Nursing Process: Overview, Assessment and Diagnosis | PDF

**Nursing Process** **Chapter 16-20** **Overview** \- utilize critical thinking, communication, building relationships and displaying professionalism \- assessment, analysis, diagnosis, identification, planning, implementation and evaluation \- the American Nurses Association developed the nurs...

**Nursing Process** **Chapter 16-20** **Overview** \- utilize critical thinking, communication, building relationships and displaying professionalism \- assessment, analysis, diagnosis, identification, planning, implementation and evaluation \- the American Nurses Association developed the nursing process (5 step process) \- not one fits all \- evidence based, holistic (whole person) and patient centered (QSEN) **Assessment** \- collecting as much information as possible (an ongoing process) \- learn about client, family and community \- a thorough and comprehensive assessment allows a nurse to sort data, find patterns and make judgements to identify health problems of the pt \- initial assessment is CRITICAL to identify problems quickly but continuing assessment throughout pt care is also important \- can be broad (judgement narrows) or situational (status change) \- assessment database changes when pt status changes *Critical Thinking: Assessment* \- helps with being deliberate and systematic with data collection \- guides your assessment \- ex. driving past a wreck and examining and analyzing the situation (who/what/why/where) *Steps of Collection: Assessment* 1\. Collection \- info from primary source (pt) and secondary source (family/friend/provider) \- relevant data, recall prior experience, apply critical thinking \- use physical, biological and social data to collect and complete history and physical of pt 2\. Interpretation \- do we need more info? \- critical decisions requires knowledge base and access to information \- it is our job to interpret the story created from the data about the specific pt *Types of Collection: Assessment* \- pt centered interview (gathered during nursing history) \- periodic assessments \- physical examination (done with initial contact and can be ongoing) \- comprehensive or problem focused Comprehensive \- detailed assessment of pt physical, psychosocial, cultural, spiritual and lifestyle needs \- can use pt centered interview \- head to toe physical exam Problem Focused \- collected during rounding, pt care times and med administration \- can use quick screenings to rule out or follow up on pt problems \- nurse uses ABCDE \- different untied or different roles may use problem-specific assessment \- problem based physical exam (lung, chest exam/leg numbness) *Types of Data: Assessment* \- primary subjective, secondary subjective, primary objective and secondary objective Primary Subjective \- pt verbal description or self report \- only given by pt \- physiological, social or psychological reports \- ex. Pain score, feeling of doom and anxiety about a procedure Secondary Subjective \- report from others (friend/family/provider) about the pt or about what the pt has relayed to them \- ex. "They told me they do not eat lunch" Primary Objective \- report from direct observation or measurement by you (the nurse) \- ex. BP reading, wound inspection, observing ambulation, observed behavior Secondary Objective \- data we collect from other sources (family/friends/health team) \- ex. BP log from home *Data Sources: Assessment* 1. 2. 3. 4. 5. *Patient Interview: Assessment* \- pt centered and organized way to gather information \- can be less than a minute up to several minutes \- good interview skills can lead to problem detection, accuracy, pt satisfaction, pt recall of information, adherence to therapy and positive pt outcomes \- observe the entire time you are with the pt Preparing for the Interview \- review records when available \- know chief complaint \- know the admitting diagnoses to know which systems to check Communication \- ask open-ended questions \- pt with low literacy may have trouble understanding questions (avoid medical terms) \- older adults typically take longer to communicate than younger adults \- always be attentive, caring and engaged (pt is less likely to withhold the truth) \- maintain eye contact \- maintain privacy *Interview Phases: Assessment* \- orientation, working phase and termination Orientation \- setting the agenda \- introduce self and explain why you are collecting data and ensure confidentiality \- explain actions \- focus on pt goals and concerns \- establish pt comfort with nurse and discussion \- show professionalism and competence Working Phase \- gather accurate, relevant and complete info \- open ended questions \- active listening (summarize key terms) \- do not rush to an opinion and do not rush a pt \- clarify key terms (dizziness/weakness) \- initial interviews will be extensive and ongoing interviews will be shorter Termination Phase \- summarize discussion \- check for accuracy of information \- give pt notice of ending the interview \- allow pt to ask additional questions \- end friendly and give patient expectation for your return Variables Affecting Interviews \- setting \- time pressure \- interruptions \- task complexity *Biographical Information: Assessment* \- age \- sex \- address \- insurance \- occupation \- marital status *Chief Concern: Assessment* \- brief statement in pt own words \- chart in quotations \- subjective data \- will give a focus on assessment *Patient Expectation: Assessment* \- ask what the pt expectations are \- communicate through the pt expectations \- pt satisfaction *PQRST's: Assessment* \- a way to chronologically frame an illness/symptoms \- assess primary symptoms/complains but also accompanying symptoms \- 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* \- meds \- allergies (if yes, include types of reactions and treatments) \- social/lifestyle (smoking, drinking, drugs, exercise, coping habits and nutrition) \- illnesses, injuries, surgeries and hospitalizations *Family: Assessment* \- at risk assessment \- immediate and blood relative issues (cancer, heart disease and stroke) \- if family does not support, do not include in care *Psychosocial: Assessment* \- info about family (spouse/children/friends) \- history of loss and grief \- coping \- stress \- pt strategies for dealing with stress *Spiritual Health: Assessment* \- religion \- faith \- rituals \- preferences *Review of Systems: Assessment* \- subjective info from pt about presence or absence of health related issues in each system \- ask about normal function or any changes in systems \- ask about abnormalities \- conduct physical assessment: inspection, auscultation, palpation and percussion *Observation: Assessment* \- done during pt interview \- verbal and nonverbal cues/behavior (does it match what the pt says) *Documentation: Assessment* \- timely, clear, concise and appropriate terminology \- no generalizations or judgements, be specific and factual \- "if you didn't chart it, you didn't do it" \- this is a legal and professional responsibility of nurses \- standardized forms \- date and time (military) in each entry \- sign name with credentials \- leave no open spaces \- errors are not whited out, they get a strike through with date and initials **Diagnosis** \- defined as a nursing diagnosis when a nurse applies critical thinking in making the clinical judgment that leads to identifying \- there are 3 types of nursing diagnoses: (medical, nursing diagnosis and collaborative problems) Medical \- ID of disease based on specific assessment of physical signs and symptoms, history and diagnostic lab results \- used by physicians and advances practice nurses \- common diagnosis is known condition, signs and symptoms and treatment needed \- nurses provide education on condition, medication and management Nursing Diagnosis \- judgement by RN of pt response or vulnerability to health condition \- diagnostic label based on patterns of assessment data \- 5 categories: pathophysiological (MI), treatment related (dialysis), personal (dying/divorce), environmental (home/safety) and maturational (peer pressure/parenthood) \- nurses can't treat medical diagnosis but can treat pt response to health conditions (pain, immobility, impaired coping) \- nurses can't order tests or medication (except advances practice) \- nurses do treat and manage responses independently Collaborative Problems \- problems that require both medical and nursing diagnosis \- not all physiological problems are collaborative \- teams come together and produce positive outcomes *Terminologies: Diagnosis* ICNP (International Classification for Nursing Practice) \- standard terminology system used worldwide \- set by ICN (International Council of Nurses) \- unified nursing language (used by WHO) \- uses positive and negative to sort diagnoses NANDA (North American Nursing Diagnosis Association) \- developed in 1982 and updated to 2018 \- a nursing diagnosis and classification system \- based on assessment data analyzed and clustered to patterns and interpreted before nurse can make a nursing diagnosis \- you can't plan and intervene correctly without knowing pt health problems \- problem focused, risk diagnosis and health promotion NOC (Nursing Outcome Classification) \- links outcomes to NANDA NIC (Nursing Interventions Classification) \- interventions to achieve outcomes Problem Focused \- negative response to existing problems (acute pain and urinary retention) Risk \- increased potential or vulnerability for pt to develop a problem (risk for fall) Health Promotion \- motivation to improve health status through a positive behavioral change (readiness for enhanced relationship) *Data Clustering and Finding Patterns: Diagnosis* \- an accurate database leads to an accurate nursing diagnosis allowing planning, implementation and interventions \- ability to recognize and analyze clues, promote diagnosis, plans and interventions will evolve with experience \- one way to help is to organize data into patters (data clusters: a set of assessment findings) \- gather data, interpret data by identifying clusters or patterns and name the problem \- compare findings with data from normal healthy pt then separate abnormal data to narrow pattern \- finding a cluster helps to think less on individual data \- a specific finding