Nursing Process Presentation 2025 PDF

The Problem Solving Approach 2025 Prepared by Teisha Vaughn MSN About ME ◼ Teisha Vaughn ◼ MSN, RN ◼ Founder and Lecturer at VHSI Nursing Academy ◼ Lecturer-University of Technology, Jamaica ◼ Certified Wound Care Nurse...

The Problem Solving Approach 2025 Prepared by Teisha Vaughn MSN About ME ◼ Teisha Vaughn ◼ MSN, RN ◼ Founder and Lecturer at VHSI Nursing Academy ◼ Lecturer-University of Technology, Jamaica ◼ Certified Wound Care Nurse ◼ Experience: ❖ Manager: Health Education EduFocal Ltd ❖ Clinical Instructor ❖ Nurse Manager Heart Foundation of Jamaica ❖ Cardiac Sonographer ❖ Director of Nursing Jamaica Health Security Network Ltd ❖ Endoscopy Nurse ❖ Adult Care ❖ Pediatric Care ❖ Occupational Health ❖ Nursing Education and Assessment OBJECTIVES At the end of this unit students will be able to: ◼ Describe the problem-solving method ◼ Identify the 5 phases of the Nursing Process ◼ List the 4 steps of the assessment phase ◼ Differentiate between nursing and medical diagnoses OBJECTIVES At the end of this unit, students will be able to: ◼ Describe the elements of the nursing care plan ◼ Explain the 4 steps in planning of nursing care ◼ Explain how a nursing care plan is implemented ◼ Identify the purpose of evaluation of nursing care  THE PROBLEM SOLVING METHOD ◼ Problem solving is part of decision making and is a systematic process that focuses on analyzing a difficult situation. (Marquis & Huston, 2017)  THE PROBLEM SOLVING METHOD Traditional process involves: ◼ 1. Identify the problem. ◼ 2. Gather data to analyze the causes and consequences of the problem. ◼ 3. Explore alternative solutions. ◼ 4. Evaluate the alternatives. ◼ 5. Select the appropriate solution. ◼ 6. Implement the solution. ◼ 7. Evaluate the results. (Marquis & Huston, 2017)  THE PROBLEM SOLVING METHOD What is the nursing process? ◼ Another theoretical system for solving problems and making decisions. ◼ Developed by Ida Jean Orlando in the late 1950s. ◼ Strong critical thinking component (Marquis & Huston, 2017) THE NURSING PROCESS THE NURSING PROCESS The 5 phases of the nursing process: 1. Assessment 2. Diagnosing 3. Planning 4. Implementing 5. Evaluation THE NURSING PROCESS 1. Try to apply this to everyday life. THE NURSING PROCESS Assessment Phase involves: ◼ Collecting data ◼ Organizing data ◼ Validating data ◼ Documenting data THE NURSING PROCESS Assessment Phase involves: Collecting data ◼ Use information about a patient’s needs to adapt your data collection. ◼ Data must be as thorough as possible. ◼ Support subjective findings with objective information. (Potter et al., 2016) ASSESSMENT Collecting the data General Assessment: Assessment in the nursing process involves: ◼ Patient interview/conversation ◼ Physical assessment ◼ Examination of diagnostic test results ◼ Examination of lab test results ASSESSMENT Subjective Data: ◼ Patient ◼ Caregiver ◼ Close friends and family members (Herdman et al., 2021) Is it subjective?: ◼ Feelings ◼ Thoughts ◼ Beliefs ◼ Just because it is said by the patient and family members, does not mean it is subjective. ASSESSMENT Objective Data: ◼ Your findings-what you saw, smelt, felt, heard ◼ Diagnostic test results ◼ Lab test results (Herdman et al., 2021) Is it objective?: ◼ Be very specific about what is observed ◼ Instead of saying patient appears a certain way, state exactly what is observed instead. ◼ Eg: Instead of: Patient appears to be in discomfort. Say: Patient is grimacing ASSESSMENT Steps for collecting assessment data: Subjective Data: ◼ Ask the patient how they feel, what they think and or belief (as it relates to the nursing diagnosis) ◼ Ensure that you cannot "prove" or "validate" what the patient said-if you can, then it is not subjective. ◼ Ask yourself if this piece of data is related to the diagnosis or problem identified. ASSESSMENT Collecting subjective data: Example: On the assessment you notice that the patient has a wound... ◼ If the patient talks about the wound, note their beliefs, concerns, thoughts and so on. What questions can you ask? ASSESSMENT Collecting subjective data: If the patient does not volunteer the data, ask them general questions such as: ◼ How do you think the wound is healing? ◼ Are you having any discomfort at the site of the wound? ◼ Do you have knowledge about what can help to improve wound healing? ◼ And so many more! The responses to these will provide subjective data (these help with creating a goal too) ASSESSMENT Collecting data: Identify the objective