Nursing Process Lecture PDF

LECTURE OF THE NURSING PROCESS The Nursing Process - is an organizational framework for nursing practice What are the purposes/goals of the process - identify health status,problems, needs - create plans to address problem/needs - implement interventions - evaluate effectiveness 5 steps o...

LECTURE OF THE NURSING PROCESS The Nursing Process - is an organizational framework for nursing practice What are the purposes/goals of the process - identify health status,problems, needs - create plans to address problem/needs - implement interventions - evaluate effectiveness 5 steps of the Nursing Process 1. Assessing - collecting, validating, & communicating of client data 2. Diagnosing - analyzing client data to identify client strengths & problems 3. Planning/Outcome Identification - specifying client outcomes & related nursing interventions 4. Implementing - carrying out the plan of care 5. Evaluating - measuring extent to which the client a achieved outcomes Nursing Process Characteristics is - Interpersonal, Systematic, Dynamic, Multi-Dimensional, Based on Knowledge & Critical Thinking, Cyclical The Scientific Problem Solving is similar to Nursing Process Apply Critical Thinking to Nursing Process & 5 steps to develop it: 1. Purpose of Thinking 2. Adequacy of Knowledge 3. Potential for Problems 4. Helpful resources 5. Critique of judgment/decisions 4 Required Nurse’s Blended Skills: - Cognitive skills - Technical skills - Interpersonal skills - Ethical/legal skills STEP 1: The Assessment Phase Assessment is a systematic process of data collection involves continuous collecting, organizing, validating & documenting of data information Its purpose is to establish a database for a client in order to meet a patient's nursing care needs. Medical Assessment vs Nursing Assessment Medical Nursing Target data pointing to Focus on the patient’s response pathologic conditions to health problems Types of Assessment 1. Initial Assessment - admission & comprehensive assessment (establish data) 2. Focused Assessment - pre-existing condition (ongoing assessment) 3. Emergency Assessment - when a physiologic or psychological crisis presents 4. Time-Lapsed Assessment - schedule to compare a patient’s current status to baseline data obtained earlier Assessment Phase Purpose of Nursing Assessment & Database Determine the client’s Health status Ability to function Strengths limitations Ability to cope with stresses Plan & deliver app care Refer to other professionals Information on the Databases Includes Nursing hx/health hx Physical examination Lab results Diagnostic tests Past Medical Records Types of Data Objective Data- observable & measurable data (signs) Main way to collect objective data by - - Physical assessment - Laboratory results - & diagnostic testing results Subjective data - information that only client feels & describe (symptoms)  - Data from the client’s point of view (verbalizations) - Feelings, perception, concerns Main way to collect data by INTERVIEWING Sources of data - Primary source : client - Secondary source: family & significant others, Patient medical records, Healthcare professionals, Other experts reports, Test & diagnostic results Data collection - takes place in the assessment phase Gathered Via - observation, interview, physical assessment, diagnostics Phases of the Interview - Preparatory Phase: reviews records, gather available data - Introductory Phase: meeting, introductions & explanations of purpose of interview - Working Phase: actual interview - Termination Phase: conclusion Interviewing Techniques Direct Approach -> closed ended questions (YES or NO) Non Direct Approach -> opened ended questions Validating Data by -> DOUBLE CHECKING or VERIFYING INFORMATION Techniques Used for Physical Assessment 1. Inspect 2. Palpitation (except for GI) 3. Percussion (we don’t do in 101) 4. Auscultate PE follows Health History STEP 2: The Diagnosis Phase The North American Nursing Diagnosis Association (NANDA) - defines nsg dx as a clinical judgment about the individual, family, or community responses to actual or potential health problems or life process NSG DX = NSG INTERVENTIONS Purpose is to Identify Responses, Identify Etiologies , Identify Resources …. Medical vs Nursing Dx Medical Dx Focus: rid the body of the illness of the diseases organ - Identify/describes a disease, illness or injury - Purpose is to identify disease or pathology - Remains the same as long as disease is present Nursing Dx Focus: Behaviors, response, reactions to disease, injury, or other stressors - Actual or Potential - Holistic: biological, emotional, interpersonal, social, spiritual, environment - Can change from day to day (as pt’s response change) Examples of Dx: NSG Dx vs MEDICAL Dx Ineffective Breathing Patterns -> Chronic Obstructive Pulmonary Disease (COPD) Activity Intolerance -> Cerebrovascular Accident (CVA) Pain -> Appendectomy Body Image Disturbance -> Amputation Risk for altered body temperature -> Strep Throat Rn DO NOT diagnose medical problems Nsg dxs DO NOT include medical dxs terminology Diagnosis Phase: After the data collection or (assessment phase) Steps: 1. Interpret data/cues (analyze data) - already gathered 2. Cluster cues (organize data) 3. Confer with approved list from nanda (identify health problems, risks, strengths) 4. Formulate Dx statements (write it) Types of NSG Dx 1. Actual Dx: - Describes a problem response that exists the time of assessment - It is identified by signs & symptoms (cues) that are present Ex: Impaired Gas Exchange 2. Risk Dx: - Describes a problem response that is likely to happen in a vulnerable client if the nurse does not intervene