NURS 515 NURSING PROCESS - Student.pdf

NURSING PROCESS: ADPIE Chapters 15-19 NURS 515  Objectives 1. Define the steps of the nursing process 2. Describe the purpose and benefits of the nursing process 3. Describe the steps of the nursing process and their relation to the other s...

NURSING PROCESS: ADPIE Chapters 15-19 NURS 515  Objectives 1. Define the steps of the nursing process 2. Describe the purpose and benefits of the nursing process 3. Describe the steps of the nursing process and their relation to the other steps in the nursing process  NURSING PROCESS  Assessment  Diagnosis (Problem Identification)  Planning  Implementation  Evaluation ASSESSMENT  Assessment ▪ Systematic and continuous collection, analysis, validation, and communication of patient data ▪ Data reflect how health functioning is enhanced by health promotion or compromised by illness/injury ▪ Database includes all the pertinent patient information collected by the nurse and other health care professionals ▪ The database enables the nurse to partner with patients to develop a comprehensive and effective care plan  Critical Thinking Activities Linked to Assessment ASSESSING DETECTING BIAS AND DISTINGUISHING MAKING JUDGMENTS IDENTIFYING SYSTEMATICALLY AND DETERMINING THE NORMAL FROM ABOUT THE ASSUMPTIONS AND COMPREHENSIVELY TO CREDIBILITY OF ABNORMAL FINDINGS SIGNIFICANCE OF DATA, INCONSISTENCIES, IDENTIFY NURSING AND INFORMATION AND IDENTIFYING THE DISTINGUISHING CHECKING ACCURACY MEDICAL CONCERNS SOURCES RISKS FOR ABNORMAL RELEVANT FROM AND RELIABILITY, AND FINDINGS IRRELEVANT DATA RECOGNIZING MISSING INFORMATION  Question #1 Tell whether the following statement is true or false. A nursing assessment duplicates a medical assessment by focusing on the patient’s health problem(s). A. True B. False Assessing: The Primary Source of Information Is the Patient DIAGNOSIS  Purposes of the Diagnosing Step IDENTIFY HOW AN INDIVIDUAL, GROUP, OR IDENTIFY FACTORS THAT CONTRIBUTE TO, IDENTIFY RESOURCES OR STRENGTHS ON COMMUNITY RESPONDS TO ACTUAL OR OR CAUSE, HEALTH PROBLEMS WHICH THE INDIVIDUAL, GROUP, OR POTENTIAL HEALTH AND LIFE PROCESSES (ETIOLOGIES) COMMUNITY CAN DRAW TO PREVENT OR RESOLVE PROBLEMS Diagnosing Nursing Concerns and Responsibilities (Alfaro-LeFevre, 2014)  Recognizing safety and infection transmission risks and addressing these immediately  Identifying human responses—how problems, signs and symptoms, and treatment regimens impact on patients’ lives—and promoting optimum function, independence, and quality of life  Anticipating possible complications and taking steps to prevent them  Initiating urgent interventions. You should not wait to make a final diagnosis if there are signs and symptoms indicating the need for immediate treatment  Recognizing significant data: Comparing data to Recognizing standards Recognizing Recognizing patterns or clusters Steps of Data Identifying Identifying strengths and current or potential problems Interpretation Identifying Identifying potential complications and Analysis Reaching Reaching conclusions Partnering Partnering with the patient and family  NO PROBLEM Reaching Conclusions POSSIBLE PROBLEM  Question #2 A nurse decides that a patient has a possible problem with high blood pressure. During which step of data interpretation would this most likely be determined? A. Recognizing significant data B. Recognizing patterns or clusters C. Identifying strengths and problems D. Reaching conclusions Planning Goal of Outcome Identification and Planning Step Identify and write Establish priorities expected patient outcomes Select evidence-based Communicate the nursing interventions nursing plan of care Outcome Identification and Planning  A Formal Care Plan Allows the Nurse to:  Individualize care that maximizes outcome achievement  Set priorities  Facilitate communication among nursing personnel and colleagues  Promote continuity of high-quality, cost-effective care  Coordinate care  Evaluate patient response to nursing care  Create a record used for evaluation, research, reimbursement, and legal reasons  Promote nurse’s professional development  Be familiar with standards and agency policies for setting priorities, identifying and Outcome recording expected patient outcomes, selecting evidence-based nursing interventions, and recording the care plan Identification, Remember that the goal of thoughtful, patient-centered practice is to keep the Planning, and patient and the patient’s interests and preferences central in every aspect of planning and outcome identification Clinical Keep the “big picture” in focus: What are Reasoning #1 the discharge goals for this patient, and how should this direct each shift’s interventions?  