Nursing Process Lecture Spring 2024 PDF

Nursing Process Part I & 2 This Photo by Unknown Author is licensed under CC BY-NC Beverly McLawyer, MSN, RN Los Angeles County College of Nursing and Allied Health [email protected] 1 1 Nursing Process Agenda Purpose and definition Professional implications 5 steps: “AAPIE” Clinical Judg...

Nursing Process Part I & 2 This Photo by Unknown Author is licensed under CC BY-NC Beverly McLawyer, MSN, RN Los Angeles County College of Nursing and Allied Health [email protected] 1 1 Nursing Process Agenda Purpose and definition Professional implications 5 steps: “AAPIE” Clinical Judgement Prioritization activity Problem identification activity All-In-One Nursing Care Plan 2 book 2 What is the Nursing Process A systematic method that directs the nurse, w/the patient’s participation to: Assess the need for patient care Determine “Patient Problem”, for actual or potential problems Identify desired outcomes and plan interventions Implement the interventions Evaluate if desired outcomes are met 3 3 1 Nursing Process A person-centered, outcome-oriented process All steps are interrelated Each step depends on the accuracy of the proceeding steps. Universally applicable to all practice settings Provides the framework for all nursing activities. 4 4 Benefits (Goals) of the Nursing Process Achieves for the patient scientifically based, holistic, individualized care, the opportunity to work collaboratively with nurses, and continuity of care 5 5 Professional Implications 1. Identifies consumer of care 2. Incorporated in Standards of Nursing Practice (ANA) 3. Board of Registered Nursing (BRN) Mandates use of the nursing process in nursing practice 6 6 2 Professional Implications 4. National Practice Standards RN accountability 5. Provides the basis for NCLEX exam 6. Tool for critical thinking in clinical 7. Aids Magnet status achievement 7 7 Nursing Process 8 This Photo by Unknown Author is licensed under CC BY-NC-ND 8 QSEN Competencies: Knowledge, Skills & Attitude Patient-centered care Incorporating patient/family preferences and values for delivery of optimal health care Teamwork and collaboration Working with inter- and intra professional teams in developing a pt centered plan of care Evidence-based practice Integrating best current evidence with clinical expertise and interventions 9 9 3 QSEN Competencies: Knowledge, Skills & Attitude Quality improvement Interventions must have been researched Evidence must be established to support their effectiveness Safety Assessment and evaluation of interventions for level of appropriateness (age/physical capability) Informatics Document and plan patient care in the EHR Taylor et al. (2023), p.358 – 370 Begin reading page 358 at QSEN Competencies. End on page 359, Box 13-7. 10 10 Nursing Process Steps “AAPIE” (You will hear about this throughout nursing and from the BRN. The following steps need to be understood to understand the Nursing Clinical Judgement Measurement Model) 1. 2. 3. 4. 5. Assessment Analysis Planning Implementation Evaluation Taylor et al. (2023), p.363 – 370 Begin reading Bottom page 363 at Nursing Process. End on page 370 just before Concept Mapping. 11 11 NCSBN - Nursing Clinical Judgement Measurement Model (NCJMM) National Council State Boards of Nursing (NCSBN) evidence-based model that identifies 6 skills nurses need Recognizing Cues Analyze Cues Prioritize Hypothesis Generate Solutions Take Action Evaluate Outcomes Taylor et al. (2023), p.388 – 391 Begin reading at National Council State Boards of Nursing. End just before Developing Competency in Nursing Practice 12 12 4 Comparison Nursing Process Steps vs NCJMM Skills Nursing Process Assess Analyze Plan Implement Evaluate Outcomes NCJMM Recognize cues Analyze cues Prioritize hypothesis Generate Solutions Take Action Evaluate Outcomes 13 13 NCJMM Skills & Nursing Process 1. Assessment and recognition of cues (to identify the client’s/patient’s needs and what matters most) 2. Analyze cues (human response needs that nurses can treat) Then, Prioritize hypotheses (identify the problem while using Maslow’s Hierarchy of needs and write what the problem is) 14 14 NCJMM Skills & Nursing Process 3. Planning (plan client’s care by generating solutions) State the desired client outcome Create the plan of care 4. Implementation (take action by doing the care that is planned or the solutions that are generated) 5. Evaluation (evaluate the success of the implemented care/actions taken to decide if the client met or partially met the desired outcome, or did not meet the desired outcome) 15 15 5 Nursing Process Remember thoughtful person-centered care. Taylor et al. (2023), p.346 - 348 Everything nurses do must keep the patient at the center. Taylor et al. (2023), p.354 - 357 The nursing process ensures nurse are person-centered rather than task oriented 16 Taylor et al. (2023), p. 366 Table 13-3; p.367 - 368. 