Week 4 NursProcess Diagnosis BlackBoard - Tagged.pdf

Clinical Decision Making Nursing Process Nursing Diagnosis COURSE OUTCOME Describe principles of safe, patient-centered, evidence-based nursing care to adults at the basic level, guided by the Caritas philosophy. Discuss critical thinking and clinical reasoning to provide quality...

Clinical Decision Making Nursing Process Nursing Diagnosis COURSE OUTCOME Describe principles of safe, patient-centered, evidence-based nursing care to adults at the basic level, guided by the Caritas philosophy. Discuss critical thinking and clinical reasoning to provide quality patient care. COMPETENCY Describe the elements of the nursing process. Discuss critical thinking strategies used when making clinical judgments. Discuss the use of critical thinking to prioritize basic elements of patient care when implementing the nursing process. CONCEPT Clinical Decision Making: A process used to examine and determine the best actions to meet desired goals; requires anticipating, recognizing and organizing patient problems to respond with urgency and/or importance in a preferential order to avoid or minimize adverse changes in a patient’s condition UNIT OUTCOMES Discuss the relationship of critical thinking to the nursing diagnostic process. Explain how the related etiological process and defining characteristics/data individualize a nursing diagnosis. Differentiate among a nursing diagnosis, medical diagnosis, and a collaborative problem. Identify a nursing diagnosis based on a nursing assessment. Nursing Process Review What is the purpose of the nursing process? Used to identify the patient’s health status and actual or potential healthcare problems or needs. Patient can be an individual, family, or a group. Nursing Process Review What do physicians treat? What do nurses independently treat? At what phase/step in the nursing process is clinical decision making? Nursing Process: Assessment Review What is the assessment phase of the nursing process? Systematic, continuous collection of data about the patient Critical thinking is carried out in all phases of the nursing process Nursing Process: Assessment Review What type of data is included in the assessment? Subjective data: patient needs, health practices, values, health history Objective: physical exam and assessment What happens after the data is collected? Validate (Assessment) Not all data needs to be validated Double check verify for accuracy Is assessment information complete? Do the subjective and objective data agree? Analyze Compare data against standards or norms Look for gaps and inconsistencies Diagnosis phase begins with clustering and analyzing data.  Applies their critical thinking skills to the assessment data gathered to identify patient problems (actual or potential) Using critical thinking (analyzing) and making a clinical judgment. Formulated by cluster/grouping assessment data to define problem or formulate a nursing diagnosis What does this thinking look like prior to the determination of a Nursing Diagnosis? Diagnostic reasoning and Do they currently have a thinking begins when What does the problem, developing a you receive information information mean for problem, at risk for a about the patient- this patient? problem? Handoff Report You see the patient. Is it what you expected? What do they look and What is the sound like? same/different? Nursing Diagnosis Nursing diagnosis: “a clinical judgment concerning a human response to health Diagnosis provides the basis for conditions/life processes, or a the interventions (nursing vulnerability for that response, actions) that are selected by an individual, family, group, or community.”  List that is formalized through North American Nursing Diagnosis Association Developed formalized nursing diagnosis statements NANDA Responsibility of the Registered Nurse Others may contribute Nursing Diagnosis made only after systematic assessment and data collection NANDA List What is the difference between a nursing diagnosis and a medical diagnosis?  Nursing Diagnosis vs Interprofessional Diagnosis Medical Diagnosis Identification of a disease condition based on specific evaluation of signs and symptoms Nursing Diagnosis Clinical judgment about the patient response to an actual or potential health problem Collaboration Problem Nurses intervene with personnel from other health care disciplines/interprofessional Clinical Diagnostic Reasoning (Thinking piece) Expert diagnosing occurs with repeated observation of patients with similar problems – Benner “Novice” Learning process Look for patterns between and among patients with similar problems Use the data to identify THE PATIENT’S PROBLEM(S)  Provides a precise identification of a patient’s problem gives nurses and health care team common language for understanding patients’ needs Allows nurses to communicate what they do among Why do themselves and with other we use health care professionals and the public it? Distinguishes the nurse’s role from that of the physician or other health care provider Helps nurses focus on the scope of nursing practice Nursing Diagnoses: Types Focus on actual patient problems (problem-focused diagnosis) Risk nursing diagnosis: problem does not exist but the