Transcript classes/nsg101/Unit III A/Nursing Process

Nursing
Process
Nursing Process
 Specific to the nursing profession
 A framework for critical thinking
 It’s purpose is to:
“Diagnose and treat human responses to actual or potential
health problems”
Nursing Process
 Organized framework to guide practice
 Problem solving method - client focused
 Systematic- sequential steps
 Goal oriented- outcome criteria
 Dynamic-always changing, flexible
 Utilizes critical thinking processes
Advantages of Nursing Process
 Provides individualized care
 Client is an active participant
 Promotes continuity of care
 Provides more effective
communication among nurses
and healthcare professionals
 Develops a clear and
efficient plan of care
 Provides personal
satisfaction as you see
client achieve goals
 Professional growth as you
evaluate effectiveness of
your interventions
5 Steps in the Nursing
Process
Assessment
Nursing
Diagnosis
Planning
Implementing
Evaluating
Assessment
 First step of the Nursing Process
 Gather Information/Collect Data
 Primary Source - Client / Family
 Secondary Source - physical exam, nursing history, team
members, lab reports, diagnostic tests…..
 Subjective -from the client (symptom)
 “I have a headache”
 Objective - observable data (sign)
 Blood Pressure 130/80
Assessment
To elicit as many symptoms as possible, the nurse should
use open-ended rather than yes/no questions.
Examples:
“Describe what you are feeling”
“How long have you been feeling this way?”
“When did the symptoms start?”
“Describe the symptoms”
This type of questions will encourage the client to give
more information about his or her situation.
Listen carefully for cues and record relevant information.
Assessmentcollecting data
 Nursing Interview (history)
 Health Assessment -Review of Systems
 Physical Exam
 Inspection
 Palpation
 Percussion
 Auscultation
Assessment-collecting
data
 Make sure information is complete & accurate
 Validate prn
 Interpret and analyze data
Compare to “standard norms”
 Organize and cluster data
Example ofAssessment
 Obtain info from nursing assessment, history and physical
(H&P) etc…...
 Client diagnosed with hypertension
 B/P 160/90
 2 Gm Na diet and antihypertensive medications were
prescribed
 Client statement “ I really don’t watch my salt” “ It’s hard to
do and I just don’t get it”
Nursing Diagnosis
 Second step of the Nursing Process
 Interpret & analyze clustered data
 Identify client’s problems and strengths
 Formulate Nursing Diagnosis (NANDA : North American Nursing
Diagnosis Association)-Statement of how the client is
RESPONDING to an actual or potential problem that requires
nursing intervention
Diagnosis Statement
A working of nursing diagnosis may have two or three
parts.
The three-part system consists of the nursing
diagnosis, the “related to” statement, and the
defining characteristics.
PES system:
P (problem) - The nursing diagnosis, the label; a
concise term or phrase that represent a pattern of
related cues
E (etiology) – “Related to” phrase or etiology; related
cause or contributor to the problem
S (symptoms) –Defining characteristics phrase;
symptoms that the nurse identified in the
assessment
Nsg Dx
 Within the scope
of nursing
practice
 Identify
responses to
health and
illness
 Can change
from day to day
vs
MD Dx
 Within the scope
of medical
practice
 Focuses on
curing
pathology
 Stays the same
as long as the
disease is
present
Example of Nursing Dx
 Ineffective therapeutic regimen management
R/T difficulty maintaining lifestyle changes and lack of
knowledge
AEB B/P= 160/90, dietary sodium restrictions not being
observed, and client statements of “ I don’t watch my
salt” “It’s hard to do and I just don’t get it”.
Types of Nursing Diagnoses
 Actual
Imbalanced nutrition; less than body
requirements RT chronic diarrhea, nausea, and
pain AEB height 5’5” weight 105 lbs.
 Risk
Risk for falls RT altered gait and generalized
weakness
 Wellness
Family coping: potential for growth RT
unexpected birth of twins.
