Nursing Process Student 2024 PDF

10/28/24 NURSING PROCESS FRAMEWORK FOR PROFESSIONAL NURSING PRACTICE /SETTING A STANDARD OF CARE D. Filos RN MSN  10/28/24 Standardized Nursing Language NANDA North American Nursing Diagnosis Association  Defines Nurs...

10/28/24 NURSING PROCESS FRAMEWORK FOR PROFESSIONAL NURSING PRACTICE /SETTING A STANDARD OF CARE D. Filos RN MSN  10/28/24 Standardized Nursing Language NANDA North American Nursing Diagnosis Association  Defines Nursing's contribution and impact in healthcare. Defines What nurses do.  Gives nurses more EB outcomes and interventions  Easily integrated into EMR  Standardizes knowledge for nursing curriculum  Promotes Nursing Research D. Filos RN MSN  10/28/24 Think Like a Nurse to develop Clinical Judgement- Why Learn it?  Prepare for NCLEX  Transform thinking into clinical judgment  Become a self-directed thinker  Reduce errors in healthcare setting D. Filos RN MSN  10/28/24 NGN Clinical Judgment Measurement Model  Recognize Cues  Analyze Cues  Prioritize Hypotheses  Generate Solutions  Take Actions  Evaluate Outcomes D. Filos RN MSN  10/28/24 Recognizing Cues OR Getting the Information/Assessing  Determine what information you need  Use Multiple sources  Eliminate preconceived ideas  Scan the environment  Identify signs and symptoms  Assess systematically and comprehensively  Ensure that you collect accurate information D. Filos RN MSN  10/28/24 Alignment of the Clinical Judgment model and the Nursing process CJM Nursing Process  Getting the Information  Assessment  Making meaning of the  Diagnosis information  Planning  Determine actions to take  Implementing  Take Action  Evaluating  Evaluate Outcomes and your thinking D. Filos RN MSN  10/28/24 ADPIE D. Filos RN MSN  10/28/24 D. Filos RN MSN  10/28/24 A Nursing 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  Evaluate patient response to nursing care  Create a record used for evaluation, research, reimbursement, and legal reasons D. Filos RN MSN  10/28/24 Characteristics of Nursing Assessments  Prioritized  Complete  Systematic  Accurate  Recorded in a standard manner D. Filos RN MSN  10/28/24 Types of Assessment  Initial  Admission  Shift  Focused D. Filos RN MSN  10/28/24 Sources of Data For Assessment  Patient  Family & Significant others  Patient Record  Other Healthcare Professionals D. Filos RN MSN  10/28/24 TYPES OF ASSESSMENT DATA  Subjective  What the Patients Feels or Says  Objective  Measurable and Observable D. Filos RN MSN How the Phases of 10/28/24 Assessment Set the Stage for Diagnosis D. Filos RN MSN  10/28/24 DIAGNOSIS Nursing Diagnosis: a clinical judgment about an individual’s responses to actual or potential health problems. Nursing diagnosis provides the basis for selection of patient outcomes and the nursing interventions to achieve the set outcomes. D. Filos RN MSN  10/28/24 Steps in Diagnostic Process  Create a list of suspected problems  Name actual and potential problems/diagnoses and clarify what is causing or contributing to them.  Determine risk factors that must be managed for a risk DX  Confirm defining characteristics for an actual DX  Prioritize Nursing Diagnoses D. Filos RN MSN  10/28/24 NURSING DIAGNOSIS  No Problem  Problem Focused Diagnosis ***  Risk Diagnosis ***  Health Promotion Diagnosis  Syndrome Diagnosis *** Types of NSG DX used in the first semester D. Filos RN MSN  10/28/24 Actual Problem 3 Part Nursing Diagnosis  Problem Related To (R/T) Etiology AEB Defining Characteristics Impaired nutrition less than body requirement R/T decreased desire to eat AEB BMI 13, Pre-Albumin of 15 (norm 40 – 100), patient consumes only 5% of meals X 5 days D. Filos RN MSN  10/28/24 Etiology’s  Onlyproblem-focused nursing diagnoses and syndromes must have related factors D. Filos RN MSN  10/28/24 Adding Secondary To The Etiology For Clarification  PainR/T Tissue Damage 2ndary to MI AEB Patient complaints of pain 8/10 substernal and pressure like, relieved with NTG D. Filos RN MSN  10/28/24 D. Filos RN MSN  10/28/24 At Risk Nursing Diagnosis  A clinical judgment concerning the vulnerability of an individual for developing an undesirable human response to health conditions or life processes  2 Part Diagnosis  Problem statement AEB Risk Factors Example: Risk for falls AEB the following risk factors: previous history of falls D. Filos RN MSN  10/28/24 Nursing Diagnosis V Medical Diagnosis  Medical DX: Myocardial Infarction  Nursing Diagnosis = response to the medical diagnosis  Pain RT tissue damage AEB patients reports of sub-sternal chest pain rated 10/10  Pain RT tissue damage 2ndary to MI AEB patients reports of sub-sternal chest pain rated 10/10  Fear RT hospitalization AEB patients statements D. Filos RN MSN “I’m afraid that I’m going to die”.  10/28/24 NSG DX - VRS - Medical DX D. Filos RN MSN  10/28/24 D. Filos RN MSN  10/28/24 Benefits of Nursing Diagnoses  Individualizing patient care  Defining domain of nursing to health care administrators, legislators, and providers  Seeking funding for nursing and reimbursement for nursing services D. Filos RN MSN  10/28/24 COMMON ERRORS  The Problem and the Etiology are the same Altered comfort related to pain (incorrect) Altered comfort related to tissue damage secondary to surgery AEB patient reports of 10/10 pain at surgical site  Medical Diagnosis in the Statement impaired skin integrity AEB arthritis AEB stage 2 pressure injury on right heel.