Transcript Nursing process

Nursing process
The Nursing Process
*An organized sequence of problemsolving steps used to identify and to
manage the health problems of clients.
• Orderly, systematic
• Central to all nursing care
• Encompasses all steps taken by the nurse
in caring for a patient
*Benefits of Nursing Process:
• Provides an orderly & systematic method for
planning & providing care
• Enhances nursing efficiency by standardizing
nursing practice
• Facilitates documentation of care
• Provides a unity of language for nursing
profession
• Is economical
• Stresses the independent function of nurses
• Increases care quality by using deliberate actions
Steps of nursing process
• Assessment
• Nursing Diagnosis
• Planning
• Implementation
• Evaluation
Characteristics of the nursing process
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Within the legal scope of nursing
Based on knowledge-requiring critical thinking
Planned-organized and systematic
Client-centered
Goal-directed
Prioritized
Dynamic
Continuity of care
Characteristics of nursing process-continued
• Prevention of duplication
• Individualized care
• Standards of care
• Increased client participation
Important
• Nurses are responsible for a unique dimension of
healthcare “the diagnosis and treatment of human
responses to actual or potential health problems”.
• Critical thinking in nursing is an essential component
of professional accountability and quality nursing
care.
• Critical thinking is careful, deliberate, and goal
directed.
• Nurse should be understanding the reason behind
knowledge.
• Nurse is curious, open-minded, non-judgmental….
ASSESSMENT
• Observation
• Interview:
– Types of questions
– Environment (physical and emotional) and
spiritual considerations
• Examination
*Types of Data to Collect:
• Objective data-observable and measurable facts
(Signs)
• Subjective data-information that only the client
feels and can describe (Symptoms)
*Sources of Data:
• Primary source: Client
• Secondary source: Client’s family, reports, test
results, information in current and past medical
records, and discussions with other health care
workers
* Assessment:
• Data base assessment – comprehensive
information you gather on initial contact with
the person to assess all aspects of health
status.
• Focus assessment – the data you gather to
determine the status of a specific condition.
* Nursing Diagnosis: Health issue that can be
prevented, reduced, resolved, or enhanced through
independent nursing measures by:
• Sorting, clustering, analyzing information
• Identifying potential problems and strengths
• Writing statement of problem or strength
• Prioritizing the problems
• Not a medical diagnosis
* Nursing Diagnosis: Judgment or conclusion about
the risk for—or actual—need/problem of the
patient (NANDA format)
Diagnostic Statements:
• Name of the health-related issue or problem as identified
in the NANDA list
• Etiology (its cause)
• Signs and Symptoms
• The name of the nursing diagnosis is linked to the
etiology with the phrase “related to,” and the signs and
symptoms are identified with the phrase “as manifested
(or evidenced) by”
• Problem: (Potential complication of seizure disorder
related to medication incompliance) (No AEB)
• Problem: (Risk of infection related to compromised
nutrition state) (No AEB)
• Strength: (Potential for effective breastfeeding related to
knowledge level and support system)
*Planning:
• The process of prioritizing nursing diagnoses and
collaborative problems, identifying measurable goals or
outcomes, selecting appropriate interventions, and
documenting the plan of care.
• The nurse consults with the client while developing
and revising the plan.
• The nurse shares the plan of care with nursing team
members, the client, and client’s family.
• The plan is a permanent part of the record.
*Setting Priorities:
• Determine problems that require immediate action
• Maslow’s Hierarchy of Human Needs
Nurse Identified Priorities
• Composite of all patient’s strengths and health
concerns.
• Moral and ethical issues.
• Time, resources, and setting.
• Hierarchy of needs.
• Interdisciplinary planning.
• Identifying Client-centered outcomes
• State what the patient will do or experience at
the completion of care.
• Give direction to the patient’s overall care.
• Patient behaviors not nurse behaviors!!
*Outcome:
-Components of Outcomes
• 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?