Case study:
A 73-year-old man has been admitted to the unit with a
diagnosis of chronic obstructive pulmonary disease
(COPD). He states that he has “difficulty breathing when
walking short distances”. He also states that his “heart
feels like it is racing” at the same time. He states that he
is “tired all the time”, and while talking to you he is
continually wringing his hands and looking out the
window.
Step II: Nursing Diagnosis
Part 1 (Problem)
Interpretation of information:
 “difficulty breathing when walking short distances”=
dyspnea
 “heart feels like it is racing”= dysrythmia
 “tired all the time”= fatigue
In Section II we can find the nursing diagnosis Activity
intolerance listed with these symptoms.
Step II: Nursing Diagnosis
To validate that the diagnosis Activity intolerance is
appropriate for the client, we have to read NANDA
definition of the nursing diagnosis.
When reading, ask Does this definition describe the
symptoms demonstrated by the client? If the
appropriate nursing diagnosis has been selected, the
definition should describe the condition that has been
observed.
Activity intolerance
 NANDA Definition
Insufficient physiological or psychological energy to
endure or complete required or desired daily activities.
 Defining Characteristics
Verbal report of fatique or weakness; abnormal heart
rate or blood pressure response to activity; exertional
discomfort or dyspnea; electrocardiografic changes
reflecting dysrhytmias or ischemia
 Related factors (r/t)
Bed rest or immobility; generalized weakness,;
sedentary lifestyle; imbalance between oxygen supply
and demand
Part 2 (Etiology)
“Reated to” Phrase
This phrase states what may be causing or contributing to
the nursing diagnosis, commonly referred to as the
etiology.
Ideally the etiologe, or cause, of the nursing diagnosis is
something that can be treated by a nurse. When this is
the case, the diagnosis is identified as an independent
nursing diagnosis. If medical Intervention is also
necessary, it might be identified as a collabarative
diagnosis.
For each suggested nursing diagnosis, the nurse should
refer to the statements listed under the heading
“Related Factors”
Part 3 (Symptoms)
Defining Characteristic phrase
 It consist of the signs and symptoms that have been
gathered during the assessment phase. Signs and
symptoms are labeled as defining characteristics in
Section III.
The use of identifying defining characteristics is similar to
the process the physician uses when making a medical
diagnosis
Writing a Nursing Diagnosis
Statement
P - Activity intolerance
E – “Related to” imbalance between oxygen supply and
demand
S – Verbal reports of fatique, exertional dyspnea
(“difficulty breathing when walking”), and dysrythmia
(“racing heart ”)
Collaborative Problems
 Require both nursing interventions and medical interventions
EXAMPLE: Client admitted with medical dx of pneumonia
Collaborative problem = respiratory insufficiency
Nsg interventions: Raise HOB, Encourage C&DB
MD interventions: Antibiotics IV, O2 therapy
Planning
Third step of the Nursing Process
 This is when the nurse organizes a nursing care plan based on the
nursing diagnoses.
 Nurse and client formulate goals to help the client with their
problems
 Expected outcomes are identified
 Interventions (nursing orders) are selected to aid the client reach
these goals.
Planning – Begin by prioritizing
client problems
Prioritize list of
client’s nursing
diagnoses using
Maslow
Rank as high,
intermediate or low
Client specific
Priorities can
change
Planning
Developing a goal and outcome statement
 Goal and outcome
statements are client
focused.
 Worded positively
 Measurable, specific
observable, timelimited, and realistic
 Goal = broad
statement
 Expected outcome =
objective criterion for
measurement of goal
 Utilize NOC as
standard
EXAMPLE
 Goal:
Client will achieve
therapeutic management
of disease process….
 Outcome Statement:
AEB B/P readings of
110-120 / 70-80 and
client statement of
understanding
importance of dietary
sodium restrictions by
day of discharge.
Planning- Types of goals
Short term goals
Long term goals
Cognitive goals
Psychomotor goals
Affective goals
Goals are patient-centered
and
SMART
Specific
Measurable
Attainable
Relevant
Time Bound
Goals
 PT. will walk 50 ft.