Trust clinical experience and judgment but be willing to ask for help when the Trust situation demands more than your qualifications and experience can provide; value collaborative practice Outcome Identification, Respect your clinical intuitions, but before establishing priorities, Planning, and Respect identifying outcomes, and selecting nursing interventions, be sure that research supports your plan Clinical Reasoning #2 Recognize your personal biases and Recognize keep an open mind  Standards to Apply to Outcome Identification and Planning  The law  Specialty professional organizations  The Joint Commission  The Agency for Healthcare Research and Quality (AHRQ)  Your employer  Three Elements of Comprehensive Planning Initial Ongoing Discharge  Developed by the nurse who Initial Planning performs the nursing history and physical assessment Addresses each problem listed in the prioritized problem list Identifies appropriate patient goals and related nursing care  Carried out by any nurse who interacts with patient Ongoing Planning Keeps the plan up to date, manages risk factors, promotes function States problem statements more clearly Develops new problem statements Makes outcomes more realistic and develops new outcomes as needed Identifies nursing interventions to accomplish patient goals  Discharge Planning Uses teaching and counseling skills Carried out by the Begins when the effectively to ensure nurse who worked most patient is admitted for that home care closely with the patient treatment behaviors are performed competently  Question #3 Which nursing action would most likely occur during the ongoing planning stage of the comprehensive care plan? A. The nurse collects new data and uses them to update the plan and resolve health problems B. The nurse uses teaching and counseling skills to help the patient carry out self-care behaviors at home C. The nurse who performs the admission nursing history develops a patient care plan D. The nurse consults standardized care plans to identify patient problems, outcomes, and interventions  Establishing Priorities  Maslow’s hierarchy of human needs  Patient preference  Anticipation of future problems  Critical thinking/clinical reasoning and judgment  Maslow’s Hierarchy of Human Needs  Physiologic needs  Safety needs  Love and belonging needs  Self-esteem needs  Self-actualization needs  What problems need immediate Clinical attention and which ones can wait? Reasoning and Establishing Which problems are the responsibility of the nurse and Priorities #1 which need to be referred to someone else? Which problems can be dealt with by using standard plans (e.g., critical paths, standards of care)? Which problems are not covered by protocols or standard plans but must be addressed to ensure a safe hospital stay and timely discharge?  Have changes in the way the patient is Have changes in the responding to health Clinical patient’s health status influenced the priority of nursing diagnoses/ problems? and illness or the care plan affected those nursing diagnoses/ problems that can be realistically Reasoning and addressed? Establishing Are there relationships among diagnoses/ Can several patient Priorities #2 problems that require that one be worked on before another can be resolved? problems be dealt with together?  Question #4 Which patient problem would most likely be considered a high priority? A. Disturbed personal identity B. Impaired gas exchange C. Risk for powerlessness D. Activity intolerance Implementation Purposes of Implementation Help Help the patient achieve valued health outcomes Promote Promote health Prevent Prevent disease and illness Restore Restore health Facilitate Facilitate coping with altered functioning Focus of Scope of Practice: Who, what, where, when, and why Nursing Implementation Nursing interventions Care coordination and continuity  Assess patients before performing Critical Thinking/ nursing actions Clinical Reasoning and Judgment, and Reassess the patient for changes in status that might dictate a different set of Implementing interventions Be sure that research supports the interventions you have selected and be open to better ways of addressing patient problems and issues Always monitor the patient’s responses to your interventions so that you can modify the care plan if needed Alfaro’s rule: “assess, reassess, revise, record”  Types of THOSE PROVIDING DIRECT AND INDIRECT CARE INDEPENDENT AND COLLABORATIVE INTERVENTIONS Nursing Interventions PROTOCOLS AND CARE BUNDLES STANDING ORDERS  Before implementing, reassess Act in partnership with the the patient to determine whether patient/family the action is still needed Implementing Approach the patient competently Approach the patient caringly Guidelines #1 Modify nursing interventions according to the patient’s (1) developmental and psychosocial background, (2) ability and willingness to participate in the care plan, and (3) responses to previous nursing measures and progress toward goal/outcome achievement Implementing Guidelines #2 Check to make sure that the nursing Always question that the nursing Develop a repertoire of skilled nursing interventions selected are consistent with intervention selected is the best of all interventions. The more options one can standards of care and within legal and possible alternatives choose from, the greater the likelihood of ethical guides to practice success  Question #5 Which one of the following nursing interventions is an indirect care intervention? A. A nurse explains available birth control measures to a young couple B. A nurse meets with the collaborative care team to