Transcript Nursing Process

Nursing Process
Part Three, 211 NUR
Learning Outcomes
1. Describe the phases of the nursing process.
2. Identify major characteristics of the nursing
process.
3. Identify the purpose of assessing.
4. Identify the four major activities associated
with the assessing phase.
Learning Outcomes (cont'd)
5. Differentiate objective and subjective data
and primary and secondary data.
6. Identify three methods of data collection,
and give examples of how each is useful.
7. Compare closed and open-ended questions,
providing examples and listing advantages
and disadvantages of each
Nursing Process
Defined as:
is a Systematic, rational method of planning to
providing nursing care.
Is “A series of steps or acts that lead to
accomplishment of some goal or purpose”
Goals of Nursing process
1. To identify Patient healthcare status, actual
or potential health problems
2. To establish plans to meet the identified
needs.
3. To deliver specific nursing interventions to
address those needs.
Benefits of Nursing process
1. Improves quality of care Pts. Receive.
2. Promotes efficient use of time & resources.
3. Serves as framework for nurses’ accountability.
4. Enhances collaboration.
5. Continuity of care and Prevention of
duplication.
Characteristics of the
Nursing Process
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7.
Cyclic and dynamic rather than static.
Client centered.
Problem-solving and systems theory.
Decision making.
Interpersonal and collaborative.
Universal applicability.
Critical thinking skills.
MARTHA ROGERS,
NURSE THEORIST
“When an apple is cut, others
see seeds in the apple. We, as
nurses, see apples in the seeds.”
5 Steps in the Nursing Process
1. Assessment
2.
3.
4.
5.
Nursing Diagnosis
Planning
Implementing
Evaluating
Figure 11-1 The nursing process in action.
Figure 11-1 (continued) The nursing process in action.
Figure 11-3
Assessing.
1. Assessment
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Collecting data
Organizing data
Validating data
Documenting data
1. Assessment
Four types of assessment
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Initial nursing assessment
Problem-focused assessment
Emergency assessment
Time-lapsed reassessment
Types of Assessments
• Initial or Comprehensive
– Performed within a specified time period
– Establishes complete database
• Problem-Focused
– Ongoing process integrated with care
– Determines status of a specific problem
Types of Assessments (cont'd)
• Emergency
– Performed during physiologic or psychologic crises
– Identifies life-threatening problems
• Time-lapsed (on going)
– Occurs several months after initial assessment
– Compares current status to baseline
Small group questions
1. Baby Jane a 2 month infant goes into the
doctor for her initial immunization and well
baby check-up. What type of assessment
should the nurse perform?
A. Comprehensive
B. Focused
C. Time-lapsed (on going)
A. Collecting Data
• Gathering information about a client’s health
status.
• It must be both systematic and continuous.
• Should include past history and current
problem.
• Can be subjective or objective.
• From primary or secondary source.
Subjective Data
• Symptoms or covert data
• Can be described only by person affected
• Includes sensations, feelings, values, beliefs,
attitudes, and perception of personal health
status and life situations
• Obtained through Nursing health history.
Objective Data
• Signs or overt data
• Detectable by an observer
• Can be measured or tested against an
accepted standard
• Can be seen, heard, felt, or smelled
• Obtained through observation or physical
examination
Small Group Questions
4. Which of the following are objective data and
which are subjective data.
A. Nausea
B. Vomiting
C. Unsteady gait
D. Anxiety
E. Bruises on the right arms and face
F. Temperature 101 F
Sources of Data
• Primary Source
– The client
• Secondary Sources
– All other sources of data
• Family members
• Other health care providers
• Medical records
Methods of Data Collection
• Observing
– Gathering data using the senses
– Used to obtain following types of data:
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Skin color (vision)
Body or breath odors (smell)
Lung or heart sounds (hearing)
Skin temperature (touch)
Methods of Data Collection
• Interviewing
– Planned communication or a conversation with a
purpose
– Used to:
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Get or give information
Identify problems of mutual concern
Evaluate change
Teach
Provide support
Provide counseling or therapy
Closed and Open-ended Questions
• Closed Question
• Restrictive
– Yes/no
– Factual
• Less effort and information from client
• “What medications did you take?”