(incorrect)  impaired skin integrity AEB immobility AEB stage 2 pressure injury on right heel. Filos RN MSN (correct)  10/28/24 PLANNING  Goals to Measure your care  Problem statement drives the patient outcomes  Interventions  Traditional, EBP  Etiology drives the nursing interventions D. Filos RN MSN  10/28/24 Goal of Planning Step  Establish priorities  Identify and write expected patient outcomes  Select evidence-based nursing interventions  Communicate the plan of care D. Filos RN MSN  10/28/24 Deriving Patient Outcomes and Nursing Interventions from Nursing Diagnoses D. Filos RN MSN  10/28/24 Four Types of Outcomes (Smart Goals  Cognitive: increase in patient knowledge  Psychomotor: patient’s achievement of new skills  Affective: changes in patient values, beliefs, and attitudes  Physiologic: physical changes in the patient D. Filos RN MSN  10/28/24 Smart Goals S = Specific  M= measurable  A= attainable  R= Realistic  T= Time bound In the next 24 hours the patient will have an oral fluid intake of at least 2 liters. D. Filos RN MSN  10/28/24 Common Errors in Outcomes  Offer Patient C 60mL of fluid every 2 hours while awake  Pt. X will know how to bath her new baby  Pt. X will list the dangers of smoking and stop smoking  The patient will cope better S = Specific M= measurable A= attainable R= Realistic T= Time bound D. Filos RN MSN  10/28/24 Interventions  Realistic  Evidenced Based  Nurse Initiated Verses Physician Initiated and Collaborative D. Filos RN MSN  10/28/24 Implementing D. Filos RN MSN  10/28/24 Clinical Judgment and Evaluation  Identify evaluation criteria  Collect data to determine whether these criteria and standards are met  Interpret the findings  Document your findings D. Filos RN MSN  10/28/24 Actions Based on Patient Response to Plan of Care in the Evaluation Phase  Direct Future Care  Terminate the plan of care when each expected outcome is achieved.  Modify the plan of care if there are difficulties achieving the outcomes.  Continue the plan of care if more time is needed to achieve the outcomes. D. Filos RN MSN  10/28/24 Narrative Evaluation of Outcomes Paragraph to include 3 ELEMENTS to Evaluate the Smart Goal (Outcome) Include: 1. Has the Smart Goal been MET OR UNMET? 2. Present Data to Support Your Decision: The Smart Goal has not been Met because of this objective proof… 3. **CRITICAL THINKING what would you need to specifically and measurably see for you to say that this problem has been resolved. Speak to the smart goal and the overall resolution of the problem. D. Filos RN MSN  10/28/24 Using the Nursing Process To Formulate a Nursing Care Plan NURSING PROCESS NURSING CARE PLAN  Assessment  Assessment Data clustered  Diagnosis  NANDA Diagnosis  Actual 3 part  High Risk 2 part  Planning  Identify Outcomes  Select Traditional Interventions  Implementation  Not actually implemented  Evaluation  Evaluation  Evaluate achievement of the outcomes  Revision of Plan  Guide future interventions D. Filos RN MSN  10/28/24 Evaluating Clinical Excellence Through Nursing Care and Documentation D. Filos RN MSN  10/28/24 HCAHPS (Hospital Consumer Assessment of Healthcare Providers and Systems)  Nationallystandardized, reported survey of patient’s perspectives of hospital care.  Reimbursementfrom Federal Government based on HCAHPS scores D. Filos RN MSN  10/28/24 HCAHPS Categories  Nurse Communication  Doctor Communication  Responsiveness of Hospital Staff  Pain Management  Communication about medicine  Cleanliness of Hospital  How Quiet was the hospital D. Filos RN MSN YOUR CARE FROM NURSES 10/28/24 1. During this hospital stay, how often did nurses treat you with courtesy and respect? 2. During this hospital stay, how often did nurses listen carefully to you? 3. During this hospital stay, how often did nurses explain things in a way you could understand? 4. During this hospital stay, after you pressed the call button, how often did you get help as soon as you wanted it? D. Filos RN MSN  10/28/24 Never Events 1. Pressure injury stages 3 and 4 2. Falls and trauma 3. Surgical site infection after bariatric surgery certain orthopedic procedures, and bypass surgery 4. Vascular-catheter associated infection 5. Catheter-associated urinary tract infection 6. Administration of incompatible blood 7. Air embolism 8. Foreign object unintentionally retained after D. Filos RN MSN surgery.  10/28/24 Always Events 1. Including 2 patient identification 2. Mandatory "read backs" 3. Disclosure of adverse outcomes and transparency with patients and families. 4. Medication error reduction strategies. 5. Surgical time-out. 6. Anesthesia monitoring that is appropriate for the level of sedation. 7. Tracking of critical imaging, lab and pathology results. 8. Making critical information availableD. Filos RNat MSN handoffs or transitions in care.  10/28/24 Financial Implications of HCAHPS Total Hip Replacement = $40,000 HCAHPS with low scores = reimbursement penalty Never Event X1 Total Reimbursement Medicare/Medicaid $25,000 D. Filos RN MSN