risk for one does Health promotion diagnosis: patient’s readiness to improve an aspect of health Syndrome diagnosis: cluster of individual nursing diagnoses that occur at the same time. Can be a combination of problem and risk. Are addressed at the same time. Actual describes human responses to health conditions or life processes that exists/occurs in an Nursing individual, family, or community. Diagnosis At Risk describes human responses to health conditions or life processes that may develop in an individual, family, or Nursing community. Diagnosis Health Promotion identifies a person’s, family’s or community’s motivation and DESIRE to increase well-being using Related to health behaviors nutrition exercise Nursing Diagnosis: How to ANALYZE THE DATA INTERPRETATION OF THE IDENTIFIES THE PROBLEM DEVELOP A STATEMENT ASSESSMENT DATA AREA REVEALS THE PATIENT’S RESPONSE TO A HEALTH PROBLEM THE PATIENT’S PROBLEM IT INCLUDES THE STATEMENT IS CALLED THE DIAGNOSTIC LABEL NURSING DIAGNOSIS. (PROBLEM) + ETIOLOGY (CAUSE, SET OF CAUSES, RISK FACTORS) + THE DEFINING CHARACTERISTICS (SYMPTOMS)  Diagnostic Label Description of patient’s response to specific condition Problem statement Focus of planning and goal setting Nursing Example: dry mouth, confusion, constipation Diagnosi s Etiology Likely causes of the patient problem Example: activity intolerance – bedrest, immobility, weakness, etc. Constipation – change in eating pattern, insufficient flid intake Nausea – earl pregnancy  “Related to” is the Etiology Etiology is the cause of this problem for the patient Use the same Nursing Diagnosis for many different patients but individualize it based on the cause. E= Example: Medical diagnosis: Post operative Etiology appendectomy Nursing Diagnosis: Pain related to disruption of skin integrity Example: Medical Diagnosis: Fractured tibia Nursing Diagnosis: Pain related to disruption of bone integrity Nursing Diagnosis Labels Example Nursing Diagnosis: Impaired Physical Actual Problems: Mobility Actual patient data: Patient Cannot Walk Add “Risk for” to the beginning of the Nursing Diagnosis statement At Risk Problems: Example Nursing Diagnosis: Risk for Impaired Physical Mobility Actual data: If you determine the patient may develop difficulty walking  Risk Factors-Do not have a current problem, they are potential problems Risk for Let’s do one: Nursing Patient data: Patient takes Diagnosi prescribed opioid drugs for surgical pain s Label Thinking: What is a side effect of opioid drugs? (GI problem)  P = Problem Label – Nursing Diagnosis (NANDA) Nursing E = What is it related to? – Diagno Etiology or cause or pathophysiology sis Format S = “as evidenced by”- signs/symptoms from patient’s assessment (what data points led you to this?) P = Label of Problem Mobility - Impaired Physical Mobility Elimination - Constipation Comfort - Acute pain Oxygenation - Impaired gas exchange Perfusion - Decreased cardiac output Elimination -Urinary retention Which above NURSING DIAGNOSIS would you select for a patient experiencing the MEDICAL DIAGNOSIS Pneumonia? E= Etiology Etiology or cause guides the nurse to select nursing interventions directed toward correcting the cause of the problem or minimizing the patient’s risk S = Signs/Symptoms Then insert the assessment data “As evidence by” gathered that led you to this nursing diagnosis  1. Identify the patient’s response, not the medical diagnosis. 2. Identify a Label – Nursing diagnostic statement from Pearson or NANDA List Diagno 3. Identify a cause-etiology-related to that is treatable through nursing intervention. stic Statem 4. Identify the patient problem. ent Guideli 5. Write what is in the scope of nursing nes practice not medical diagnosis. Example S: as evidence by coughing when trying P: Imbalanced E: related to difficulty to swallow solid food Nutrition: less than chewing without “I forgot my dentures. I body requirements dentures don’t want to eat it’s scary to choke.” Weight 1-8-21 = 55 kg Weight 1-11-21 =50kg Which of the three types of nursing diagnoses was noted in the prior example? C. Health A. Actual B. Risk nursing promotional nursing diagnosis nursing diagnosis diagnosis  Answer: A Rationale: An actual nursing diagnosis describes a response to a health condition the patient is experiencing. Cultural Relevance of Nursing Diagnoses How has this health problem affected you and your family? Consider patients’ cultural diversity What do you believe will help or fix the when selecting a nursing diagnosis. problem? Ask questions such as: Are there practices within your culture would you want the nurses and staff follow while you are here? Cultural awareness and sensitivity improve your accuracy in making nursing diagnoses Exam 1 * Week 5 * Exam starts at the beginning of class – CANNOT BE LATE! * All Readings, activities, and assignments *Computerized Test  Multiple choice with 1 answer options Multiple choice questions Exam 1 that are “Select all that Apply” (SATA) Must identify all correct options No partial credit No partial answers Review the syllabus Use the unit and course outcomes to guide your study Review the syllabus for the exam policies Read the testing information in the syllabus Bring your log in information Review test policy