*Steps for deriving outcomes from Nursing
Diagnosis:
• Look at the first clause of the nursing dx and
restate in a statement that describes
improvement, control or absence of the
problem.
• Risk for infection R/T surgical procedure.
• The client will demonstrate no signs or
symptoms of infection.
*Short-Term Goals:
• Outcomes achievable in a few days or 1 week
• Developed form the problem portion of the diagnostic
statement
• Client-centered
• Measurable
• Realistic
• Accompanied by a target date
*Long-Term Goals:
• Desirable outcomes that take weeks or months to
accomplish for client’s with chronic health problems
*Selecting Nursing Interventions:
• Planning the measures that the client and nurse will
use to accomplish identified goals involves critical
thinking.
• Nursing interventions are directed at eliminating the
etiologies.
*Selecting an intervention:
• The nurse selects strategies based on the knowledge
that certain nursing actions produce desired effects.
• Nursing interventions must be safe, within the legal
scope of nursing practice, and compatible with
medical orders.
*Nursing Interventions:
• Monitor health status.
• Minimize risks.
• Resolve or control a problem.
• Assist with ADLs.
• Promote optimum health and independence.
• Either:
• Direct interventions: actions performed through
interaction with clients.
• Indirect interventions: actions performed away
from the client, on behalf of a client or group of
clients.
*Evaluation:
• The way nurses determine whether a client has reached a goal.
• It is the analysis of the client’s response, evaluation helps to
determine the effectiveness of nursing care.
• Ongoing part of the nursing process
• Monitoring the patient’s response to drug therapy
• Identifying the variables affecting outcome achievement
• Deciding whether to continue, modify, or terminate the plan
-Determining Outcome Achievement:
• Must be aware of outcomes set for the client.
• Must be sure patient is ready for evaluation.
• Is patient able to meet outcome criteria?
• Is it: (Completely met? ,Partially met?, Not met at all?)
• Record in progress in notes.
• Update care plan.
*Identifying Variable Affecting Outcome Achievement
• Maintain individuality of care plan:
1. Is the plan realistic for the client?
2. Is the plan appropriate at the time for this particular
client?
3. Were changes made in the plan when needed?
4. How does the client feel about the plan?
*Predict, Prevent, and Manage:
• Focus on early intervention
• Based on research
• Predict and anticipate problems
• Look for risk factors
*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)
• Use patient’s own words in subjective data – enclose in
“ ___” (quotation marks)
• Avoid generalizations – be specific
• Don’t make summative statements – describe - e.g.
patient is being ornery should be patient resists
instruction or patient states “Don’t talk to me, I don’t
care about that”
Functional Health Pattern
(NANDA)
Health Perception-Health management pattern
Nutritional-Metabolic Pattern
Elimination Pattern
Activity-Exercise Pattern
Sexuality-Reproduction Pattern
Sleep-Rest Pattern
Sensory-Perceptual Pattern
Cognitive Pattern
Role-Relationship Pattern
Self-Perception-Self- Concept Pattern
Coping-Stress Tolerance Pattern
Value-Belief Pattern
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Health Perception-Health Management Pattern
Energy Field Disturbance.
Altered Growth and Development.
Altered Health Maintenance.
Ineffective Management of Therapeutic Regimen: Individual.
Health Seeking Behaviors
Effective Management of Therapeutic Regimen
Risk for Injury
Risk for diagnoses
Risk for Suffocation
Risk for Poisoning
Risk for Trauma
Risk for Peri-operative Positioning Injury
Nutritional-Metabolic Pattern
Decreased Adaptive Capacity: Intracranial.
Ineffective Thermo regulation.
Fluid Volume Deficit
Fluid Volume Excess
Altered Nutrition: Less than body requirements
Altered Nutrition: More than body requirements
Ineffective Breastfeeding
Interrupted Breastfeeding
Ineffective Infant Feeding Pattern Impaired Swallowing
Altered Protection
Impaired Tissue Integrity
Altered Oral Mucous Membrane
Impaired Skin Integrity.
