Nursing Process Nursing Care Plan PDF

Nursing Process NURS1162 Fundamentals of Nursing I Ricky Ahmat 1 Learning Outcomes After completion of this lecture, students will be able to: 1. Describe the five phases of nursing process 2. Describe the differences between a nursing diagnosis...

Nursing Process NURS1162 Fundamentals of Nursing I Ricky Ahmat 1 Learning Outcomes After completion of this lecture, students will be able to: 1. Describe the five phases of nursing process 2. Describe the differences between a nursing diagnosis and a collaborative problem 3. Discuss the importance of nursing diagnosis and nursing process in informing nursing care 4. Formulate appropriate nursing diagnostic statements 5. Apply the nursing process to develop a nursing care plan 6. Examine the current research evidence on the development and applications of nursing diagnoses and nursing care plans 2 Nursing Process An organized sequence of problem-solving steps used to identify and to manage the health problems of clients. Formulate individualized nursing case “The provision of holistic, client-centered care requires research-based professional knowledge and skills through the implementation of the nursing process; the adoption of a caring and responsible attitude; effective communication and interpersonal skills as well as ethical principles.” (Nursing Council of Hong Kong, 2012) 3 Nursing Process: Five Phases Evaluation Assessment Implementation Diagnosis Planning 4 Nursing Process Accepted standard for clinical practice by the American Nurses Association Promote individualized care, client participation and autonomy Promote efficiency, collaboration, continuity and coordination of care Help people understand what nurses do Increase job satisfaction 5  Universally applicable Client-centered Continuous, but overlapping and interrelated Characteristics Prioritized, planned, goal/ outcome directed of Nursing Process Evidence-based Flexible Interactive and collaborative 6 1st step: Assessment ‘In assessing a patient, nurses do not just consider test results. Through the critical thinking exemplified in the nursing process (see below), nurses use their judgment to integrate objective data with subjective experience of a patient’s biological, physical and behavioural needs. This ensures that every patient……receives the best possible care regardless of who they are, or where they may be.’ (American Nurses Association, 2020) 7 Phases of Assessment Assessment Collect data Initial comprehensive Ongoing assessment assessment Nursing history Physical Interview Examination / Interview examination (subjective Observation (subjective Examination / data) (objective data) data) Observation (objective data) Validate data (compare subjective and objective data, validate conflicting data) Organize and record data 8 1st step: Assessment A preliminary idea when you start knowing your client Sources Medical records Information collected from colleagues 9 Types of assessment Initial / Baseline / Screening assessment Comprehensive To collect predetermined set of data and make initial problem list Example: Gordon's functional health patterns Ongoing assessment Focus assessment (Specific problem) Evaluate outcomes achievement and problem resolution, Identify new problems 10 Data collection methods Interview Physical assessment Head-to-toe assessment Inspection Auscultation Percussion Palpation Vital signs Observation Diagnostic test results Clinical records (Doenges, & Moorhouse, 2013) 11 Classification of Data: By type By type Subjective data (Covert data / symptoms) Objective data (Overt data / signs) By source Primary data Secondary data Refer to eLearning 1 Nursing Care Plan and diagnosis for details! 