Transcript Certification Review

Certification Review
The Nursing Process
Jan Brooks RN, BSN, CGRN
HRSGNA
Nursing Process
• Objectives: Assessment
• 1. Identify steps of a nursing assessment as it
applies to the GI Patient
• 2. Discuss the assessment of the patient
receiving sedation and analgesia in the GI
Setting
Nursing Process
• Nursing Process is a systematic, interactive
approach to Nursing care.
• Steps:
– Assessment
– Nursing Diagnosis
– Planning
– Implementation
– Evaluation
Nursing Process
Assessment
Medical Assessment is used to define the
existence of medical problems and underlying
pathology
Nursing assessment is to identify the response
to medical conditions, treatments and
changes in activities of life
Nursing Process
Assessment
– Performed initially to gather data about a patient
– Focus assessment used to look further at a
specific issue
– Requires updating and reassessment at regular
intervals
– May also include an emergency assessment with a
life threatening situation
– May require a collaborative effort with
multidisciplinary team
Nursing Process
Assessment
• Steps of a Nursing Assessment:
• We do these automatically and don’t think about steps
1. Collecting Data
• Interview --subjective and objective
• Observation –involves all senses
• Physical Exam—Inspection, Palpation, Percussion and
Auscultation
• Review of Records and Diagnostic reports
• Collaboration with Colleagues
Nursing Process
Assessment
2.Identifying cues and making inferences
Inferences are made after collecting
subjective and objective data as related to the
patient and his or her illness or situation
3. Validating Data
Confirmation of data received or may
require further explanation
Example is pt who states NKA, yet is documented with an allergy
Nursing Process
Assessment
4. Clustering Data
The organization of the data to assist with the Nursing Diagnosis
Needs to also be organized to focus on priority of care
5. Identifying patterns and Testing First
Impressions
Validation of information from initial assessment,
What is relevant or irrelevant?
Communication with other Team members
Nursing Process
Assessment
6. Reporting and Recording Data
All data must be communicated and/or recorded
in a timely manner
Critical information must be recognized and
communicated immediately
Data must be recorded legibly, in a timely
manner
Data should include descriptive, subjective and
objective information supported by documented
facts
Nursing Process
Assessment
• Assessment for the GI Patient
– Many patients are frequently sedated for
procedures
• Assessment includes:
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NPO status
Medications currently prescribed
Underlying medial problems
Any diagnostic testing completed
Respiratory status
Other underlying or contributing factors
Ride home
Nursing Process
• Objectives: Nursing Diagnosis
– 1. Define Nursing Diagnosis
– 2. Identify actual and potential nursing diagnoses
applicable to GI patients
Nursing Process
Nursing Diagnosis
• Term began being used in 1950’s
• 1996 Dr. Lester King wrote an article that
refuted the idea that Physicians were the only
ones to diagnose.
• Defined as: A statement of an actual or
potential health problem that can be
alleviated or prevented by independent
Nursing intervention.
Nursing Process
Nursing Diagnosis
• Provides a basis for selecting nursing
interventions
• Provides useful and practical method for
organizing nursing knowledge
• Based upon data obtained from nursing
assessment
• Is a concise statement of interpretation of
data collected
Nursing Process
Nursing Diagnosis
• Types of Nursing Diagnoses:
– Actual—Made when condition is validated by
presence of clinical characteristics
– Risk—Patient/family or community are vulnerable to a
potential problem
– Possible—problem that is suspected, but requires
further supportive data
Nursing Process
Nursing Diagnosis
• Types of Nursing Diagnoses
Wellness—taking an individual, group or
family from one level of wellness to a higher
level
Syndrome—Fairly new concept
Describes a cluster of signs and symptoms
Example—Disuse syndrome would incorporate risk for
infection, constipation, thrombosis, activity tolerance
Nursing Process
Nursing Diagnosis
• Medical Diagnosis: Focuses on identification
of diseased based pathology and etiology
• Nursing Diagnosis: Focuses on present health
problems, strengths and limitations and
methods of adapting to health problems
• Collaborative Diagnosis: Utilizes other
members of the health care team
Nursing Process
Nursing Diagnosis
• Nursing diagnosis as related to the GI Patient
Actual--Elimination process—alteration of normal
bowel patterns due to ulcerative colitis
Actual or potential—Knowledge deficit related to
procedure and sedation
Potential—Impaired physical mobility due to
sedation
Nursing Process
• Objectives: Planning
– 1. List three types of planning utilized in care
planning
– 2. Compare nursing and medical plans of patient
care
Nursing Process
Planning
• Planning --Development of Nursing activities
based on nursing diagnosis for the purpose of
preventing, reducing or resolving health
problems through Nursing intervention.