16 Step 1: Assessment Different Types of Nursing Assessments Initial assessment – performed shortly after a client is admitted to a health care facility Focused assessment – data gathered about a specific problem already identified Quick Priority assessment – quick, focused to gain the most important information needed first Taylor et al. (2023), p.407-411 Begin reading at Types of Nursing Assessments Stop at the end of Triage Assessment 17 17 Step 1: Assessment Different Types of Nursing Assessments Emergency assessment – to identify lifethreatening problems when a client presents with a physiologic or psychologic crisis. Time-Lapsed – to compare a client’s current status to the baseline data obtained earlier. Triage assessment – screen clients to determine the extent and severity of their problems, then recommend appropriate follow-up. 18 18 6 Step 1: Assessment To establish a database of the client’s response to health concerns/illness and their ability to manage health needs Begin recognizing cues Ask self – What assessment data is pertinent? 19 19 Assessment Activities 1. Establishing a database Review records & literature Obtain health history (hx) Perform physical assessment Consult support persons & health professionals 2. Update, organize, and validate data 3. Communicate/document data   Assessment activities continue through all steps of the Nursing Process. 20 20 Collecting Data 1. Before you see the client 2. Getting report during hand off communication and when looking into the patient's electronic health record and other health related records and exams. When you see the client The assessment you do and vital signs. Also, when speaking with the patient you will gather information 3. After you see the client comparing labs, following up on care and client requests. When collaborating with other care providers like CNAs, Physicians, PT, OT, Pharmacy, Social Worker, RT, etc. 21 21 7 Taylor et al. (2023), p.414 - 415 Collecting data Subjective Data (Symptoms) Apparent only to the person affected Can be described/verified only by the person affected Sensations, feelings, values, beliefs, attitudes & perceptions of personal health status & life situations “I feel like my heart is racing” “I have pain” 22 22 Objective Data (Signs) Taylor et al. (2023), p.414 - 415 Collecting data Detectable by an observer Can be measured or tested against an accepted standard Can be seen, heard, felt, or smelled Obtained through observation or physical examination Example: Apical HR 150, regular & strong 23 23 Sources of Data The client is the Family primary source Support persons Taylor et al. (2023), p.416 – 417 & 439 Sources of data Health professionals Medical records Validate information ✓When is it appropriate to use a secondary resource? ₌ Too ill, unconscious, child, confused, on request, not able to communicate, etc.... 24 24 8 Methods of Data Collection Taylor et al. (2023), p.418 - 419 Methods of Data Collection 1. Observing 2. Interviewing 1. Setting 2. Questions 3. Techniques 3. Assessment 25 25 Observing Gathering data using senses Vision, hear, touch, and/or smell Used to obtain the following types of data (for example): Skin color (vision) Body or breath odors (smell) Lung or heart sounds (hearing) Skin temperature (touch) Taylor et al. (2023), p.418 Methods of Data Collection-Observation 26 26 Interviewing Planned purposeful communication Positive, professional, and unbiased Purpose Obtain or give information Identify problems Evaluate change Teach Provide support & counseling 27 Taylor et al. (2023), p.418 – 419 & 420 Patient Interview 27 9 The Interview Setting Preparation Time Place Seating arrangements Respectful distance Language Interpreter, translator, or family? 28 28 Interview Tips Terminating interview & assessment Time constraints Summarizing End on positive: Offer availability Common communication errors Using first name(unless it is client preference) or endearing names Talking down or ignoring cultural considerations 29 29 Questioning Techniques Closed-ended questions Do you get along with your family? Are you allergic to Motrin? Yields yes or no answers Open-ended questions How is your relationship with your family? What reaction do you have to Motrin? Yields explanations 30 30 10 Nursing Physical Assessment 1. Focuses on client’s functional abilities 2. Purposes of the physical assessment include: Appraisal of health status Identification of health problems (recognizing cues) Establishment of a database for nursing interventions 3. In different settings different, nurses may use different techniques