Ex: Risk for falls, Risk for Infection 3. Possible Dx: - Describes a situation here evidence bout a health problem may be incomplete or unclear Ex: Potential risk for skin breakdown, Possible risk for infection 4. Wellness Dx: - Describes the transition of an individual, family or community from one level of wellness to a higher level of wellness (postpartum client) - There is no identified health problem Ex: Readiness for enhanced health maintenance Components of a Nursing Diagnosis PES - Problem (diagnosis or diagnostic label): identifies what is unhealthy about the client It should be refined to explain the meaning of the label or distinguish the label from similar nursing diagnoses Ex: alteration in comfort = chest pain or back pain … - Etiology (cause): identifies factors maintaining the unhealthy state Ex: alteration in comfort = chest pain related to increased oxygen demand - Sign & Symptoms (Defining Characteristics): identifies the subjective & objective data that signal the existence of a problem Ex: alteration in comfort = chest pain related to increased oxygen demand as evidence by SOB pt’s ℅ substernal chest pain rated 6/10 on pain scale. The Planning Phase The nurses work with the client & family to: prioritize problems, formulate goals, select evidence based interventions, and write nursing orders. Communicate plan of nursing care! Elements of Comprehensive Planning 1. Initial Planning: developed by the nurse who performs the initial nursing HX & PE 2. Ongoing Planning : Carried out by any nurse interacting with the client - to keep the plan up to date 3. Discharge Planning: Information or teaching needed before D/C. - this planning begins when client is admitted Plan by using Maslow’s in order to list from high priority to medium priority to low priority HIGHEST PRIORITY AT BASE GOALS: 2 Types of Goals 1. Short-Term: goals achieved within a few hours or days 2. Long-Term: goals achieved over a longer period; weeks to months or more Categories of Outcomes - COGNITIVE: Describes increase in client knowledge or intellectual behaviors - PSYCHOMOTOR: Describes patients’s achievements of new skills - AFFECTIVE: Describes changes in client's values' beliefs & attitudes NANDA -> NIC -> NOC NIC: Nursing Interventions Classification: standardized classification of interventions. Describes direct or indirect care activities by nurses Consist of label, a definition, & a list of nursing activities to carry out the intervention NOC: Nursing Outcomes Classification: a standardized system. To describe client outcomes that respond to nursing interventions 5 Steps: Subject, Verb, Conditions or Modifiers, Performance Criteria, Timing Three Types of Nursing Actions (Interventions) 1. Independent (nurse initiated) : actions performs without a physician orders 2. Collaborative (Interdependent) : actions performed whenever the nurse works jointly with other members of the team healthcare to resolve client problems (ex: reinforces exercises by the physical therapist) 3. Dependent (physician initiated): actions performed when the nurse functions under orders written by the physician (ex: administration of medications) The Implementation Phase In this stage previously planned nursing actions (interventions) are carried out. Process of the Implementation Phase: Reassess: client as needed Determine: need for assistance Organize: resources & care delivery (equipment, personnel, environment) Implement: carry out or delegate the nursing interventions Supervise: any delegated care Document: all nursing activities & interventions provided The Evaluation Phase Determines if the EO have been met, partially met, or not met 1. Review evaluative criteria & standards 2. Collect data to determine if criteria & standards were met 3. Interpret & summarize findings 4. Document judgment Evaluating Outcomes - Cognitive EO: Increase in client knowledge - ask pt to repeat or explain information, or apply new knowledge  - Psychomotor EO: Patient’s achievement in new skills - ask pt to demonstrate a new skill - Affective EO: Changes in client values, beliefs, and attitudes - observe behaviors - Physiologic EO: physical changes in the client - collect & compare data QUALITY ASSURANCE (QA) Focus= on organization, influenced by outside factors (JHCO, state mandates, etc) Goal is the evaluation of: Structure- physical environment/ standards, policies & procedures/ equipment… Process- nature & sequence of activities/ criteria & acceptable levels of performance Outcomes- Focuses on measurable changes in the health status of the client/ or the end results of nursing care Methods of Assuring Quality 1. Quality by Inspection: finding deficient workers & removing them 2. Quality by Opportunity: finding opportunities for improvement & teamwork QUALITY IMPROVEMENT (QI) known as Performance Improvement (PI), Continuous Quality Improvement(CQI), Total Quality Management (TQM) Focus= on client care rather than organizational structure - Focuses on client care - It is internally driven - Has no ends points - Goal is to improve quality rather than assure quality Nursing Audit Examines data related to: - safety measures, - treatment interventions & client responses - client teaching - pre-established outcomes used as basis for interventions - discharge planning adequacy of staffing patterns - Concurrent or Retrospective Audits From the book - Concurrent evals. conducted by nursing direct observation of nursing care, patient interviews, & chart reviews to determine where the criteria are met Retrospective evals. may use postdischarge questionnaires, patient interviews, (by telephone or face to face), or chart review to collect date (Joint Commission)