• “Are you having pain now?”
Closed and Open-ended Questions (cont'd)
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Open-ended Question
Specify broad topic to discuss
Invite longer answers
Get more information from client
Useful to change topics and elicit attitudes
The Interview Setting
• Time
– Client free of pain
– Limited interruptions
• Place
– Private
– Comfortable environment
– Limited distractions
The Interview Setting (cont’d)
• Seating Arrangement
– Hospital
– Office or clinic
– Group
• Distance
– Comfortable
• Language
– Use easily-understood terminology
Methods of Data Collection
• Examining (physical examination)
– Systematic data-collection method
– Uses observation and inspection, auscultation,
palpation, and percussion
– Vital signs, height and weight
b. Organizing data
• Nursing Models Framework
– Gordon’s functional health pattern framework
– Orem’s self-care model
– Roy’s adaptation model
b. Organizing data
• Wellness Models
• Nonnursing Models
– Body systems model
– Maslow’s Hierarchy of Needs
– Developmental theories
Validating Data
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Assessment complete
Objective and related subjective data agree
Additional data overlooked
Avoiding jumping to conclusions
Cues: subjective & objective
Inferences = nurse’s interpretation of the cues
Documenting
• Record client data
• Record factual manner not interpreting by
nurse
• Record subjective data with quotes in client’s
own words
Question
Which of the following behaviors would indicate that
the nurse was utilizing the assessment phase of the
nursing process, to provide nursing care?
A. Propose hypotheses
B. Generate desired outcomes
C. Reviews results of laboratory tests
D. Documents care
Question
Which of the following elements is best categorized as
secondary subjective data?
A. The nurse measures a weight loss of 10 pounds
since the last clinic visit.
B. Spouse states the client has lost all appetite.
C. The nurse palpates edema in lower extremities.
D. Client states severe pain when walking up stairs.
2. Diagnoses
Figure 12-1 Diagnosing. The pivotal second phase of the nursing process.
• Nursing diagnosis:
– “A clinical judgment about individual, family or
community responses to actual or potential heal
problems / life processes.
– A nursing diagnosis provides the basis for
selection of nursing interventions to achieve
outcomes for which the nurse is accountable.”
Diagnoses
• Diagnosing refers to the reasoning process
• Diagnosis is a statement or conclusion
regarding the nature of a phenomenon
• Diagnostic labels are the standardized NANDA
names
• Nursing diagnosis is the problem statement
consisting of the diagnostic label plus etiology
Types of Nursing Diagnoses
• Actual Diagnosis
– Problem presents at the time of the assessment
– Presence of associated signs and symptoms
• Risk Diagnosis
– Problem does not exist
– Presence of risk factors
Types of Nursing Diagnoses (cont'd)
• Health Promotion Diagnosis
– Preparedness to implement behaviors to improve
their health condition
– Example: Readiness for enhanced Nutrition
• Wellness Diagnosis
– Describes human responses to levels of wellness
in an individual, family, or community
– Example: Readiness for Enhanced Family Coping
Components of a Nursing Diagnosis
• Problem statement (diagnostic label)
– Describes the client’s health problem or response
– Qualifiers added to give additional meaning
• Etiology (related factors and risk factors)
– Identifies one or more probable causes of the
health problem
Components of a Nursing Diagnosis
• Defining characteristics
– Cluster of signs and symptoms indicate the
– presence of a particular diagnostic label (actual
diagnoses)
– Actual nursing diagnoses client’s have signs and
symptoms
– For risk for nursing diagnoses no subjective or
objective data
Nursing Diagnoses
• A statement of nursing judgment based on
education, experience, expertise and licensed
to treat
• Describes human response, a client’s physical,
sociocultural, psychological, and spiritual
responses to an illness or a health problem
• Changes when client’s responses change
Medical Diagnoses
• Made by a physician
• Refers to a disease process
• Remains the same for as long as the disease
process is present
Ex: Diagnosis
Nursing diagnosis
Medical diagnosis
Breathing patterns,
ineffective
Chronic obstructive
pulmonary disease
Activity intolerance
Cerebrovascular accident
Pain
Appendectomy
Body image disturbance
Amputation
Body temperature, risk for
altered
Strep throat
Steps in Diagnostic Process
• Analyzing Data
– Compare data against standards
– Cluster cues
– Identify gaps
– Identifying health problems, risks, and strengths
• Formulating diagnostic statements
Writing Nursing Diagnoses
• Basic Two-Part Statement
– Problem (P)
– Etiology (E)
• Basic Three-Part Statement
– Problem (P)
– Etiology (E)
– Signs and symptoms (S) what’s the evidence of the
problem.