 Pt. will eat 75% of meals
 Pt. will be OOB 2-4 Hrs.
 Pt. will maintain HR <100
 To will state pain level is acceptable 6 (0-10)
Planning-select interventions
 Interventions are selected and written.
 The nurse uses clinical judgment and professional knowledge
to select appropriate interventions that will aid the client in
reaching their goal.
 Interventions should be examined for feasibility and
acceptability to the client
 Interventions should be written clearly and specifically.
Interventions – 3
types
 Independent ( Nurse initiated )- any action the nurse can
initiate without direct supervision
 Dependent ( Physician initiated )-nursing actions requiring
MD orders
 Collaborative- nursing actions performed jointly with other
health care team members
Implemention
 The fourth step in the Nursing Process
 This is the “Doing” step
 Carrying out nursing interventions (orders) selected during
the planning step
 This includes monitoring, teaching, further assessing,
reviewing NCP, incorporating physicians orders and monitoring
cost effectiveness of interventions
 Utilize NIC as standard
Implementing“Doing”
 Monitor VS q4h
 Maintain prescribed diet (2 Gm
Na)
 Teach client amount of sodium
restriction, foods high in
sodium, use of nutrition labels,
food preparation and sodium
substitutes
 Teach potential
complications of
hypertension to instill
importance of maintaining
Na restrictions
 Assess for cultural factors
affecting dietary regime
Implementing –
“Doing”
 Teach the clienthypertension can’t be
cured but it can be
controlled.
 Remind the client to
continue medication
even though no S/S are
present.
 Teach client importance of life
style changes: (weight
reduction, smoking cessation,
increasing activity)
 Stress the importance of
ongoing follow-up care even
though the patient feels well.
Evaluation- To determine
effectiveness of NCP
 Final step of the Nursing Process but
also done concurrently throughout client care
 A comparison of client behavior and/or
response to the established outcome criteria
 Continuous review of the nursing care plan
 Examines if nursing interventions are working
 Determines changes needed to help client
reach stated goals.
Evaluation
 Outcome criteria met? Problem resolved!
 Outcome criteria not fully met? Continue plan of careongoing.
 Outcome criteria unobtainable- review each previous
step of NCP and determine if modification of the NCP is
needed.
 Were the nsg interventions appropriate/effective?
Evaluation
Factors that impede goal attainment:
 Incomplete database
 Unrealistic client outcomes
 Nonspecific nsg interventions
 Inadequate time for clients to achieve outcomes.
Checkpoint
Identify which stage of the nursing
process
is being described below:
 The nurse writes nursing interventions
 A goal is agreed upon
 The nurse performs a physical assessment
 A revision is made to the NCP
 The nurse administers antibiotic
medication
 A statement is written that outlines the
clients response to a potential health
problem
S and O Data Quiz
 RR 22/min, even unlabored
 “I can only walk 3 blocks before my
legs start to hurt”
 Pain rated 3 on a scale of 0-10
 Skin pink, warm and dry
 Urine output 300mL/8 hr
 “My wife doesn’t come to visit very
often”
 Dressing clean, dry and intact.
NCLEX Time
 The nurse records the following subjective data in the
client’s medical record:
 A.Breath sounds clear to auscultation
 B.Amber urine in sufficient quantities
 C.Pain intensity 8 out of 10
 D.Skin warm and dry
NCLEX Time
 When interviewing a client, the nurse
uses the following open-ended style
sentence:
 A.Do you have any concerns right
now?
 B.Is your family worried about you
being in the hospital?
 C.How many times do you get up to go
to the bathroom at night?
 D.What do you mean when you say, “I
don’t feel quite right?”
NCLEX Time
In order for an actual nursing diagnosis to be valid it must
have one or more supporting:
 A.Laboratory results
 B.Diagnostic data
 C.Defining characteristics
 D.Medical diagnoses
NCLEX Time
Nursing diagnoses are aimed at identifying client problems
that are treatable by _______.
 A.The physician
 B.The nurse
 C.Invasive techniques
 D.Complementary strategies