• Involves setting priorities for care
• Determining patient goals and expected
outcomes
Nursing Process
Planning
• Reasons for Developing a Plan of Care
– Assists to assign priorities of care
– Provides a means of communication
– Uses universal language
– Gives professional quality to the act of nursing
– Has an economic impact especially related to
Medicare and diagnosis related groups
Nursing Process
Planning
• Medical and Nursing Plans of Care
– Similar –both derived from assessment
– Both describe monitoring signs and symptoms
– Both prescribe measures based on scientific
knowledge
– Nursing diagnosis focus on patient responses to
medical treatment.
– Nursing interventions can include actions that nurses
can legally perform
Nursing Process
Planning
• Clinical Pathways
– Set along specific time lines
– Multiple disciplinary
– Provide teaching tools to patients and families
– Demonstrate quality care
Nursing Process
Planning
• Planning involves
– Initial Planning
– Ongoing Planning
– Discharge Planning
– Identifying NURSING actions
• IE: Access breath sound immediately post procedure
• Explain signs and symptoms of bleeding and
interventions to be taken if bleeding were to occur post
procedure
Document Plan of care
Nursing Process
Implementation
• Objectives:
– 1. Define general guidelines for implementing
care of the GI Patient
– 2. Discuss the nurse’s role when implementing
care of the GI Patient
Nursing Process
Implementation
• Is the Blue Print that guides Nursing Care
• Based on Scientific Principles
• Reflects the rights and desires of the patient and
significant others
• Actions are carried out safely, skillfully and
efficiently
Nursing Process
Implementation
• Implementation is impacted by the Care
Team’s:
– Cognitive Ability
– Interpersonal Skills
– Technical Skills
Nursing Process
Implementation
• Functions:
– Independent Interventions
– Interdependent Interventions
– Dependent Interventions
– Based on Nurse Practice Acts
Nursing Process
Implementation
• Variables that Affect Care Implementation
– Patient Variables
– Nurse Variables
– Standards of Care
– Research Findings
– Resources
– Ethical and Legal Guides to Practice
Nursing Process
Implementation
• Importance of Documentation
– Formal method of communication
– Used in multiple ways—
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Planning
Process improvement audits
Research
Education
Legal Evidence
Historical Document
Nursing Process
Implementation
• Patient Teaching
– Integral part of the Implementation Process
• Still has same activities
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Assessing and diagnosing knowledge deficit
Planning learning Activity
Providing learning Activities
Evaluating learning
Nursing Process
Implementation
• Counseling
– The Act of rendering guidance to a patient and /or
significant other
– May be short term, long term, or motivational
Advocacy
--Informing patients and families
--Supporting that decision
Nursing Process
Implementation
• Informed Consent
– Between the physician and the patient
• Exchange of information
• Interaction not a thing (legal document)
• Required Admission
Before diagnostic procedure or surgery
Before any experimentation is enacted
Nursing Process
Implementation
Advocacy in Ethical Dilemmas
Seen especially with feeding tubes
Guidelines in ethical decision making
1.
2.
3.
4.
5.
6.
7.
Teach, clarify, reinforce medical information
Remain as objective as possible
Provide willing ear, cautious mouth
Approach respectfully
Accept and support patient and family decisions
Observe and communicate
Work through appropriate channels
Nursing Process
Evaluation
• Objectives:
– 1. Explain the tasks involved in the evaluation
process
– 2. Explain the role Standards of Care have in the
Nursing Process
Nursing Process
Evaluation
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The Final phase in the Nursing Process
Is the analytical portion
Were the things implemented effective?
Time of reassessment, modifications made
Is the goal realistic?
Nursing Process
Evaluation
• Nursing Practice is based on a Scientific
Framework including:
Critical Thinking
Communication
Adherence to a STANDARD of CARE
Criteria are measurable qualities that
apply to Standard of Care or Practice
Nursing Practice
• Guidelines vs Standards
– Guidelines
• Suggested performance
• Current recommendations
• May deal with technical performance
Nursing Process
 Standards
• Measurable criteria to evaluate practice
• Incorporate a stronger statement of expected
performance
 Regulation
Legal statement that defines Required
Performance
Nursing Process
Evaluation
• Standards of Care or Practice
– 1. Quality of Care
– 2. Performance Appraisal
– 3. Education
– 4. Collegiality
Nursing Process
Evaluation
Standards of Care (or Practice)
5. Ethics
6. Collaboration
7. Research
8. Resource Utilization
9. Leadership found in Practice
Nursing Process
Review Questions
1. A nursing assessment:
A.
B.
C.
D.
Is a systematic approach to nursing care
Is always comprehensive
Is a process of identifying a patient problem
Should precede a nursing history
2. Validation is the act of:
A.
B.
C.
D.
Clarification
Verification
Repeating a patient’s responses twice
Checking to be sure a nursing history was taken
Nursing Process
Review Questions
1. A nursing assessment:
A.
B.
C.
D.
Is a systematic approach to nursing care
Is always comprehensive
Is a process of identifying a patient problem
Should precede a nursing history
2. Validation is the act of:
A.
B.
C.
D.