plan nursing measures for a patient C. A nurse prays with a patient prior to surgery D. A nurse administers pain medication to a patient with end-stage renal cancer Implementing  Determine the patient’s new or continuing need for Determine assistance Implementing the Plan of Care Promote Promote self-care #1 Assist Assist the patient to achieve valued health outcomes Reassess Reassess the patient and review the plan of care Use Use patient boards or whiteboards Plan ahead and Plan ahead and organize resources organize Clarify Clarify prerequisite nursing competencies  Anticipate unexpected outcomes and Implementing solutions the Plan of Care #2 Ensure quality and patient safety Promote self-care: teaching, counseling, and advocacy Assist patients to meet health outcomes  Be sure that each nursing intervention is supported by a sound scientific rationale, as Reassessing the demanded by an evidence-based practice Patient and Reviewing the Be sure that each nursing intervention is consistent with professional standards of care Care Plan and consistent with the protocols, policies, and procedures of the institution or agency Be sure that the nursing actions are safe for this particular patient and individualized to the patient’s preferences Clarify any questionable orders  Patient variables Variables Developmental stage Influencing Outcome Psychosocial background and culture Achievement Nurse variables Resources Scope of practice and current standards of care Research findings Ethical and legal guides to practice Common Reasons for Noncompliance Lack of Low value Lack of family understanding attached to support about the outcomes benefits Adverse physical or emotional Inability to afford Limited access effects of treatment to treatment treatment Question #6 Tell whether the following statement is true or false. When a patient fails to cooperate with the care plan despite the nurse’s best efforts, it is time to reassign the patient to another caretaker. A. True B. False Planning  Nurse and patient together measure Evaluating Step how well the patient has achieved the outcomes specified in the care plan The nurse identifies factors that contribute to the patient's ability to achieve expected outcomes and, when necessary, modifies the plan of care The purpose of evaluation is to allow the patient's achievement of expected outcomes to direct future nurse– patient interactions  Identifying evaluative criteria and standards Five Classic Elements of Collecting data to determine whether criteria Evaluation and standards are met Interpreting and summarizing findings Documenting judgment Terminating, continuing, or modifying the plan Evaluating  Question #7 Tell whether the following statement is true or false. The purpose of evaluation is to allow the patient’s achievement of expected outcomes to direct future nurse–patient interactions. A. True B. False Evaluative Statements Decide how well outcome was met (met, partially met, or not met) List patient data or behaviors that support this decision  Patient Variables Affecting For example, a patient gives up Outcome and refuses treatment Achievement Nurse For example, a nurse is suffering from burnout Health care system For example, inadequate staffing  Delete or modify the diagnosis/ Actions Based problem on Patient Response to Make the outcome statement more Care Plan realistic Ime criteria in outcome statement Change nursing interventions  Question #8 Which action should the nurse take when a patient has achieved each expected outcome in the care plan? A. Terminate the care plan B. Modify the care plan C. Continue the care plan  Question #9 Tell whether the following statement is true or false. An outcome evaluation focuses on measurable changes in the health status of the patient or the end result of nursing care. A. True B. False APPLICATION Case Study  Case Study # 1: ADPIE  You are a nurse preparing to receive a new patient, fresh from surgery, to your unit. The patient is a 71-year-old man who underwent a surgical repair of a fractured hip. As you receive a report from the post anesthesia recovery unit, you learn that his medical history includes hypertension, 40 pack-years of  smoking, and COPD. His surgical repair was successful but complicated by excessive bleeding, and he is currently receiving a blood. His significant other has recently passed away, and he has no other family close by. He lives alone and receives Meals on Wheels three times each week.  a. Based on the relevant cues provided, what general priorities would you expect to establish from this information?  b. What might you identify as expected patient outcomes in this case?  c. What nurse-initiated interventions may be appropriate for this patient?  d. What are the challenges related to developing a formal care plan? References  References  Taylor, C., Lillis, C., LeMone, P., & Lynn, P. (2023). Fundamentals of Nursing: The Art and Science of Nursing Care (10th ed.). Philadelphia: Lippincott, Williams, and Wilkins ISBN: 9781975205263 CoursePoint  Lynn, P. (2021). Lippincott Skills for Nursing Education +. Philadelphia: Lippincott, Williams, and Wilkins. ISBN: 9781975213770