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• The Nursing Process involves critical thinking, communication, building relationships and displaying professionalism
• The Nursing Process includes assessment, analysis, diagnosis, identification, planning, implementation, and evaluation
• The American Nurses Association developed the 5-step nursing process.
• The nursing process is evidence based, holistic, and patient centered.

Assessment

• Involves collecting as much client information as possible and is an ongoing process
• It is important to learn about the client, their family, and community
• Thorough assessments allow nurses to sort data, find patterns, and identify health problems.
• Initial assessments are critical for quick problem identification.
• Assessments can be broad or situational and change as patient status changes
• Assessment database changes when patient status changes
• Assessment helps with deliberate and systematic data collection with consideration to who, what, why and where of a situation

Steps of Collection: Assessment

• Involves collection and interpretation of information
• Gather info from the primary source (patient) and secondary sources (family/friend/provider)
• Use relevant data, recall prior experience, and apply critical thinking
• Use physical, biological, and social data to complete patient history and physical examination
• Interpretation requires a knowledge base and access to information
• It is a nurse's job to interpret the story that emerges from the data about the specific patient.

Types of Collection: Assessment

• Patient-centered interviews are gathered during nursing history
• Periodic assessments are performed
• Physical examinations begin with initial contact and can be ongoing
• Assessments can be comprehensive or problem-focused.

Comprehensive Assessment

• Involves detailed assessments of physical, psychosocial, cultural, spiritual, and lifestyle needs
• Head-to-toe physical exams and patient centered interviews can be used

Problem Focused Assessment

• Data collected during rounding, patient care activities, and medication administration
• Quick screenings can be used to rule out or follow up on patient problems
• Nurses can use the ABCDE framework
• Different units or nursing roles may use problem-specific assessments
• A problem-focused physical exam can involve lung or chest exams for example

Types of Data: Assessment

• Primary subjective, secondary subjective, primary objective, and secondary objective data

Primary Subjective Data

• The patient's verbal description or self-report, given only by the patient
• Includes physiological, social, or psychological reports
• Examples include pain scores, feelings of doom, or anxiety about a procedure

Secondary Subjective Data

• Reports from others such as friends, family, or providers about the patient
• Can also be about what the patient has relayed to them

Primary Objective Data

• Reports from direct observation or measurement by the nurse
• Examples include blood pressure readings, wound inspections, observing ambulation, or observed behavior

Secondary Objective Data

• Data collected from other sources such as family, friends, or the healthcare team
• Examples include blood pressure logs from home.

Data Sources: Assessment

• Patients are the best source when cognitive
• Family, caregivers, and friends are helpful for confirming patient information with consent and cultural sensitivity
• The Health Care Team provides hand-off reports and physician insights
• Medical records include history, assessments, care activities, physical findings, and treatment plans
• Nurse's experience is a valuable source of retained knowledge.

Patient Interview: Assessment

• It is a patient-centered and organized way to gather information.
• Can range from less than a minute to several minutes
• Good interview skills can lead to problem detection, accuracy, patient satisfaction, recall of information, adherence to therapy, and positive patient outcomes
• It is important to observe the patient the entire time you're with them
• Communication is key
• It is important to ask open-ended questions
• It is important to avoid medical terms with patients that have low literacy
• Time to communicate typically takes longer in older adults compared to younger adults
• Always be attentive, caring, and engaged to encourage truthfulness
• Maintain eye contact and privacy

Interview Phases: Assessment

• Includes orientation, working phase, and termination

Orientation

• Setting the agenda involves introducing yourself, explaining data collection purposes, and ensuring confidentiality
• Explain actions, focus on patient goals and concerns, and establish patient comfort
• Show professionalism and competence

Working Phase

• Gathering accurate, relevant, and complete information
• Use open-ended questions and active listening
• Avoid rushing to opinions or rushing the patient
• It is important to clarify key terms, such as dizziness
• Initial interviews will be extensive; ongoing interviews will be shorter

Termination Phase

• It is important to summarize the discussion and check for accuracy of information,
• Give the patient notice of ending the interview
• Allow the patient to ask additional questions and end on a friendly note, providing expectations for return