Clarification
Verification
Repeating a patient’s responses twice
Checking to be sure a nursing history was taken
Nursing Process
Review Questions
3. The correct order of physical assessment is:
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A.
B.
C.
D.
Inspection, palpation, percussion, auscultation
Palpation, percussion, inspection, auscultation
Auscultation, percussion, inspection, palpation
Inspection, percussion, palpation, auscultation
• 4. Formulating a nursing diagnosis provides:
– A.
– B.
– C.
– D.
Important assessment data
An interpretation of data collected
Interdependent nursing interventions
Outcome criteria for evaluation
Nursing Process
Review Questions
3. The correct order of physical assessment is:
•
•
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•
A.
B.
C.
D.
Inspection, palpation, percussion, auscultation
Palpation, percussion, inspection, auscultation
Auscultation, percussion, inspection, palpation
Inspection, percussion, palpation, auscultation
• 4. Formulating a nursing diagnosis provides:
– A.
– B.
– C.
– D.
Important assessment data
An interpretation of data collected
Interdependent nursing interventions
Outcome criteria for evaluation
Nursing Process
Review Questions
5. “Cholecystitis with cholelithioasis” is an example of a:
A.
B.
C.
D.
Collaborative diagnosis
Nursing Diagnosis
Medical Diagnosis
Medical History
Nursing Process
Review Questions
5. “Cholecystitis with cholelithioasis” is an example of a:
A.
B.
C.
D.
Collaborative diagnosis
Nursing Diagnosis
Medical Diagnosis
Medical History
Nursing Process
Review Questions
6. The Nursing Care Plan:
A. Is based on scientific principles and incorporates
findings of nursing research
B. Advances nursing’s four aims and is tailored to the
individual patient.
C. Is designed to meet developmental, psychological,
sociological and physiological needs of patients.
D. All of the above.
Nursing Process
Review Questions
6. The Nursing Care Plan:
A. Is based on scientific principles and incorporates
findings of nursing research
B. Advances nursing’s four aims and is tailored to the
individual patient.
C. Is designed to meet developmental, psychological,
sociological and physiological needs of patients.
D. All of the above.
Nursing Process
Review Questions
7. A GI nurse might vary the way he or she comforts
an anxious 10 year old boy based on:
A. The developmental task of children aged 7-11
B. His willingness to participate in counseling
C. Recent findings concerning the impact of certain words
in calming or provoking anxiety
D. All of the above
Nursing Process
Review Questions
7. A GI nurse might vary the way he or she comforts
an anxious 10 year old boy based on:
A. The developmental task of children aged 7-11
B. His willingness to participate in counseling
C. Recent findings concerning the impact of certain words
in calming or provoking anxiety
D. All of the above
Nursing Process
Review Questions
• 8. Administering Medication is:
A. An independent nursing activity
B. An interdependent task
C. A dependent nursing obligation
D. A non-nursing chore
Nursing Process
Review Questions
• 8. Administering Medication is:
A. An independent nursing activity
B. An interdependent task
C. A dependent nursing obligation
D. A non-nursing chore
Nursing Process
Review Questions
9. Nurses accomplish patient teaching in four
phases, including: planning the learning
activity, providing learning opportunities,
evaluating learning, and:
A.
B.
C.
D.
Correcting mistakes
Diagnosing a patient’s knowledge deficit
Explaining the patient’s privacy needs to s/o
Helping patients make informed decisions
Nursing Process
Review Questions
9. Nurses accomplish patient teaching in four
phases, including: planning the learning
activity, providing learning opportunities,
evaluating learning, and:
A.
B.
C.
D.
Correcting mistakes
Diagnosing a patient’s knowledge deficit
Explaining the patient’s privacy needs to s/o
Helping patients make informed decisions
Nursing Process
Review Questions
• 10. Criteria are:
A.
B.
C.
D.
Nationally recognized standards
Facts
Interventions
Measurable
Nursing Process
Review Questions
• 10. Criteria are:
A.
B.
C.
D.
Nationally recognized standards
Facts
Interventions
Measurable
Nursing Process
Review Questions
11. The reason the nursing professionals evaluate
the quality of care include all of the following except:
A. Nursing professionals aim to promote excellence in
nursing care.
B. Nurses must be accountable to society for the quality
of the care they provide.
C. Nurses want to improve professional performance.
D. Nurses recognize that quality in health care is elusive
and complex.
Nursing Process
Review Questions
11. The reason the nursing professionals evaluate
the quality of care include all of the following except:
A. Nursing professionals aim to promote excellence in
nursing care.
B. Nurses must be accountable to society for the quality
of the care they provide.
C. Nurses want to improve professional performance.
D. Nurses recognize that quality in health care is elusive
and complex.
Nursing Process
• Thank you
• Thank you to all SGNA Board:
– Lisa, Mary, Lynn, Brenda and Debra
– As well as Rita, Candice, Laura, Randy and others
behind the sceens.