for different purposes Taylor et al. (2023), p. 419 & 421 Physical Assessment 31 31 Physical Assessment 1. Systematic data-collection method Head-to-toe Review of Systems 2. Technique Observation, inspection, auscultation, palpation, percussion 3. Data obtained BP, HR, heart, lung, & GI sounds, skin color, temperature & moisture, & muscle strength, and more. 32 32 AAPIE – Assessment (Recognize the Cues) Assessment Recognize Cues Subjective Data: Write comments the patient makes regarding their health and assessments. What the patient says about their symptoms. Can only be verified by the patient. Analysis Analyze Cues Prioritize Hypothesis Cluster Abnormal Cues: Identify Priority Patient Problem: Prioritize the cues according to Maslow’s Hierarchy of Needs and Cluster the information Write the priority problem that is identified and write what it is due to. [Use the All-In-One book to help with identifying a problem] ________________ due to __________________. Planning Implementation Evaluate Generate Solutions Take Action Evaluate Outcome Generate Desired Outcome (Ensure it is a SMART Outcome): Client will ______________ _____________by time on date Generate Independent Nursing Interventions (solutions): Independent Nursing Interventions Implemented: Assess: Rationale: Assessed: Client Response: Do1: Rationale: Did1: Client Response: Do2: Rationale: Did2: Client Response: Teach: Rationale Taught: Client Response: Objective Data: These are symptoms and assessment that can be verified by another observer. Can be measured against an accepted standard. Can be seen, heard, smelled or felt. Includes all of the abnormal assessment items, VS, and labs that you identify. Evaluate the Desired Outcome: (Use one of the evaluations below) Was the Outcome Met? Briefly explain how. Or Was the Outcome Partially Met? Briefly explain and revise the plan by revising the interventions. Or Was the Outcome Unmet? Briefly explain and revise the entire plan and interventions. 33 33 11 Clustering (Organizing) Data & Analyze Cues 1. Compare subjective & objective data Follow- up on conflicting information Cluster data 2. Unreliable source Altered client 3. Recheck abnormal findings Compare findings to normal values Found in the eHR and textbooks Report to primary RN, Nursing Instructor, and provider (when needed) 34 Taylor et al. (2023), p.422 - 423 Methods of Data Collection 34 Clustering (Organizing) Data & Analyze Cues 1. Interpret & analyze data Compare data against standards Identify gaps and inconsistencies 2. Determine client’s strengths, risks, needs, & problems 3. Identification of problems What are the problems identified by the assessment findings? 35 Taylor et al. (2023), p.422 – 423, 436 - 437 Methods of Data Collection 35 Problem Identification Activities 1. Prioritize problems Set priorities according to Maslow’s Hierarchy of Needs 36 36 12 Types of Client/Patient Problem 1. Actual Problem is current Decrease – the problem is current and is a decrease from normal 2. Potential For Problem that has not yet occurred but there is a risk of occurring 3. Need For Health Teaching When this is used it must be qualified by the reason there is a need 37 Taylor et al. (2023), p.439 Reaching Conclusions 37 Types of Client/Patient Problem Actual A health problem exists There is evidence of the problem For example Decreased Functional Ability due to fracture in left patella (or you could use kneecap) The nurse needs to know the difference between an Actual Problem and a Potential Problem 38 38 Types of Client/Patient Problem Risk / Potential for Health problem may develop if the nurse does not intervene Identifiable risk factors, no evidence of the problem Put Potential for and what the potential problem is due to For Example: Potential for Injury due to impaired sensory reception The nurse needs to know the difference between an Actual Problem and a Potential Problem 39 39 13 Types of Client/Patient Problem 1. Need For Health Teaching When this is used it must be qualified by the reason there is a need Same language use for all health teaching needs The “due to” distinguishes the problem. For example: Need for Health teaching due to depressed gag or cough reflex Need for Health Teaching due to unfamiliarity with self-care regarding urinary diversion 40 40 Collaborative Problems: Nurses manage using both independent & dependent interventions Focus: monitoring client condition & preventing complications from developing Requires nursing & medical interventions The hope is to better coordinate language with all clinical practice for optimal collaboration 41 Prioritize Hypothesis (Prioritize the Client Problem: Prioritize the Hypothesis: Ask: What is the main problem with the patient the nurse can treat? Identify