and subjective data in the scenario below: ◼ Mr Brown, is a 40 year old Farmer who lives in Cedar Valley Manchester. He presented to the hospital this morning with complaint of chest pain rated 10/10. The nurse observed that he has difficulty breathing and his respiratory rate was 28bpm. He also stated “I am afraid that i might be having a heart attack”. THE NURSING PROCESS Assessment Phase involves: Organizing data ◼ Differentiate important data ◼ Determine whether abnormal findings are present ◼ What are the signs and symptoms? ◼ Can these be clustered/grouped? ◼ Is more data needed? (Potter et al., 2016) THE NURSING PROCESS Assessment Phase involves: Validating data ◼ Clarify vague or unclear data. ◼ The comparison of data with another source to determine data accuracy. ◼ Check the information you have collected to avoid making incorrect inferences. ◼ Ask patients to validate unclear information obtained during an interview and history. ◼ Comparing data in the medical record and consulting with other nurses or health care team members. (Potter et al., 2016) THE NURSING PROCESS Assessment Phase involves: Validating data ◼ If you see someone crying, what are reasons that may be inferred? THE NURSING PROCESS Assessment Phase involves: Documenting data ◼ Different methods of documenting (depends on institution policies) ◼ Nurses notes ◼ Relevant charts DIAGNOSIS Can Nurses Diagnose? Nursing Diagnoses or Medical Diagnoses ◼ Did you know that nurses can diagnose? ◼ Did you know that we have our own diagnoses? ◼ Standardized language (NANDA-I) DIAGNOSIS ◼ During assessment, actual problems, potential problems and opportunities for health promotion are identified. ◼ Applicable nursing diagnoses are chosen from NANDA-I ◼ Read the diagnostic label and choose the most applicable diagnosis ◼ Formulate diagnosis properly DIAGNOSIS ◼ Let us get to know NANDA-I DIAGNOSIS Different types of nursing diagnoses: 1. Problem-focused/actual diagnoses ◼ Three part statements: Label + related factor + defining characteristics 2. Potential Diagnoses: Risk diagnoses ◼ Two part statements: Label + (related to) risk factors Health promotion diagnoses ◼ Two/Three parts statement 3. Syndrome diagnoses ◼ Three part statements: Label + related factor + defining characteristics (Herdman et al., 2024) DIAGNOSIS Identify different types of nursing diagnoses: 1. Risk for infection related to break in skin continuity, low white blood cell count (3000 cells per microliter) and history of frequent viral infections. 1. Impaired tissue integrity related to insufficient oxygen delivery to tissues due to chronic hyperglycemia as evidenced by pressure ulcer to right heal, blood glucose levels elevated at 300-450mg/dl over past 2/52. 1. Readiness for enhanced health literacy related to patient’s expression of wanting to learn more about managing her critical illness. How do we decide on the diagnosis? How do other professions diagnose? Identify the Nursing Diagnoses ◼ Student A Patient presents with a complaint ◼ Student B reads objective data ◼ Student C identifies nursing diagnosis based on the data presented ◼ Student D reads the definition from NANDA-I to check if student C is correct When it's time to write the related factor Identifying Part 2 (Related Factor) ◼ Related factors are used in diagnostic statements as of 2024 ◼ Problem focused/Actual Diagnoses---Related factor is the CAUSE ◼ Other labels---related factor is just a connector Risk for infection related to break in skin continuity, low white blood cell count (3000 cells per microliter) and history of frequent viral infections. Impaired tissue integrity related to insufficient oxygen delivery to tissues due to chronic hyperglycemia as evidenced by pressure ulcer to right heal, blood glucose levels elevated at 300-450mg/dl over past 2/52. Identifying Part 2 (Related Factor) ◼ The challenge: ◼ Identifying the cause ◼ Phrasing the cause ◼ NANDA-I Guidelines: Not related to medical procedure Not related to medical diagnosis Must be modifiable by the nurse Identifying Part 2 (Related Factor) ◼ The challenge: ◼ Identifying the cause ◼ Phrasing the cause Impaired tissue integrity related to insufficient oxygen delivery to tissues due to chronic hyperglycemia as evidenced by pressure ulcer to right heal, blood glucose levels elevated at 300-450mg/dl over past 2/52. Identifying Part 2 (Related Factor) ◼ The challenge: ◼ Identifying the cause ◼ Phrasing the cause Maladaptive coping related to inadequate confidence in ability to deal