may apply to one or more patterns of data (slow limb - mobility and comfort) Interpretation \- as you cluster data, you will reveal a nursing diagnosis or be able to label how the pt is responding the problem \- critical thinking must be sued to interpret data and give the right diagnosis *Formulating a Diagnosis Statement: Diagnosis* Phrasing a Nursing Diagnosis Affects the Following: \- how you communicate a pt problem to other staff \- which interventions you choose \- how you evaluate a pt outcomes Diagnostic Label \- nursing diagnosis approved by NANDA, ICNP or system used by institution \- ex. Anxiety, impaired mobility, body weight problem Related Factors \- condition or set of conditions that caused or influenced the problem \- gives clarity and makes interventions more specific \- it is not a "cause and effect" statement \- ex. Uncertainty over surgery, acute pain, nausea and vomiting Evidence \- major assessment findings \- written "as evidenced by" \- AEB offers guidelines for how you will evaluate the efficacy of nursing care \- ex. Restlessness and unable to sleep, limited ROM of right leg or pain scale 7/10, weight loss in 1 month NANDA \- *problem focused nursing diagnosis* in 3 parts: diagnostic label, related factors and evidence \- ex. Ineffective airway clearance related to thick mucous production as evidence by productive cough, wheezing and difficulty expectorating \- *risk focused nursing diagnosis* in 2 parts: a diagnosis as evidence by \- do not use related to because this is just a potential problem \- ex. Risk for falls as evidence by impaired mobility and decreased visual acuity \- *health promotion diagnosis* in 2 parts: diagnosis and defining characteristics \- clinical judgement about a pt desire to improve their health and well being \- ex. Sedentary lifestyle as evidence by insufficient motivation for physical activity and readiness for enhanced nutrition as evidence by willingness to follow meal plan **Planning** \- a care plan is a road map for for delivering nursing care \- we have a problem and we need a plan to fix it \- prioritize nursing diagnosis based on the urgency and the order interventions will be implemented \- order may change as pt condition changes (can change in a matter of minutes) \- review order at the beginning of every shift to keep them updated \- problem focused takes priority over risk and health promotion diagnosis Categorizing priorities \- high intermediate and low \- high: if left untreated, can result in harm to pt (airway, breathing, circulation, safety, pain) \- Intermediate: non emergent, non life threatening (risk for infection) \- low: not always related directly to an illness (future well being and long term care needs) \- ethic care: ethical issues can disrupt priorities, be clear with pt, family and caregivers (ex. Fear of dying may take priority over pain) *Outcomes: Planning* \- what does my pt need to achieve? \- outcome measurement is a major factor in how agencies measure quality care \- core measures = funding \- expected outcomes are specific statements about pt responses (physical or behavioral) that you expect to achieve through your interventions \- sets a clear direction for interventions and sets specific measures for evaluating the effectiveness of meeting outcomes \- outcomes should be measurable \- all team members contribute to pt outcomes and goals Nursing Sensitive Outcomes \- measurable behavior or perception in response to nursing interventions \- characteristics: \- pt functional status (maintained or improved) \- pt safety (protected or unharmed) \- pt satisfaction (pt reports comfort and contentment) Nursing Outcome Classification \- links outcomes to NANDA diagnosis \- multiple outcomes for each diagnosis (evidence based) \- include indicators for evaluating process \- a goal statement How to Write Goals and Outcome Statements: Planning SMART \- specific, measurable, attainable, relevant and times Specific \- pt ambulates in the hallway 3x a day by 4/22 \- 1 behavior per goal Measurable \- body temp will remain below 98.6 \- avoid using vague terms such as, normal, acceptable and stable (these are not measurable) \- quality, quantity, frequency, length or weight Attainable \- these are mutually set with the pt and increases likelihood of success \- ensures pt agrees with plan Realistic \- consider pt preferences, needs and resources Timed \- includes a specific amount of time to reach and outcome \- within pt limitations and abilities *Interventions: Planning* \- any treatment or action that the nurse performs using clinical judgement too achieve pt outcome \- should be evidence based and including the knowledge about your pt \- pt assessment gives data about related factors and risk factors associated with a nursing diagnosis \- these same related factors or risk factors are indicators for intervention choice Types of Intervention \- direct and indirect (both can be applied to pt) \- *direct*: performed through interaction with pt and involves laying of hands (bathing, wound care and IV insertion) \- *indirect*: performed away, but on behalf, of pt (managing care environment and consultation) \- interventions are