the client’s strengths and health problems that can be prevented or resolved by independent nursing interventions In the next semesters this will include collaborative nursing interventions 42 42 14 Prioritize Hypothesis 1. Formulate problem statement 1. Also use Maslow’s Hierarchy of needs to help decide which problems to prioritize for developing a plan of care 2. Document problem statement 43 (See the All-IN-One Book) 43 Physiologic Problems/Psychological Problems Formal functions of the body Examples: Pain, Acute Peripheral tissue perfusion, decreased Aspiration, Potential for Mental or emotional Examples Potential for social isolation Decreased selfesteem Anxiety Grieving 44 44 AAPIE – Analyze Cues & Identify Priority Problem Assessment Recognize Cues Subjective Data: Write comments the patient makes regarding their health and assessments. What the patient says about their symptoms. Can only be verified by the patient. Analysis Analyze Cues Prioritize Hypothesis Cluster Abnormal Cues: Identify Priority Patient Problem: Prioritize the cues according to Maslow’s Hierarchy of Needs and Cluster the information Write the priority problem that is identified and write what it is due to. [Use the All-In-One book to help with identifying a problem] ________________ due to __________________. Planning Implementation Evaluate Generate Solutions Take Action Evaluate Outcome Generate Desired Outcome (Ensure it is a SMART Outcome): Client will ______________ _____________by time on date Generate Independent Nursing Interventions (solutions): Independent Nursing Interventions Implemented: Assess: Rationale: Assessed: Client Response: Do1: Rationale: Did1: Client Response: Do2: Rationale: Did2: Client Response: Teach: Rationale Taught: Client Response: Objective Data: These are symptoms and assessment that can be verified by another observer. Can be measured against an accepted standard. Can be seen, heard, smelled or felt. Includes all of the abnormal assessment items, VS, and labs that you identify. Evaluate the Desired Outcome: (Use one of the evaluations below) Was the Outcome Met? Briefly explain how. Or Was the Outcome Partially Met? Briefly explain and revise the plan by revising the interventions. Or Was the Outcome Unmet? Briefly explain and revise the entire plan and interventions. 45 45 15 Planning (Generating Solutions) To develop an individualized care plan that specifies client goals/desired outcomes, and related nursing interventions 46 46 Planning (Generating Solutions) 3 types of planning: 1. Initial planning: Developing the preliminary plan of care (on admission) 2. Ongoing planning: Updates of care based on reassessment 3. Discharge planning: Anticipation & preparing for the patient’s needs after discharge 47 47 Setting Priorities to address Client/Patient Problem Establishing a sequence for addressing Client/Patient Problems & interventions 1. High priority (life-threatening) 2. Medium priority (health-threatening) 3. Low priority (developmental needs) 48 48 16 Factors to Consider when Setting Priorities to Address the Problem Maslow’s Hierarchy of Needs: Setting Priorities 49 49 Factors to Consider when Setting Priorities to Address the Problem Set priorities & desired outcomes in collaboration with patient/client Client’s health values & beliefs Client priorities Resources available to the nurse & client Urgency of the health problem Medical treatment plan 50 50 Planning - (Generating Solutions) Desired Outcome What the nurse hopes to achieve in the patient once actions are taken through nursing interventions 1. 2. 3. 4. 5. Purpose: Provides direction for planning nursing interventions Serve as criteria for evaluating client progress Enable the nurse to determine when the problem has been resolved Help motivate the client and nurse by providing a sense of achievement Each outcome is derived from only 1 Client problem 51 51 17 Planning - (Generating Solutions) Desired Outcome What is the desired outcome for the client Written Outcomes should be SMART: Specific Measurable Attainable Realistic Time bound 52 52 Planning (Generating Solution) 1. Write desired outcome Begin statement with “Client will” (if preferred you may use the word patient instead client) Do Not use (“at end of shift”) As first semester students you are not there until the end of the shift. Please make it time bound. Usually it will be “1300” or “1200.” 53 Verbs for Writing Desired Outcomes Measurable Verbs Apply, breathe, choose, define, demonstrate, select, state, turn, verbalize, prepare, identify, inject, describe, name… Non-measurable Verbs Know, think, understand, feel… 54 54 18 Desired Outcome Examples 1. “The client will identify two nonpharmacologic modalities to decrease pain to a level