Nu 116 Module 1 Nursing Process PDF

Nu 116 Module 1 Nursing Process Theresa L. Arida, FNP-BC, MS, RN Nursing Faculty  NURSING PROCESS: SYSTEMATIC MANNER OF 1. Determining a patient’s problem 2. Making plans to solve them 3. Initiating a plan to solve the problem This may be...

Nu 116 Module 1 Nursing Process Theresa L. Arida, FNP-BC, MS, RN Nursing Faculty  NURSING PROCESS: SYSTEMATIC MANNER OF 1. Determining a patient’s problem 2. Making plans to solve them 3. Initiating a plan to solve the problem This may be the nurse doing This may be the nurse assigning 4. Evaluating the extent to which the plan was effective in resolving the problem that was identified  Evidence Based Practice (EBP) Nursing practice is based on evidence, research and best practices EBP has found that having a universal language (Nursing Process) assists the nurse to meet their patients’ needs through this problem solving method.  National Council of State Boards of Nursing (NCSBN) Clinical Judgment Measurement Model Recognize cues Analyze cues Prioritize hypotheses Generate solutions Take actions Evaluate outcomes ASSESSMENT The first step in the nursing process Step ONE Assessment ASSESSMENT CONSISTS OF Assessment consists of: Data Collection Data analysis Types of Physical Assessment Comprehensive assessment Focused assessment Emergency assessment Triage PHYSICAL ASSESSMENT An organized and systematic examination to obtain appropriate data Identifies physical, psychological, and emotional states that are in need of nursing care. Requires the use of sight, hearing, touch, smell, and interview skills and techniques.  Data Collection Subjective- Patient/family says Nursing history Objective-observed Nursing exam IPPA  NURSING EXAM -- IPPA Inspection Palpation Percussion Auscultation  Patient Profile  Past Life Events  Current Medications  Education & Occupation  Financial Resources  Environment  Lifestyle Patterns  Disability  Sexuality  Risk for Abuse  Stress & Coping Responses  Components of the Physical assessment  Initial Observations  Posture  Body Movements  Nutritional Status  Speech  Vital Signs & Pain Assessment  Focused Assessment  Inspection  Palpation  Percussion  Auscultation Components of the Health History  Biographical data  Chief Complaint  Present Health  Past Health Hx  Family Hx  Review of Systems  Patient Profile  Considerations—Effective Communication  Establish rapport  Make eye contact  Listen  Be aware of nonverbal communication  Consider patient’s educational/cultural background  Language proficiency  Avoid technical terms/medical jargon  Summarize at end of visit  Considerations - Ethical Explain the health history and physical examination How the information will be obtained How it will be used Private setting The Health Insurance Portability and Accountability Act (HIPAA) 1996 EHR DIAGNOSIS The SECOND step in the nursing process Nursing Diagnosis Statements Problem-focused (actual diagnosis) Risk (high risk for diagnosis) Health promotion (health promotion diagnosis)  NURSING DIAGNOSIS Statement of patient’s RESPONSE to THE condition that is actually or potentially UNHEALTHY- Describes the patients present health status- example PAIN, CONSTIPATION, HRF INFECTION Problem- (UNHEALTHY RESPONSE) must be one that nursing intervention can help to change to a healthful response  PARTS (PHRASES) OF NURSING DIAGNOSIS 1. Unhealthful Response - Diagnostic label- a standardized problem label Obtained from NANDA list 2. Probable cause of problem written as R/T. 3. Validation written as AMB (as manifested by) These are the signs and symptoms observed by the nurse Problem R/T Cause AMB Signs/Symptoms Acute Pain R/T Surgical Incision AMB pt states “I have pain level of 8 in my abdomen.”  CATEGORIES OF NURSING Actual Problem DIAGNOSIS ▫ defining characteristics present (signs/symptoms) ▫ Validation -yes there is a problem Example Constipation R/T decreased fluid intake, lack of roughage AMB absence of bowel movement for three days (assessment)  Potential Problem (High Risk For or HRF) ▫ presence of risk factors only ▫ there will be no validation-no signs and symptoms ▫ Example: ▫ HRF Constipation R/T age, decreased fluid intake, inactivity ▫ HRF Falls R/T ▫ HRF Infection R/T PLANNING The THIRD step in the nursing process  Establish priorities PLANNING Number the diagnoses per priority Use Maslow's hierarchy Set expected outcome (criteria/goals/outcomes) Attainable and quantifiable Establish goals: Immediate (24 hours)  Determine nursing interventions Plan interventions Identify Nursing orders  OUTCOME CRITERIA also called GOALS The FIRST phrase of the nursing diagnosis (Constipation) is used to formulate the OUTCOME CRITERIA (goal) TPW have a soft, formed bowel movement within one day following interventions. Incorrectly stated goals The patient will never be constipated again. The patient will have a BM. The nurse will give the patient an enema. TPW take a laxative Realistic, measurable, time frame, patient centered, positively stated Acute Pain R/T Surgical Incision AMB patient states pain level of 8. GOAL: TPW have a decrease in their pain to a level of 1, 30 minutes after interventions. (pain medication back rub, etc.) Realistic, measurable, time frame, patient centered, positively stated The patients incision will heal in one week (NOT focused on Nursing diagnosis of Pain) IMPLEMENTATIO N The fOURTH step in the nursing process Taking Action  Carry out the plan of care  Nurse assumes responsibility  Goals are used as a focus  “Ongoing” assessment  Make revisions when necessary  All interventions should be patient focused, and outcome directed!  What can the nurse do to solve the problem or obtain the goal??? MUST INDIVIDUALIZE FOR YOUR PATIENT NOT “GIVE PAIN MEDICATION” GIVE SPECIFIC DRUG THAT IS ORDERED- ▫ ACETAMINOPHEN 650 MGS po Q4H ▫ MUST HAVE TIME FRAME!!!! Interventions must be clear, concise, specific and individualized Incorrect: Administer laxative at hs. Correct: Administer 30 ml of MOM at hs. Interventions-must include Assessment Nursing actions to meet the goal Health Teaching Health Promotion/Prevention Must include time frames-how often will the nurse perform this? EVALUATION The FIFTH step in the nursing process EVALUATION Did the patient meet the goal? Did the plan work? Is modification necessary? Constipation R/T lack of roughage, immobility, decreased fluid intake AMB no BM in three days Goal: TPW have a soft formed medium sized BM by the end of this shift Interventions: 1. Assess patients bowel movement regimen qd. 2. Encourage patient to increase fiber intake qd. 3. Increase intake of fluids; 120 mls per meal 4. Administer Colace 100mg po qd. 5. HT the importance of responding to the urge to defecate as needed.  Evaluation of a Goal Goal: Patient will have soft, formed stool today EVALUATION: Goal met, patient had a medium sized formed BM Goal partially met patient had a small hard stool Goal not met. Patient has not had BM today PRIORITIZING  Establishing Priorities Prioritizing nursing diagnoses or patient problems uses determinations of importance to establish a preferential order for nursing actions. Helps nurses anticipate and sequence nursing interventions Example: Oxygen or Laxative Classification of priorities: High (Emergent) Intermediate Low (Affect patient’s future well-being) Maslow Theory of Hierarchy LET’S PRACTICE  Car broke down on the way to clinical Assessment _____ Diagnosis _____ Plan _____ Implementation _____ Evaluation _____ Patient says they have pain level 8 Assessment _____ Diagnosis _____ Plan _____ Implementation _____ Evaluation _____ Patient states they have not had a bowel movement for five days Assessment _____ Diagnosis _____ Plan _____ Implementation _____ Evaluation _____ Questions