Elimination Pattern
Altered Bowel Elimination Constipation
Colonic constipation
Perceived constipation
Diarrhea
Bowel Incontinence
Altered Urinary Elimination Patterns of Urinary
Retention
Total Incontinence
Functional Incontinence
Reflex Incontinence
Urge Incontinence
Stress Incontinence
Risk for constipation
Risk for altered urinary elimination
Activity- Exercise Pattern
Activity Intolerance
Impaired Gas Exchange in effective Airway Clearance
Ineffective Breathing Pattern
Decreased Adaptive Intracranial Capacity
Decreased Cardiac Output
Disuse syndrome
Diversional Activity Deficit
Impaired Home Maintenance Management
Impaired Physical Mobility
Dysfunctional Ventilatory Weaning Response
Inability to Sustain Spontaneous Ventilation
Self-Care Deficit: (Feeding, Bathing/Hygiene, Dressing/Grooming,
Toileting)
Altered Tissue Perfusion: (Specify type: Cardiac, Cerebral, and
Cardiopulmonary. Renal, Gastrointestinal, Peripheral)
Disorganized Infant Behavior
Risk for Disorganized Infant Behavior
Risk for Peripheral Neurovascular Dysfunction
Risk for altered respiratory function
Sexuality-Reproduction Pattern
Risk- Diagnoses
Risk for altered sexuality pattern
Actual Diagnoses
Sexual Dysfunction, Altered Sexuality Patterns
Sleep-Rest Pattern
Wellness Diagnoses:
Opportunity to enhance sleep
Risk Diagnoses:
Risk for sleep pattern disturbance
Actual Diagnosis:
Sleeps Pattern Disturbance
Sensory-Perceptual Pattern
Wellness Diagnosis:
Opportunity to enhance comfort level
Risk Diagnoses:
Risk for pain, Risk for Aspiration
Actual Diagnoses:
Pain, Chronic Pain and Dysreflexia.
Cognitive Pattern
*Actual diagnosis
Acute confusion
Chronic Confusion
Decisional Conflict
Impaired Environmental Interpretation Syndrome
Knowledge Deficit (Specify)
Altered Thought Processes
Impaired Memory
*Wellness Diagnosis:
Opportunity to enhance cognition
*Risk Diagnoses:
Risk for altered thought processes
Role-Relationship Pattern
*Actual Diagnoses
Impaired Verbal Communication
Altered Family Processes: Alcoholism
Anticipatory Grieving
Dysfunctional Grieving?
Altered Parenting
Parental Role Conflict
Altered Role Performance
Impaired Social Interaction: Social Isolation
*Risk Diagnoses
Risk for dysfunctional grieving, High risk for Loneliness.
Risk for Altered Parent/Infant/Child Attachment
Self-Perception-Self-Concept Pattern
*Actual Diagnoses
Anxiety fatigue - Fear - Hopelessness- PowerlessnessPersonal Identity.
Disturbance - Body Image
Disturbance- self Esteem
Disturbance.
Risk Diagnoses
Risk for hopelessness
Risk for body image disturbance
Risk for low self esteem
Coping-Stress Tolerance Pattern
*Actual Diagnoses
Impaired Adjustment
Ineffective Individual Coping
Ineffective Family Coping: Disabling
Ineffective Family Coping: Compromised
Ineffective Community Coping: Post-Trauma Response,
Rape-Trauma Syndrome Relocation and Stress Syndrome.
*Risk Diagnoses
Risk for ineffective coping (individual, family, or community)
Risk for self-harm
Risk for self- abuse.
Risk for Self-Mutilation
Risk for suicide
Risk for Violence; Self- directed or directed at others
Value-Belief Pattern
*Actual Diagnosis
Spiritual disturbance (distress of the human spirit).