Variables Affecting Interviews

• Variables include setting, time pressure, interruptions, and task complexity

Biographical Information: Assessment

• Includes age, sex, address, insurance, occupation, and marital status

Chief Concern: Assessment

• Brief statement in the patient's own words, charted in quotations, and subjective data
• Helps to focus the assessment

Patient Expectation: Assessment

• Requires asking what the patient’s expectations are and communicating through them
• Improves patient satisfaction

PQRST's: Assessment

• A method to chronologically frame an illness or symptoms
• Assesses primary symptoms/complaints and accompanying symptoms

Components of PQRST's: Assessment

• P: Provokes (precipitating and relieving factors)
• Q: Quality (what does it feel like?)
• R: Radiates (location of symptoms, where it radiates)
• S: Severity (pain scale rating 0-10)
• T: Time (onset and duration)

Patient History: Assessment

• Involves gathering information on meds, allergies, social/lifestyle habits (smoking, drinking, drugs, exercise, coping habits, and nutrition)
• Also involves gathering information on illnesses, injuries, surgeries, and hospitalizations

Family Assessment

• Involves at-risk assessments, and immediate and blood relative issues like cancer, heart disease, and stroke
• If family does not support the patient, do not engage them in care

Psychosocial Assessment

• Involves gathering information about family, history of loss and grief, coping mechanisms, stress levels, and the patient's strategies for dealing with stress

Spiritual Health: Assessment

• Includes gathering information about religion, faith, rituals, and preferences

Review of Systems: Assessment

• Includes subjective information from the patient about the presence or absence of health-related issues
• Requires asking about normal function, any changes, and abnormalities
• Requires conducting physical assessments through inspection, auscultation, palpation, and percussion

Observation: Assessment

• It is done during patient interviews
• Involves observing verbal and nonverbal cues and confirming they match what patient says

Documentation: Assessment

• Should be timely, clear, concise, and use appropriate terminology
• Avoid generalizations or judgements; be specific and factual.
• This is a legal and professional responsibility, using standardized forms with date, time, signature, and credentials
• Sign with credentials and leave no open spaces
• Errors should be struck through with a date and initials

Diagnosis

• A clinical judgement a nurse makes using critical thinking that leads to indentifying a diagnosis
• Medical, nursing diagnosis and collaborative problems form the 3 types of nursing diagnoses

Medical Diagnosis

• Identification of a disease based on physical signs, symptoms, history, and diagnostic lab results
• Advanced practice nurses and physicians make these
• A common diagnosis includes condition, signs, symptoms, and treatment needed
• Nurses educate on conditions, medications, and management

Nursing Diagnosis

• An RN's judgement to a patient's response or susceptibility to health conditions
• Diagnostic labels based on assessment

Nursing Diagnosis Categories

• Includes 5 seperate issues
• Pathophysiological (MI), treatment related (dialysis), personal (dying/divorce), environmental (home/safety) and maturational (peer pressure/parenthood) fall under said Diagnosis

Nursing Responsibility

• Nurses can't treat medical diagnoses but can treat patient responses to health conditions such as pain, immobility, and impaired coping
• It, however, nurses do treat and manage responses independently
• Nurses cannot order tests or medication

Collaborative Problems

• Problems require both medical and nursing diagnoses
• Not all physiological issues are collaborative
• Teams can come together and produce positive outcomes

Terminology

• Nursing uses unique data to communicate effectively
• Nursing Practice uses International Classification
• Set by worldwide standards and councils with a unified nursing language
• Sorts diagnosis data for WHO

NANDA

• (North American Nursing Diagnosis Association)
• A nursing diagnosis and classification system, developed in 1982 and upadted to 2018
• Is based on assessment data analyzed and clustered to patterns and interpreted before diagnosis from a nurse
• Planning and intervention are negatively impacted without prior patient health assessments

Health Status

• Patient health problems are based on problem-focused, risk diagnosis and health promotion

NOC (Nursing Outcome Classification)

• Links outcomes to NANDA

NIC (Nursing Interventions Classification)

• Interventions to acheive outcomes

Problem Focused

• Addresses negative responses to existing problems like acute pain and urinary retention

Risk

• Recognizes increased potential or vulnerability for a patient to develope an issue like a fall
• Risk statements reflect an increased potential for development

Health Promotion

• Identifies motiviation to improve health through positive behavioral change (Readiness for enhanced relationship)