with a situation as evidenced by refusing to eat, patient ruminating over upcoming surgery and repeatedly saying “I can’t deal with this on my own”. Practice Practice Practice Planning PLANNING ◼ Goals and expected outcomes formulated ◼ Planned interventions ◼ Care plan written ELEMENTS OF THE NURSING CARE PLAN ◼ Assessment (subjective and objective data that support nursing diagnosis) ◼ Nursing Diagnosis ◼ Goals and Expected Outcomes ◼ Interventions ◼ Evaluation ELEMENTS OF THE NURSING CARE PLAN Assessment Nursing Diagnosis Goal and Expected Interventions and Evaluation Outcomes Rationale Subjective Data One diagnosis per page Goal agreed on with What will we do the Was the goal achieved? Proof of the diagnosis patient (if possible), achieve the goal and To what extent and in Related to the diagnosis must address the expected outcomes? what time? diagnosis SMART Objective Data Proof of the diagnosis Related to the diagnosis STEPS IN PLANNING NURSING CARE 1. Prioritize problems/nursing diagnoses 2. Formulate goals/desired outcomes 3. Select nursing interventions 4. Write nursing care plan PRIORITIZATION TIPS FOR PRIORITIZATION ◼ Look at the signs and symptoms ◼ Diagnostic findings ◼ Medical diagnosis ◼ Life-threatening problems should be given high priority (airway, breathing, circulation) ◼ Ask yourself: Which nursing diagnosis requires attention first? ◼ Utilize Maslow’s Hierarchy of Needs Goals and Expected Outcomes ◼ A goal is a broad statement that describes a desired change in a patient’s condition, perceptions, or behavior. ◼ A short-term goal is an objective behavior or response that you expect the patient to achieve in a short time, usually less than a week. ◼ A long-term goal is an objective behavior or response that you expect the patient to achieve, usually over several days, weeks, or months. (Potter et al., 2016) Goals and Expected Outcomes ◼ An expected outcome is the measurable change (patient behavior, physical state, or perception) that must be achieved to reach a goal. ◼ Think of a goal as an ultimate outcome and expected outcomes as the measurable changes that a patient achieves to reach a goal. (Potter et al., 2016) Goals and Expected Outcomes Goals & Outcome statements must have: ◼ Subject-this is the patient/family/community/group (in your case this is always the PATIENT) ◼ Verb-what do you want the patient to do? ◼ Conditions-under what conditions do you want the patient to do this? Could also be a timeline. ◼ Criteria-how will you measure that the patient did this? How will you know? What exactly will the patient say or demonstrate to indicate that the verb was done? (these are expected outcomes) (Potter et al., 2016) Goals and Expected Outcomes Goals & Outcome statements must be: ◼ S-specific ◼ M-measurable ◼ A-achievable ◼ R-realistic ◼ T-time bound Goals and Expected Outcomes Goals and Expected Outcomes Sample Goal & Outcome statements: 1. Within 30 minutes of nursing interventions, the patient will experience a reduction in pain as evidenced by patient rating pain 3 or less out of 10 on the pain scale. 1. By discharge, the patient will demonstrate understanding of insulin administration and glucose monitoring as evidenced by patient choosing appropriate locations and technique for self- administration of insulin and correctly performing the finger prick glucose test. Goals and Expected Outcomes Goal/Outcome don'ts: ◼ Do not make the nurse the subject of the outcome (Do not write what the nurse will do) ◼ Do not try to fix all the problems/signs and symptoms in a short space of time ◼ Do not use these terms: "will know" (will demonstrate knowledge), "will understand" (will display/express understanding), "should have" ◼ Avoid saying "at least" (if you do, you must include more criteria than the number you mentioned) Goals and Expected Outcomes Formulating the Goal & Outcome statement: Ask yourself: ◼ What is the problem? (this is the diagnosis/related factor) ◼ What does the patient want to achieve as it relates to this problem (you can ask the patient) ◼ What can be realistically achieved in this time span? ◼ Can I fix the problem? ◼ If it cannot be fixed, can the problem be improved? ◼ If it cannot be improved in the timeline, can we implement actions that will eventually result in improvement? Goals and Expected Outcomes Formulating the Goal & Outcome statement: ◼ Be clear about the type of interventions ◼ Will you be collaborating? ◼ Will you use dependent interventions (eg medication administration) ◼ Are the interventions