*Risk diagnosis
Risk for spiritual distress
*Wellness Diagnosis
Potential for enhanced spiritual Well- Being
**PRACTICAL STEPS
• Perform assessment
• Look at the NANDA list
• Look for the defining characteristics or symptoms
from your assessment
• Look for the related factors - things that cause the
symptoms
• Make the sentence read: NANDA
Diagnosis…RT…AEB…
• Develop SMART patient goals or the "patient will"
statements
– Specific & Individualized
– Measurable
– Attainable
– Reasonable Timed, and a date
• Write nursing interventions
• Write rationale that match the intent of the
interventions and goals
• Evaluate the outcome or result of goal interventions.
• More specifically...as you begin to write the care
plan, refer to your assessment findings. What is the
priority problem? Are there clues to the need for
patient teaching? What symptoms is the patient
experiencing?
• Often it helps to look at the NANDA list first, and see
if there is one particular diagnosis that seems to fit
the situation. Then look up that diagnosis in the
Nursing Diagnosis book. Look at their definition, to
see if it fits your patient.
Then look for the defining characteristics or
evidence: These are the signs and symptoms you
have seen in the patient. They will be the "as
evidenced by" or AEB of the diagnosis statement.
• Next, look for the related factors:
These are the "related to" or R/T part of the
statement. Remember, avoid using the medical
diagnosis as a "related to" part. However, it may be
used as a "secondary to" statement. Then change it
around to make the sentence read: NANDA
Diagnosis…RT…AEB…
• For example, if my patient has sores on his legs, and
he also has Diabetes Mellitus, you might use the
statement:
Decreased blood flow and nutrients to tissues of the
lower extremities, secondary to Diabetes
Mellitus AEB a 2 cm skin lesion on the left great toe,
and a 4 cm lesion on the inner aspect of the right
ankle."
• Nursing diagnoses that are in the "risk for"
categories do not need the AEB portion of the
statement, since there is no actual evidence.
However, you should avoid using too many "risk
for" diagnosis. One or two, out of eight to ten, is
acceptable.
• Assessment abnormalities should always be
reflected in the nursing diagnosis, and subjective
and objective data. If the assessment data is not
there, you have no evidence.
• Gradually, with practice, you will find that nursing
diagnoses are easier and easier to develop.
*GOALS or OUTCOMES:
• Next you'll want to develop patient goals or the
"patient will" statements. These must be specific,
measurable, attainable, realistic, timed, and dated.
Collaborate with the patient, to gain cooperation
with the planned goals. They should also be
measurable, and include a time frame, and a date.
Goals should conform to the nursing diagnosis. Make
them specific to your patient's problem.
• They should be individualized to your patient, not
just "canned" from the book.
• They should be attainable for your patient.
• Then look in the Nursing Diagnosis book for nursing
interventions that could be used to assist the patient
to attain the goal (s), you have established.
• Next, find the rationale that match the intent of the
interventions and goals.
• And finally, evaluate the outcome of the
interventions. These statements should match the
wording used in the goal column, and be followed by
the statement as to whether the goal was "met,
partially met, or not met.
Nursing Care Plan 1
*Nursing Diagnosis: ALTERED THOUGHT PROCESSES
*Definition: A state in which an individual experiences a
disruption in cognitive operations and activities
*Possible Etiologies (related to)
• Withdrawal into the self
• Underdeveloped ego; punitive superego
• Impaired cognition fostering negative
perception of self or the environment
*Defining Characteristics (evidenced by)
• Inaccurate interpretation of environment
• Delusional thinking
• Hypovigilance
• Altered attention span-distractibility
• Egocentricity
• Impaired ability to make decisions, problem-solve,
reason
• Negative ruminations
*Goals/objectives
**Short-Term Goal
• Patient will recognize and verbalize when
interpretations of the environment are inaccurate
within 1 week.
**Long-Term Goal
• Patient will experience no delusional or distorted
thinking by discharge.
*Interventions with Selected Rationales
• Convey your acceptance of patient’s need for the
false belief, while letting him or her know that you
don’t share the delusion. A positive response would
convey to the patient that you accept the delusion as
reality.