further classified as nurse initiated, healthcare provider initiated and other provider initiated (pharmacist, RT and OT) \- *nurse initiated*: independently initiated without orders or direction (ADLs, positioning, mobility and education) \- *HCP initiated*: requires an order (med admin, foley Cath and IV) \- *other provider initiated*: interdependent, social work, rehab and pharmacy \- before doing HCP or OP initiated interventions, verify that it is correct and appropriate \- know agency policy and procedures \- errors happen all the time when orders are transcribed \- RN is responsible for errors carried out *Intervention Selection: Planning* \- don't select based on diagnosis, consider desires pt outcome, characteristics of nursing diagnosis, research based knowledge, feasibility for doing the intervention acceptability to the pt and your own competence \- review NOC and NIC resources and agency policies \- choose best potential to reach pt outcome Care Plans \- create care plans for each pt \- depending on specialty or unit, there will be a standardized plan or individual care plan \- care plan is all of the above but in written form \- plans are revised as pt status changes but provides continuity for with staff \- pt in facilities can have care plans from more than one nurse/provider \- used for discharge planning \- families are often a resource for helping pt meet their goals \- care plans will help you learn problem solving using the nursing process and organizing nursing care \- helps apply knowledge in practice situations \- make connection of rationales to interventions \- include rationale and reference for each intervention \- needs to be specific and unique to each pt situation **Implementation** \- carrying out the nursing interventions selected while using good judgement \- starts after pt care plan \- carrying out direct and indirect measures \- initiated by nurse, HCP or other \- direct care: hands on personal interactions with the pt \- indirect care: performed away from the pt Scope of Nursing Practice \- set by ANA and each state board of nursing \- describes what a nurse is licensed to perform \- KNOW YOUR SCOPE OF PRACTICE *Standard Nursing Interventions: Implementation* \- there are times when you have standard intervention sets or protocols \- nursing interventions are complex \- proper prep ensures efficient, safe and effective care \- errors and bad outcomes happen when rushing \- there are 5 steps to ensure proper care 1. - 2\. Review Nursing Care Plan and Revise as Needed - - 3\. Organize Necessary Resources and Delivery of Care - - - - - - - - 4\. Anticipate and Prevent Complications - - - - - 5\. Implement Correctly - - - - *Direct Care vs Indirect Care: Implementation* \- implementation requires cognitive, interpersonal and psychomotor skills Direct Care \- measures treatment and procedures \- ADL's: breathing, ambulation, toileting, dressing and eating \- Instrumental ADL's: shopping, taking meds, writing checks and prepping meals Physical Care Techniques \- safe and competent administration of nursing process \- insertion of feeding tube, med admin and IV insertion \- requires nurses to protect themselves and the pt Lifesaving Measures \- care techniques used when pt psychologic or physiologic state is threatened \- purpose is to restore homeostasis \- CPR, crisis counseling, emergent med admin and protection for confused pt Counseling \- care method to help pt problem solve and manage stress \- counsel to accept actual or impeding changes \- can include emotional, intellectual, spiritual and psychological support (terminal or chronic illness) Education \- emphasis on pt education \- nurses are always teaching \- pt education is evaluated in in a lot of surveys and can impact funding \- always use layman's terms when educating \- when teaching a skill, use return demonstration Controlling for Adverse Reactions \- learn to anticipate what to expect \- ex. When giving meds know the side effects Preventative Intervention \- promote health and prevent illness to avoid need for rehab or acute care \- wellness, immunization, exercise and health screenings Indirect Care Measures \- nursing treatments or procedures performed away from the pt but on behalf of pt \- managing pt care environment, inter professional collaboration, documentation, hand off report and delegation to AP's Communicating Nursing Interventions \- electronic, written or verbal \- effective communication prevents medical errors and adverse outcomes \- miscommunication is often the root case for most adverse or sentinel events Delegating, Supervision and Evaluation of Other Staff Members \- because you create a care plan, does not mean you will complete all interventions \- you may delegate AP's, RN's or LPN's \- RN can delegate task but not nursing process \- RN holds accountability to delegation and the care provided \- delegation requires clinical judgement **Evaluation** \- have assessment findings remained the same, improved or changed since interventions? \- when outcomes are achieved, the related factors or risk factors usually no longer exist or are better managed \- decide to continue, discontinue or revise