12 14 After collection, what’s next? Organize data Nursing models/ theoretical framework Gordon’s Functional Health Patterns Body systems examination Maslow’s Hierarchy of Needs Record data Avoid vague generalities Validate data Ethical and Legal Considerations Record data: Cues vs inferences A cue is a fact (data). Example: Mr Lee is 1.6m tall and 60 kg weight Inferences are conclusions (judgments, interpretations) that are based on the data Example: Mr Lee is under stress 14 Validate Data To ensure that assessment information is complete, accurate, and factual https://images.app.goo.gl/zn3hd92iiow2FstW8 (Doenges, & Moorhouse, 2013) 15  nd 2 Step: Diagnosis 1. Identify significant cues 2. Cluster cues and identify data gaps 3. Draw conclusions about present health status 4. Determine etiologies & categorize problems 5. Verify the diagnoses 6. Label the diagnoses 16 Nursing Diagnosis “A clinical judgment concerning a human response to health conditions/ life processes, or vulnerability for that response, by an individual, family, group, or community.” Types Problem-focused diagnosis Risk diagnosis Health promotion diagnosis Syndrome (Herdman & Kamitsuru, 2014) 17 Nursing Diagnoses Label: clear and concise that convey meaning of the diagnosis Definition: add clarity to the diagnostic label Defining characteristics Major: at least one must be present for validation Minor: provide supporting evidence, may be present Related factors Pathophysiologic, biologic, psychological Treatment-related Situational (personal, environmental) Maturational (age-related) 18 1 2 3 (Carpenito-Moyet, 2017) 19 2 0 4 (Carpenito-Moyet, 2017) 20 Types and components of a Nursing Diagnosis Problem - focused Risk Health Promotion 1. Label ✓ ✓ ✓ 2. Definition ✓ ✓ ✓ 3. Diagnostic indicators Defining characteristics (major/ ✓ ✓ ✓ minor) Related factors ✓ +/- Risk factors ✓ 21 Parts of a Nursing Diagnosis Label Modifier Diagnostic focus Ineffective Airway Clearance Risk for Overweight Readiness for Enhanced Knowledge Impaired Memory Ineffective Coping 22 Writing Diagnostic Statements P.E.S. Format Three-part statement Example: Anxiety / related to change in environment /as evidenced by insomnia and restless. Problem (r/t) Etiology (as evidenced by) Signs and Symptoms NANDA label (r/t) (Related factor) (as evidenced by) (Defining characteristics) 23 Writing Diagnostic Statements [nursing diagnosis] related to [related factors] (+/- secondary to [conditions/ diseases]) as evidenced by [defining characteristics]. Example: Ineffective airway clearance related to excessive and thick secretions secondary to asthma as evidenced by decreased breath sounds bilaterally, crackles over left lobe and persistent, ineffective coughing. 24 Writing Diagnostic Statements Risk Nursing Diagnosis Two-part statement Risk for problem related to risk factors E.g. Risk for Impaired Skin Integrity (pressure sores) related to immobility secondary to casts and traction. [nursing diagnosis] related to [related factors] 25 Writing Diagnostic Statements Health-Promotion Nursing Diagnosis/ Syndrome Nursing Diagnosis One-part statement E.g. Readiness for Enhanced Family Processes. ‘Unknown etiology’ Used when defining characteristics of a nursing diagnosis are present but the etiologic and contributing factors are unknown. 26 NANDA-I (www.nanda.org) The North American Nursing Diagnosis Association International NANDA-I Taxonomy II Currently includes over 250 nursing diagnoses Classified within 13 domains of nursing practice and 47 classes. Peer-reviewed Continued submissions and/or revisions 27 Functional Health Patterns with common Nursing Diagnoses Health perception–Health Activity–Exercise management Activity intolerance Health maintenance, Ineffective Physical mobility Impaired Falls, Risk for Nutritional–Metabolic Infection, Risk for Sleep–Rest Nutrition, Imbalanced: Less than body Sleep pattern, Disturbed requirements Elimination Constipation Diarrhoea (Carpenito-Moyet, 28 2017) Functional Health Patterns with common Nursing Diagnoses Cognitive–Perceptual Sexuality–Reproductive Acute pain Breastfeeding, Ineffective Risk for aspiration Sexuality patterns, Ineffective Self-Perception-Self-Concept Coping–Stress tolerance Anxiety Coping, Ineffective Disturbed body image Values– Beliefs Roles–Relationships Spiritual Distress Communication Impaired verbal Social isolation 29 Download this template in blackboard 30 Nursing Diagnosis NOT merely a label that “sounds like” to explain what you are seeing in your patient NOT another way of explaining the medical diagnosis NOT something that “goes with a particular medical diagnosis” ‘Clinical judgment about individuals, family, or community responses to actual or potentials health problem/ life process’ (NANDA-I, 2015a) 31 Collaborative Problems Certain physiologic complications that nurses monitor to detect onset or changes of status Implement both physician-prescribed & nursing-prescribed interventions to minimize the complications of the events.’ Diagnostic statement e.g. Risk for Complications of Haemorrhage Potential Complications: Haemorrhage 32  Decision tree for Nursing Diagnosis and Collaborative Problems Does a group of cues indicate a health problem? No Yes Is the nurse licensed to make the definite Strength or Wellness diagnosis and prescribe the primary Diagnosis interventions to treat or prevent the problem? Yes No, is the problem actual or potential? Actual Potential Nursing complications Diagnosis Medical Diagnosis Collaborative Diagnosis 33 3rd Step: Planning Establishing priority diagnoses Planning goal and expected outcomes Prescribing nursing interventions Designating evaluation methods * Writing up nursing care plans* 34 Planning: Establishing Priority Diagnoses Preservation of life High: life-threatening Medium: physical/emotional changes Low: minimal nurse support Maslow’s Hierarchy of human Needs Physiologic > Safety & security > Social > Esteem > Self-actualization Client preference ** Priorities change as client’s condition changes ** Problem-focused diagnoses should not be viewed as more important than risk diagnoses 35 Planning goal and expected outcomes: Goal Setting Standards or criteria used to evaluate the client’s progress. Goal: broadly defined Client goal Nursing goal Short-term goal Long-term goal 36 Planning goal and expected outcomes: Setting Expected Outcomes SMART Specific, Measurable, Achievable, Realistic, and Timely More specific, observable criteria to evaluate whether the goal has been met Nursing sensitive outcome One that can be achieved or influenced by nursing interventions 37 Example: Acute pain Goal The client will experience decreased pain. Expected outcome 1. The client will identify three non-pharmacological pain-relieving methods within one day. 2. The client will rate pain as less than 3 on a 1-10 scale within three days. 38 Prescribing nursing interventions ‘Any nursing treatment based upon clinical judgment and knowledge, that a nurse performs to enhance patient/ client outcomes’. Types of interventions Independent Dependent Collaborative Nursing Interventions Classification Seven domains: basic physiological, complex physiological, behavioural, safety, family, health system, and community 39 Planning interventions Problem-focused nursing diagnoses Reduce/ eliminate contributing factors or diagnosis Promote higher-level wellness Monitor & evaluate status Risk nursing diagnoses Reduce/ eliminate risk factors Prevent the problem Monitor & evaluate status Collaborative problems Monitor for changes and evaluate status Manage changes in status 40 Writing nursing orders Nursing orders are written, detailed instructions for performing nursing interventions indicated for the nursing diagnoses or correcting the related factors. Components of nursing orders Subject Action Verb Descriptive Phase Time Frame (Nurse) (will) auscultate bowel sounds q4h. (Nurse) (will) assist Patient to ambulate to the door t.i.d. Examples of action verbs: offer, assist, instruct, refer, assess, change, give, listen, demonstrate, turn etc. 41 Nursing Intervention Ethical and Legal consideration Autonomy Accountable Balance the values of cost and care 42 Writing Outcome Statements Individualized Specific Measurable Achievable Relevant Time frame Client and family agree with the goals Address all important client needs https://images.app.goo.gl/mYinvjGwQZdLQJGt8 43  Outcome Statements - Components of goal/ expected outcome statements Subject Action Special Performance Target Verb Conditions Criteria Time Patient Will list (after Two low-fat foods from each By attending of the Food Guide Pyramid discharge. nutrition class) groups. Patient’s Will be -- Clear to auscultation Within 24 lungs hours. Client Will walk (using walker) To bathroom and back Within 3 without shortness of breath days. 44  Writing Outcome Statements - Components of expected outcome statements Verb Performance Modifiers Criteria Examples: Apply, Amount: what, How, when, where, choose, when how much. communicate, Accuracy: How, what define, demonstrate, Quality: What, Examples: describe, explain, express, how How: using a walker identify, list, report, Distance and amount: When: after consulting with verbalize, use, walk where, when dietician Where: in one-to-one session 45 4th Step: Implementation Nursing assessment Perform or assist activities for clients Health teaching Consultation Referral Documentation e.g. format: SOAP/SOAPIER (Next lecture) Oral report 46 5th Step: Evaluation Client’s health status, progress toward goals and the nursing care plan Effectiveness of the nursing care plan 47 Evaluation Review desired outcomes Outcomes of the care plan Client’s outcome Compare and draw a conclusion Write the evaluative statement Types Process evaluation (Care plan quality) Impact evaluation (Immediate) Outcome evaluation (long term) 48 Area of Evaluation Cognitive Psychomotor Affective Body function and appearance 49 Name of Client: Age: Sex: Medical diagnosis: Diagnostic statement (PES):. “Methods of evaluation” before you conduct evaluation Examples: - Asks the client to verbalize three factors that promote wound healing. - Asks the client to demonstrate deep breathing techniques. 50 55 Name of Client: Age: Sex: Medical diagnosis: Diagnostic statement (PES):. Evaluation “Evaluation” after you have conducted evaluation Examples: - The client verbalized appropriately three factors that promote wound healing, including ….. - The client demonstrated correct deep breathing techniques. 51 56  Outcome achieved Actual problem has been resolved Potential problem has been prevented All problems have been resolved; there are no new problems Outcome partially achieved Problem has been reduced, Evaluation has been continue with the same plan but conducted allow more time; or Problem has been reduced and plan of care needs revisions Outcome not achieved Problem still exists, re-examine entire plan of care and decide whether to continue or revise the plan. 52 Evaluation Examples Desired outcomes: The client verbalized feeling less anxious. Actual outcomes (data): When dyspneic, states, ‘What should I do? Can you help me?’ No statements of feeling less anxious Conclusion: Outcome not achieved. Desired outcomes: The client verbalized understanding of hospital routines and treatments. Actual outcomes (data): States, ‘I understand about the hospital routines and the breathing treatments. Those things really aren’t causing any anxiety.’ Conclusion: Outcome achieved. 53 Cues when formulating accurate nursing diagnostic statements 1. Choose the most appropriate nursing diagnosis Example Risk for Aspiration related to difficulty swallowing. Impaired swallowing related to decreased gag reflex secondary to Parkinson’s disease as evidenced by stasis of food in oral cavity. 2. Avoid using medical diagnosis as etiology or etiologic factors that cannot be intervened by nursing interventions alone Example Risk for deficient fluid volume related to increased capillary permeability and inflammatory process secondary to burn injuries. Risk for Complications of Fluid/Electrolyte Imbalance. 54 Cues when formulating accurate nursing diagnostic statements 3. Differentiate between signs/symptoms and etiology Example Constipation related to reports of infrequent hard, dry faeces. Constipation related to inadequate fiber intake as evidenced by infrequent hard, dry faeces. 4. Avoid legally inadvisable or judgmental statements E.g. Impaired communication related to failure of staff to use effective communication techniques as evidenced by impaired ability to speak. 55 Factors affecting diagnostic accuracy Critical-thinking abilities Clinical reasoning skills Analytical and inference skills Be open-minded Truth-seeking disposition Availability of knowledge sources Complexity of patient’s situation Diagnostic education and resources in nursing practice Hospital policy and diagnostic environment 56 References Berman, A., Snyder, S. J., & Frandsen, G. (2020). Kozier and Erb’s Fundamentals of nursing: Concepts, process and practice (11th ed.). Pearson. Carpenito-Moyet, L. J. (2017). Nursing diagnosis: Application to clinical practice (15th ed.). Lippincott. 57 END 58