthetics)

Concept Of Nutrition and Dietary Pattern

• Pattern of food and fluid consumption relative to metabolic need.
• Includes all aspects of nutrition (digestion, absorption, metabolism) Dietary intake is essential for good health and is influenced throughout the lifespan.

Essential Nutrients (for body growth):

• Protein
• Fats
• Carbohydrates

Concept of Sleep & Rest

• Sleep is a basic human need and is a part of biological rhythms.
• Rest is a state of decreased activity and free from stress.
• Different stages and types of sleep can be identified.
• Sleep needs can vary depending on a person's age/developmental stage.

Common Sleep Disorders

• Insomnia (trouble falling asleep)
• Excessive daytime sleepiness - hypersomnia
• Narcolepsy (sleep attacks)
• Sleep apnea (inability to breathe while sleeping)
• Parasomnias (sleep-related behaviors such as bruxism, sleepwalking, and nightmares)

Factors affecting sleep:

• Age
• Illness
• Environment
• Lifestyle and habits
• Emotional stress
• Stimulants and Alcohol
• Diet

Nursing Process for promoting sleep:

• Assessment - Sleep history, physical examination, sleep diary and questionnaires
• Interventions - Provide safe and supportive environment to promote sleep, educate about behaviors that promote sleep
• Evaluation - Determine client's progress towards achieving sleep goals

Concept of Sexuality

• A range of thoughts, feelings, behaviors, and roles regarding sexual attraction and gratification.
• Affected by biological, social, psychological and cultural influences.
• Important for relationships, family, and society.
• Can be affected by various factors in the individual's lifespan.

Factors affecting sexuality

Quality of relationship, cognition, culture, values, beliefs, self-concept, previous experience, environment, pregnancy, illness, disease, and other critical life events.

Types of sexual problems

• Sexual dysfunction, sexual abuse, impairment
• related to age/developmental stage, medical conditions.
• Other potential issues influence sexuality- cultural/historical/social values/attitudes

Stages of Sexual Development (some models)

• Freud's psychosexual stages (Oral, Anal, Phallic, Latency, Genital)

Nursing implications for working with clients concerning sexuality

• Establish a trustworthy, respectful relationship
• Maintaining privacy
• Active listening
• Clarify that sexuality encompasses more than intercourse
• Discuss alternative approaches

Nursing Diagnosis for Sexual Issues

• Ineffective sexual pattern
• Sexual dysfunction
• Rape trauma syndrome

Human responses to illness

• Definition of Health: A complete state of physical, mental and social well-being.
• Wellness: A dynamic process involving attitudes and behaviors directed at maximizing an individual's potential and meeting standards of functioning.

Dimensions of Wellness

• Physical: Ability to carry out daily tasks
• Social: Able to interact
• Emotional: Ability to manage stress, expressing emotions apropiately and accepting shortcomings
• Intellectual: Learn and use information to develop personally
• Environmental: Promote health in a community
• Spiritual: Belief in a force greater than self (morals, values,ethics)
• Occupational: Achieving balance between personal and work time

Concepts of illness and disease

• Disease: An alteration in body functions resulting from an identifiable condition, e.g., cancer.
• Illness: The individual response of a person to a disease. (emotional, subjective, and personal)
• Variables affecting illness behavior:
• Internal- perception, nature of illness, individual characteristics
• External- visibility, social group, culture, economic status, accessibility to care

Types of Illness:

• Acute illness: relatively short duration of symptoms
• Chronic illness: lasts longer than 6 months, may result in permanent changes

Illness Behavior

• How a person recognizes, evaluates, and reacts to symptoms. Includes seeking or avoiding help, coping mechanisms, and compliance with medical advice.
• Stages:
• Symptom experience
• Assumption of sick role
• Medical care contact
• Dependent stage
• Recovery/rehabilitation

Emotional responses to illness

• Fear
• Over-dependence/ Helplessness
• Anxiety
• Hope
• Anger/Hostility

Effect of illness

• Impact on client: physical, psychological, spiritual, and social
• Impact on family: emotional, financial, and social

Support during illness:

• Family support
• Health care providers support
• Complementary and alternative medicine
• Faith healing
• Homeopathy

Models of Health and Illness

• Agent-host-environment: Factors such as agents (bacteria, viruses), Host (who they impact and have factors to support them), and environment (lack of sleep, cold temperatures, etc.)
• Health-illness Continuum: Moving away from peak wellness to critical illness or death.
• High-level wellness model: Health-environmental axis to measure health and wellness levels
• Heath belief model: Addresses how individual perceptions affect responses to the threat of disease
• Health Promotion model: Looks at individual, social and experiences related to health behaviors to attain the best outcomes

Loss & Grieving

• Loss: Something valued that is changed or removed
• Types
  • Actual
  • Perceived
  • Anticipated
• Grief: The emotional process related to loss
• Stages of grief:
  • Denial.
  • Anger.
  • Bargaining.
  • Depression.
  • Acceptance
• Nursing implications: Understand the patient's experience, provide comfort and support

This quiz explores the critical aspects of nursing interventions, including the importance of client reassessment, documentation procedures, and maintaining client privacy. It further addresses the evaluation phase in nursing and the supervision of delegated care. Enhance your understanding of effective nursing practices through this assessment.