Nursing Diagnosis
• Problem( Diagnostic Label)-based on your
assessment of client…(gathered
information), pick a problem from the
NANDA list...
• Etiology- determine what the problem is
caused by or related to (R/T)...
• Defining characteristics- then state as
evidenced by (AEB) the specific facts the
problem is based on...
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”.
Table 12-6 Guidelines for
Writing a Nursing Diagnostic
Statement
Question
In the diagnostic statement “Excess fluid volume
related to decreased venous return as manifested by
lower extremity edema (swelling),” the etiology of the
problem is which of the following?
A.Excess fluid volume
B.Decreased venous return
C. Edema
D.Unknown
Question
Which of the following nursing diagnoses contains the
proper components?
A. Risk for caregiver role strain related to
unpredictable illness course
B. Risk for falls related to tendency to collapse when
having difficulty breathing
C. Impaired communication related to stroke
D. Sleep deprivation secondary to fatigue and a noisy
environment
3. Planning
Figure 13-1 Planning. The third phase of the nursing process, in which the nurse and client develop client
goals/desired outcomes and nursing interventions to prevent, reduce, or alleviate the client’s health problems.
Initial Planning
• Developed the initial comprehensive plan of
care
• Planning should be initiated after the initial
assessment
Ongoing Planning
• Done by all nurses who work with the client
• Individualization of initial care plan
• Also occurs at the beginning of a shift
Discharge Planning
• Process of anticipating and planning for needs
after discharge
• Addressed in each client’s care plan
• Begins at first client contact
• Involves comprehensive and ongoing
assessment
The Planning Process
• Consists of following activities:
– Setting priorities
– Establishing client goals/desired outcomes
– Selecting nursing interventions
– Writing individualized nursing interventions on
care plans
Setting Priorities
• Establishing a preferential sequence for
addressing nursing diagnoses and
interventions
– High priority (life-threatening)
– Medium priority (health-threatening)
– Low priority (developmental needs)
Maslow’s Hierarchy of Needs
Goals/Desired Outcomes
• Goals are broad statements about the client’s
status
• Desired outcomes are more specific,
observable criteria used to evaluate whether
the goals have been met
Table 13-2 Deriving Desired
Outcomes from Nursing
Diagnoses
Components of Goal/Desired Outcome
Statements
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Subject: who is the person expected to achieve the
outcome?
Verb: what actions must the person take to achieve the
outcome?
Condition: under what circumstances is the person to
perform the actions?
Performance criteria: how well is the person to perform
the actions?
Target time: by when is the person expected to be able
to perform the actions?
Guidelines for Writing Goals/Desired
Outcomes
SMART Specific
Measurable
Attainable
Relevant
Time Bound
Pt will walk 50 ft.
Pt will maintain HR<100
Pt will state pain level is acceptable 6 (0-10)
Guidelines for Writing Goals/Desired
Outcomes
• Must be realistic
• Ensure compatibility with the therapies of
other professionals
• Derive from only one nursing diagnosis
• Use observable, measurable terms
• Make sure client considers them to be
important and values them.