Data Clustering and Finding Patterns: Diagnosis

• An accurate database leads to an accurate nursing diagnosis allowing for planning, interventions, and treatment administration
• The ability to realize clues improves with nurses experience and ability to recognize and analyze
• Allows for evolved treatment and diagnosis

Data is Organized by Patters

• Data Clusters: is set of finding to indentify problems and name them to allow nurses to seperate abnormal data
• Critical Thinking must be used

Formulating a Diagnosis Statement: Diagnosis

• Effective communication of patient issues to other staff
• In selecting which interventions to choose and how pt outcomes are evaluted

Diagnostic Label

• Approved by NANDA, ICNP or system used by institution
• Ex: anxiety, body weight problems etc

Related Factors

• Clarifies conditions that caused the problem
• Gives clarity and makes interventions more specific
• It NOT a "cause and effect" statement
• Ex: Uncertainty over surgery, nausea and vomiting etc

Evidence

• Major assessment findings
• Is evidenced by written data (AEB)
• AEB offers guidance for how the efficacy of nursing care can be evaluted

NANDA (Diagnosis in 3-parts)

• Indentifies label, factors, and evidence
• Risk label in 2-parts with diagnosis and evidence
• Do not use related to statements as it creates potential for misinterpretations

Health Promotion diagnosis in 2 parts

• Identifies diagnosis and characteristics
• Employs clinical judgement about a patient to improve their health and well-being
• (Example: Sedentary lifestyle and readiness to improve)

Planning

• Care plans are a road maps for nursing care to address problems and ensure quality intervention
• Prioritize all nursing diganosis and interventions
• Orders can change as patient's health evolves
• Review order at the begining

Prioritizing can be categorized as follows

• High: if left untreated, results in harm (breathing, airway and circulation)
• Intermediate: non life threatening (risk of infections)
• Low: not always directly related to an illness (long-term)

Outcome: Planning

• What the patient needs to achieve
• Agencies can measure quality care through outcome measurement
• Core measures are funding related
• Expected outcomes are statements regarding pt responses to intervention
• Outcomes should be measureable
• All memebers should contribute and set directions to acheieve desired intervention

Key Qualities

• Characteristics can be improved, and it is desired that pts are unharmed or protected
• Patient satisfaction and safety matters

How to write goals and outcomes statements

• SMART; measurable, specific, attainable, recerse and timed
• Specific and behavior driven
• Avoid vague terms and measures pt preference

Interventions: Planning

• Treatment, judgement and actions that nurses perform that are evidence based and include knowledge of their patient
• Patient assessment provides data for diagnosis and indicators for intervention to use

Types of Intervention

• Direct and Indirect: Direct is laying intervention to pt with hands, and Indirect is laying intervetion away from pt
• Nurse initiated: initiated without orders with providers
• HCP initiated: requires orders like medication, and it is RN repsobility to transcribe and review
• RN is responsible for errors after orders are carried out

Intervetion Selection: Planning

• Don't select based on diagnosis without considering pt desiries, research, or acceptability of the intervention from the pt
• Review all reasources

Care Plans

• Created based on individual needs; its will be writted down in someform or fashion regarding pts unit
• Plans are revised but are needed for staff continuity
• Family are reasources
• Helps with problem solving and knowledge in practical situations

Implementation

• Involves with good judgement
• Action after care palns
• Use direct and indirect measures

Scope of Nursing Practice

• Defined by ANA and state
• KN NOW ALL PROTCOLS

Standard Nuring INterventions: Implementation

• Nuring are complex but need prep
• errors lead to bad outcome
• Follow 5 steps to ensure good care

Reasses to

• CLient
• Review
• Get Resources
• Anticipate and prevent compliations

implement Correction

• Oberserve adn get help when you implement
• Implement is cognitive
• ADLs; Eat, bath etc all actions

Physical Care Technique

• Administration

Lifesaving

• Restore homostaiss

Counsleing

• Emphasize the eduation for pt; Pt should be evaluated
• Always explain and demonstrate
• Tell pt advere

Perventive intervetion

• Wellness

Indirect

• Away from patient
• Communacation

delegate to apporate roles

• RN can delegate tasks but not the nursing process
• Clinical judgement is always needed

Evaluation

• Have outcomes been achcieved and improve and evaluate all factors
• Assess all findings and discontinue/discontinue/revise