Nursing Process and Evaluation

Assessment - Nursing Diagnosis

• Nurses perform ongoing assessments throughout the nursing process, establishing a database.
• Nursing history gathers patient health status, strengths, problems, risks, and needs for care.
• A physical examination is also used to collect relevant data.

Types of Nursing Assessments

• First Assessment: Conducted after patient admission, creating a comprehensive database for care planning. Data collection includes patient's health, priorities for ongoing focus, and comparison to future assessments.
• Focused Assessment: Data collection focuses on a specific, identified problem. Key questions include: symptoms, onset, factors that worsen or improve symptoms, and current treatment.
• Emergency Assessment: Performed during a physiologic or psychological crisis (e.g., choking, bleeding, unresponsive). It aims to identify life threatening problems.

Data Collection

• Data is structured systemically because many different types of data is collected about patients.
• Nurses internalize assessment guidelines to effectively focus on the patient.
• Gordon's framework identifies functional health patterns, organizing patient data.
• Maslow's hierarchy of five human needs is also used as a guide.

Types of Data: Subjective and Objective

• Subjective data: Information only perceived by the affected person, not verifiable by others (e.g., feelings, pain). Also called symptoms or covert data.
• Objective data: Observable and measurable data, verifiable by others (e.g., temperature, skin condition, refusal of food). Also called signs or overt data.
• Examples of subjective data include feeling nervous, nauseated, chilly and pain.
• Examples of objective data include elevated temperature (39.2°C), moist skin, and refusal to eat.

Data Collection- Characteristics of Data

• Purposeful: Nurses identify assessment purpose (comprehensive, focused, emergency, time-lapsed) before collecting data.
• Complete: Collect all relevant data to understand patient health problems and create care plans.
• Factual and Accurate: Describe observed behaviors, not just interpretations.
• Example of factual data collection: Patient is observed lying with his face to the wall, refused lunch, and ate only soup.

Sources of Data

• Patient: The primary source of information (unless unable to communicate).
• Family and Significant Others: Are helpful when the patient has limited capacity.
• Patient Record: Important for comprehensive care, containing medical history, physical examination, and progress notes.
• Consultations: Specialists are consulted if needed, for diagnosis or treatment.
• Reports of Laboratory and Other Diagnostic Studies: Includes lab results and imaging reports.
• Reports of Therapies by Other Healthcare Professionals: Documentation from physical therapy, speech therapy, or nutritionists is included.
• Nursing and Other Healthcare Literature: Consult literature to broaden understanding of specific health problems.

Methods of Data Collection

• Nursing History: Obtained as soon as possible after patient presentation, including strengths, weaknesses, health risks, and existing problems.
• Nursing Physical Assessment: This examination follows the nursing history and may verify or add to initial findings.

Data Collection- Methods of Data Collection- Nursing History

• Patient Interview: A planned communication method, requiring strong interviewing skills to create a successful working partnership with the patient.

Data Collection- Methods of Data Collection- Nursing Physical Assessment

• Physical assessment is the patient examination for objective data to better understand their condition and aid in care planning. This typically occurs after the nursing history.

Data Reporting and Recording

• Patient data should be shared with other healthcare professionals promptly, especially any critical changes.
• Initial data should be recorded the same day of admission.

Diagnosing

• Assessment: Collecting data and making inferences.
• Interpreting data: Analyzing and synthesizing collected data to create a list of potential problems/diagnoses.
• Diagnosis: Completing the list of suspected problems/diagnoses, and naming those that are actual. Determining contributing factors and identifying risk factors.

History of Nursing Diagnoses

• The term "nursing diagnosis" emerged around 1950.
• The ANA (American Nurses Association) defined the first nursing diagnoses in 1973.
• NANDA-I maintains a list and research continues to include new concepts as the need is recognized.

Nursing Diagnosis vs Medical Diagnosis

• Nursing diagnoses focus on unhealthy responses to health/illness, while medical diagnoses identify diseases.
• Nursing diagnoses are written to describe patient problems that nurses can treat independently.
• Medical diagnoses remain relatively constant, whereas nursing diagnoses might change as the patient's responses change.

Data Interpretation and Analysis

• Experienced nurses begin interpreting data while collecting data.
• "Cues" are significant pieces of data.
• Important data should trigger attention.
• Nurses must discern normal from abnormal responses based on patient’s specifics.