Types of Nursing Interventions
• Independent interventions
– Those activities nurses are licensed to initiate (i.e.,
physical care, ongoing assessment)
• Dependent interventions
– Activities carried out under physician’s orders or
supervision, or according to specified routines
Types of Nursing Interventions (cont'd)
• Collaborative interventions
– Actions nurse carries out in collaboration with
other health team members
– Reflect overlapping responsibilities of health care
team
Criteria for Choosing Appropriate
Interventions
• Safe and appropriate for the client’s age,
health, and condition
• Achievable with the resources available
• Congruent with the client’s values, beliefs, and
culture
• Congruent with other therapies
• Based on nursing knowledge and experience
or knowledge from relevant sciences
Writing individualized Nursing
Interventions
• Date when they are written
• Verb
– Action verb starts the interventions and must be
precise
• Conditions
• Modifiers
• Time element
– How long or how often the nursing action is to
occur
Question
The nurse selects the nursing diagnosis of Risk for Impaired
Skin Integrity related to immobility, dry skin, and surgical
incision. Which of the following represents a properly
stated outcome/goal? The client will:
A. Turn in bed q2h.
B. Report the importance of applying lotion to skin daily.
C. Have healthy intact skin during hospitalization.
D. Use a pressure-reducing mattress.
4. Implementation
Figure 14-1 Implementing. The fourth phase of the nursing process, in which the nurse implements the nursing
interventions and documents the care provided.
The Nursing Process - Implementing
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Based on first three phases
Assessing
Diagnosing
Planning
Provides the basis for the nursing actions
performed during the implementing step
• Provides actual nursing activities and client
responses are examined during evaluating phase
Successful Implementation
• To implement care successfully, nurses need:
– Cognitive skills
– Interpersonal skills
– Technical skills
Cognitive Skills (Intellectual)
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Problem solving
Decision making
Critical thinking
Creativity
Interpersonal Skills
• Verbal and nonverbal
• Effectiveness depends largely with ability to
communicate
• Therapeutic communication
• Necessary for caring, comforting, advocating,
referring, counseling, and supporting
Interpersonal Skills (cont'd)
• Include conveying knowledge, attitudes,
feelings, interest
• Appreciation of the client’s cultural values and
lifestyle
Technical Skills
• Purposeful “hands-on” skills
• Often called tasks, procedures, or
psychomotor skills
• Psychomotor refers to physical actions that
are controlled by the mind, not reflexes
• Require knowledge and frequently manual
dexterity
Five Activities of the Implementing Phase
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Reassessing the client
Determining the nurse’s need for assistance
Implementing nursing interventions
Supervising delegated care
Documenting nursing activities
Reassessing the Client
• Reassess to make sure the intervention is still
needed
• Client’s condition may have changed
Determining the Nurse’s Need for Assistance
• Unable to implement the nursing activity
safely
• Assistance will reduce stress on the client
• Lacks the knowledge or skills to implement a
particular nursing activity
Implementing Nursing Interventions
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Base on scientific knowledge
Clearly understand interventions
Adapt activities to the individual client
Implement safe care
Provide teaching, support, and comfort
Implementing Nursing Interventions
(cont'd)
• Be holistic
• Respect the dignity of the client and enhance
self esteem
• Encourage active client participation
Supervising Delegated Care
• Responsible for the client’s overall care
• Validates and responds to any adverse findings
or client responses
5. Evaluation
Documenting Nursing Activities
• Record nursing interventions and client
responses
• Must not be recorded in advance
Figure 14-3 Evaluating. The final phase of the nursing process, in which the nurse determines the client’s progress
toward goal achievement and the effectiveness of the nursing care plan. The plan may be continued, modified, or
terminated.
Components of the Evaluation Process
• Collecting data related to the desired
outcomes (NOC indicators)
• Comparing the data with outcomes
• Relating nursing activities to outcomes
• Drawing conclusions about problem status
• Continuing, modifying, or terminating the
nursing care plan
EVALUATION & REASSESSMENT
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1. Goal met
2. Goal partially met
3. Goal not met
4. Goal in progress
Reassessment= the entire plan of care (data,
ND, goal/O, Nsg orders) must be reassessed
Documentation
• Clear and concise
• Appropriate terminology
– Usually on a designated form
• Physical assessment
– Usually by Review of Systems
• Overview of symptoms
• Diet
• Each body system
References
• Kozier & Erb's Fundamentals of Nursing by
Audrey T Berman, Samuel Merritt
CollegeShirlee Snyder, Nevada State
CollegeGeralyn Frandsen, EdD, MSN,
RN, Maryville University