Professional practice final

Nursing Process Overview

• The nursing process is a cognitive framework for identifying, diagnosing, and treating health issues using a holistic approach.
• It is patient-centered, systematic, universally applicable, and guides clinical judgment, decision-making, and reflective practice.
• The process involves five steps: Assessment, Diagnosis, Planning, Implementation, and Evaluation (ADPIE).

Steps of the Nursing Process

• Assessment: Gather comprehensive information about the client's condition.
• Diagnosis: Identify the client’s health problems based on assessment data.
• Planning: Establish care goals, desired outcomes, and appropriate nursing actions.
• Implementation: Execute the nursing interventions identified during planning.
• Evaluation: Assess if goals were met and outcomes achieved.

Types of Assessments

• Initial Assessment: Conducted at admission to establish a baseline data set.
• Focused Assessment: Frequent evaluations on specific issues, depending on patient's status.
• Emergency Assessment: Prioritization of life-threatening issues before completing a full assessment.

Types of Data in Assessment

• Subjective Data: Patient's verbal expressions of health concerns, such as feelings or self-reported symptoms.
• Objective Data: Measurable or observable data, such as vital signs and physical examinations.

Sources of Data

• Primary: Directly from the patient when they are alert and able to provide accurate information.
• Secondary: From caregivers or the patient's medical record, including shift reports and lab results.
• Tertiary: From external sources such as textbooks and the nurse's experience with similar cases.

Data Collection Methods

• Interviews: Collect subjective information through structured phases:
  • Orientation: Explain purpose and confidentiality.
  • Working: Gather detailed information using open and closed questions.
  • Termination: Summarize and clinically conclude the interview with the patient.

Nursing Diagnosis

• A clinical judgment identifying actual or potential health issues within nursing's domain.
• Nursing diagnoses follow a 2–3 part format: problem statement, etiology (cause), and defining characteristics.

Differences in Diagnosis Types

• Nursing Diagnosis: Focuses on health problems needing nursing intervention.
• Medical Diagnosis: Identifies disease conditions based on specific evaluations.
• Actual Nursing Diagnosis: Identifies present health issues.
• Potential Nursing Diagnosis: Identifies risks for developing health issues.

Goal Setting and Expected Outcomes

• Goals are specific patient behaviors or physiological responses aimed for resolution of health problems.
• SMART Criteria: Goals should be Specific, Measurable, Achievable, Relevant, and Timed.

Implementation Strategies

• Implementation includes executing planned nursing actions, managing care, and delegating tasks when necessary.
• Direct Care Interventions: Direct interaction with patients (e.g., administering medications).
• Indirect Care Interventions: Actions taken on behalf of patients (e.g., delegating nursing tasks).

Nursing Intervention Classification (NIC)

• Nursing interventions are categorized into domains and classes, helping in selecting appropriate actions based on patients' diagnoses.

Evaluation Process

• Final step assessing whether goal criteria and expected outcomes are met.
• Evaluates through five elements: establishing criteria, data collection, findings interpretation, documentation, and care plan revision.
• Positive outcomes indicate successful care interventions; unmet outcomes signal the need for adjustments.

Nursing Outcomes Classification (NOC)

• Developed to classify and label sensitive patient outcomes, aiding in evaluating nursing effectiveness.

Evaluating Findings

• To assess success, compare actual patient behaviors against established outcome criteria and investigate barriers to agreement when outcomes are not met.

Evaluation in Nursing Process

• Final step of the nursing process; assesses patient outcomes and effectiveness of care.
• Involves examining a condition/situation and making judgments on whether change has occurred.
• If nursing care is unsuccessful, the nursing process restarts to enhance patient well-being.

Elements of the Evaluation Process

• Identify evaluation criteria and standards to measure outcomes.
• Collect data to assess whether set criteria or standards are met.
• Interpret and summarize findings for understanding care effectiveness.
• Document findings and clinical judgments for continuity and accountability.
• Decide whether to terminate, continue, or revise the care plan based on evaluation.

Factors for Selecting Interventions

• Nursing diagnosis determines appropriate care strategies.
• Establish clear goals and expected outcomes for the patient.
• Interventions should be backed by evidence-based research.
• Consider feasibility of interventions in the patient's context.
• Ensure acceptability of interventions to the patient.
• Assess the competence of the nursing staff involved in the interventions.

Categories of Nursing Interventions

• Nurse-Initiated Interventions:

  • Independent actions that do not require orders from other healthcare providers.
  • Grounded in evidence-informed decision-making.
  • Examples include assessing edema, educating patients about medication side effects, or instructing splinting during coughing.

• Physician-Initiated Interventions:

  • Dependent actions needing orders from physicians.
  • Focuses on treating or managing specific medical diagnoses.
  • Nurse practitioners (NPs) can provide these orders.
  • Nurses must understand drug classifications, dosages, and potential adverse effects when administering medications.

• Collaborative Interventions:

  • Require teamwork and combined expertise of multiple healthcare professionals.
  • Important to clarify unclear orders and maintain professional communication.
  • Nurses are accountable for their actions and should document any concerns professionally.

Nursing Diagnosis

• Determines health problems within nursing's scope.
• A clinical judgment related to actual or potential health issues, guided by NANDA.
• Distinguishes nursing roles from other healthcare providers, centering on nursing practice.

Sources of Data for Evaluation

• Primary Data: Obtained directly from the patient who is alert, safe, and able to provide reliable information.
• Secondary Data: Collected from caregivers, medical records, and shift reports among nurses communicating essential patient information.
• Tertiary Data: Information gathered from external sources, such as textbooks, prior nursing experiences, or patterns observed in similar patient cases.

Explore the nursing process and its significance in providing effective nursing care. This quiz delves into the historical development of the nursing process and its structured approach, highlighting its patient-centered focus and cognitive framework. Understand how the nursing process can be used to address health problems holistically.