Data Interpretation and Analysis- Recognizing Significant Data

• Differentiating normal patient responses from abnormal ones.
• Heart rate, oxygen saturation, and other factors provide context when interpreting patient data.
• A heart rate of 60-100 beats per minute is usually considered normal but athletic patients may have lower resting rates.
• Normal oxygen saturation is 95-100%, though 88-92% may be normal for COPD patients.

Data Interpretation and Analysis- Recognizing Patterns

• Data clusters form the basis for nursing diagnoses, rather than single data points.
• Clinical examples may help determine if a pattern is actually significant or could be a normal response (e.g. patient crying may be a healthy response, not a sign of a diagnosed illness).

Data Interpretation and Analysis - Identifying Strengths and Problems

• Assessing patient strengths related to coping and problem management.
• Identifying limitations and problems from the patient's data interpretation.
• Examples of using patient history to assess strengths related to coping and problem management, or identifying limitations related to eating poorly as a contributing factor to illness.

Data Interpretation and Analysis- Identifying Potential Complications

• Patient are susceptible to many complications arising from their diagnoses, medication, or treatments.
• Examples include slurred speech, changes in skin color/texture, or changes in levels of consciousness.

Data Interpretation and Analysis - Reaching Conclusions

• Nurses gather conclusions after interpreting and analyzing data (e.g., no problem, possible problem, actual or potential nursing diagnosis, other clinical diagnosis).

Formulating and Validating Nursing Diagnoses

• NANDA describes different types of nursing diagnoses (actual, risk, possible, wellness and syndrome).
• Actual: The problem is already noted based on validated defining characteristics; components include label, definition, defining characteristics and related factors.
• Risk: Identifies patient vulnerability to a problem greater than other patients in a similar situation.
• Possible: A statement of suspected problem that needs more information to validate.
• Syndrome: A cluster of actual or risk diagnoses that typically result from one event or condition (e.g., self-care deficiency or post-trauma syndromes).

Parts of Nursing Diagnosis Statements

• Problem: Describes the patient's health state or health problem clearly.
• Etiology: The contributing factors believed to be related to the problem (cause or trigger).
• Defining Characteristics: Objective and subjective data that signal the existence of an actual or potential health problem.

Planning Nursing Care

• Outcome Identification and Planning: Identifying patient-centered goals, along with associated expected outcomes, and creating individualized interventions.
• Planning involves setting priorities and working with patients, families, and the care team for ongoing consultation. This plan should be dynamic, adapting to patient needs.
• Unique focus—nursing plans are designed for prevention, reduction, or resolution of identified patient health problems.

Identifying and Writing Outcomes

• Outcomes might be either short-term or long-term
• Outcome timelines should be established in conjunction with the patient.

Identifying Nursing Interventions

• Nurse-initiated interventions: Actions performed independently by the nurse, including monitoring health status, reducing risks, resolving problems, facilitating self-care, and promoting well-being.
• Physician-initiated interventions: Actions provided in response to a physician's orders, based on medical diagnoses.
• Collaborative interventions: Actions undertaken by nurses working with other healthcare professionals (e.g., pharmacists, physical therapists, respiratory therapists).

Implementing the Plan of Care

• Executing the planned interventions based on patient needs, resources, and other influencing factors.
• Reassessing patient status and altering as needed to ensure effective care.
• Importance of organizing resources in terms of equipment, personnel, and environment.
• Teaching, counseling, and advocating for patient self-care.

Establishing Priorities

• High priority diagnoses pose the greatest threat to patient well-being.
• Medium priority diagnoses are related to the patient's current health problems.
• Low priority diagnoses are typically not currently affecting the patient.

Continuing Data Collection and Risk Management

• Skilled nurses monitor patient responses to interventions and update the plan of care accordingly.
• Ongoing risk management involves being alert to new or worsening problems requiring new diagnoses or collaborative interventions.

When a Patient Does Not Cooperate with the Plan of Care

• Reasons for non-compliance include lack of family support, lack of understanding, negative effects of treatment, inability to afford treatment, or limited access to treatment.

Evaluating

• Nurses and patients work together to evaluate how well the outcomes have been achieved.
• This may necessitate terminating the plan of care, modifying it, or continuing it.
• Different types of outcomes are used for assessment, including cognitive, psychomotor, affective, and physiologic outcomes.
• Time criteria are used to determine when evaluations should occur.

Modifying the Plan of Care

• The evaluation process may reveal that the plan of care must be altered.
• Deletion, modification, or adjustment may be necessary.