independent nursing interventions? ◼ State which types of interventions will be utilized to achieve the desired outcome. Goals and Expected Outcomes Formulating the Goal & Outcome statement: Verbs that can be used: ◼ Achieve ◼ Verbalize ◼ Participate ◼ Demonstrate ◼ Remain ◼ Display ◼ Maintain This is not a finite list Goals and Expected Outcomes Formulating the Goal & Outcome statement: Scenario: Patient has a wound to the left knee. T 37 degrees celsius; no signs of infection. Nursing diagnosis: Risk for infection as evidenced by open wound to left knee. ◼ Write goal and expected outcomes for this patient. Goals and Expected Outcomes Formulating the Goal & Outcome statement: Write an overall goal statement that reflect clearly what you and the patient want to happen and then write how you will know that the goal was achieved... Eg: Overall goal: Patient will remain free from infection How will I know this? As evidenced by absence of signs and symptoms of infection such as... Tip: Ensure that the overall goal has words from the diagnostic statement (helps to ensure that the outcome is related to the diagnosis) In the example above the word from the diagnostic statement is infection Goals and Expected Outcomes Formulating the Goal & Outcome statement: Include all parts of the goal & outcome: Throughout the 8 hours of independent and dependent interventions, the patient will remain free from infection as evidenced by T in normal range (35.8-37.0), absence of signs of infections such as redness, swelling, increase in and change in type of drainage, wound size remaining at … Goals and Expected Outcomes Formulating the Goal & Outcome statement: Include all parts of the goal & outcome: Subject-patient Verb-remain free from infection Conditions-throughout 8 hours of independent and dependent interventions Criteria-T in normal range (35.8-37.0°C), absence of signs of infections such as redness, swelling, increase in and change in type of drainage, wound size remaining at … INTERVENTIONS ◼ Must be congruent with goal and expected outcome ◼ No redundancies ◼ Begin with a verb (write what you will do) ◼ Do not use word “Assess” ◼ Scepticism with verbs such as "ensure" and "encourage" ◼ Scientific rationales ◼ The underlying reasons for which the nursing intervention was chosen. INTERVENTIONS ◼ Choose interventions to alter the etiological (related to) factor or causes of the diagnosis. ◼ When an etiological factor cannot change, direct the interventions toward treating the signs and symptoms. ◼ For risk diagnoses, direct interventions at altering or eliminating the risk factors for the diagnosis. (Potter et al., 2016) ◼IMPLEMENTATION IMPLEMENTATION PROCESS ◼ Doing planned interventions ◼ Reassessing the patient at each interaction ◼ Delegating ◼ Supervising ◼ Documenting (Potter et al., 2016) IMPLEMENTATION PROCESS Requires skills: ◼ Cognitive (critical thinking and decision making) ◼ Interpersonal ◼ Psychomotor (Potter et al., 2016) IMPLEMENTATION PROCESS Direct care interventions: ◼ Activities of daily living ◼ Physical care techniques ◼ Life saving measures ◼ Counseling ◼ Teaching ◼ Preventative (Potter et al., 2016) IMPLEMENTATION PROCESS Indirect care interventions: ◼ Performed away from but on behalf of patient ◼ Not usually included on care plans ◼ Hand-off reports ◼ Delegation ◼ Documentation ◼ Infection control and environmental safety measures (Potter et al., 2016) EVALUATION PURPOSE OF EVALUATION ◼ Determines whether a patient’s condition or well-being improved after nursing interventions were delivered. ◼ Provides valuable information about the efficacy of your interventions. ◼ Tells whether the goals or expected outcomes were achieved. ◼ The outcomes are the criteria for judging the success in delivering nursing care. (Potter et al., 2016) PURPOSE OF EVALUATION ◼ Outcome evaluation is a part of every health care organization’s quality assessment to determine what clinical practices and nursing care standards are effective. ◼ Evaluation is critical to knowing a patient’s health status. (Potter et al., 2016) EVALUATIVE MEASURES EVALUATION (summary) ◼ Planned, ongoing, purposeful activity ◼ Client’s progress towards the achievement of goals or desired outcomes, and the effectiveness of the nursing care plan (NCP). ◼ Determines whether the nursing interventions should be terminated, continued, or changed. ◼ Determines if the desired outcome was achieved and to what extent. ◼ Written in past tense Any Questions?  The end! Thank you for attending!