• Do not argue to deny the belief. Use REASONABLE
DOUBT as a therapeutic technique: “I find that hard
to believe.” An arguing with the patient or denying
the belief serves no useful purpose; delusional ideas
are not eliminated by this approach, and the
development of a trusting relationship may be
impeded.
• Use the technique of CONSENSUAL VALIDATION and
SEEKING CLARIFICATION when communication
reflects alteration in thinking. (Examples: “Is it that
you mean? “or“ I don’t understand what you mean
by that. Would you please explain?”) These
techniques reveal to the patient how he or she is
being perceived by others, while the responsibility for
not understanding is accepted by the nurse.
• Reinforce and focus on reality. Talk about real events
and real people. Use real situations and events to
divert patient away from long, purposeless, repetitive
verbalizations of false ideas.
• Give positive reinforcement, as patient is able to
differentiate between reality- and nonreality-based
thinking. Positive reinforcement enhances selfesteem and encourages repetition of desirable
behaviors.
• Teach patient to intervene, using thought-stopping
techniques, when irrational or negative thoughts
prevail. Thought stopping involves using the
command slop!” or a loud noise (such as hand
clapping) to interrupt unwanted thoughts. This noise
or command distracts the individual from the
undesirable thinking that often precedes undesirable
emotions or behaviors.
• Use touch cautiously, particularly if thoughts reveal
ideas of persecution. Patients who are suspicious
may perceive touch as threatening and may respond
with aggression.
*Desired Patient Outcomes/Discharge Criteria
1.Patient’s thinking processes reflect accurate
interpretation of the environment.
2.Patient is able to recognize negative or irrational
thoughts and intervene to stop their progression.
Nursing Care Plan 2
*Nursing Diagnosis: ALTERED NUTRITION, LESS THAN
BODY REQUIREMENTS
*Definition: The state in which an individual
experiences an intake of nutrients insufficient to meet
metabolic needs
*Possible Etiologies (related to)
**Inability to ingest food due to:
• Depressed mood
• Loss of appetite
• Energy level too low to meet own nutritional needs
• Regression to lower level of development
• Ideas of self-destruction
• Lack of interest in food
*Defining Characteristics (evidenced by)
• Loss of weight
• Pale conjunctiva and mucous membranes
• Poor muscle tone
• Amenorrhea
• Poor skin turgor
• Edema of extremities
• Electrolyte imbalances
• Weakness
• Constipation
• Anemias
*Goals/Objectives
**Short-Term Goal
• Patient will gain 2 Ib per week for the next 3 week.
**Long-Term Goal
• Patient will exhibit no signs or symptoms of
malnutrition by discharge (e.g.; electrolytes and
blood counts will be within normal limits; a steady
weight gain will be demonstrated; constipation will
be corrected; patient will exhibit increased energy in
participation of activities).
*Interventions with Selected Rationales
• In collaboration with dietitian, determine number
of calories required to provide adequate nutrition
and realistic (according to body structure and
height) weight gain.
• Ensure that diet includes foods high in fiber
content to prevent constipation. Encourage
patient to increase fluid consumption and
physical exercise to promote normal bowel
functioning. Depressed patients are particularly
vulnerable to constipation due to psychomotor
retardation. Constipation is also a common side
effect of many antidepressant medications.
• Keep strict documentation of intake, output, and
calorie count. This information is necessary to make
an accurate nutritional assessment and maintain
patient’s safety.
• Weigh patient daily. Weight loss or gain is important
assessment information.
• Determine patient’s likes and dislikes and collaborate
with dietitian to provide favorite foods. Patient is
more likely to eat foods that he or she particularly
enjoys.
• Ensure that patient receives small, frequent feedings,
including a bedtime snack, rather than three larger
meals. Large amounts of food may be objectionable,
or even intolerable, to the patient.
• Administer vitamin and mineral supplements and
stool softeners or bulk extenders, as ordered by
physician.
• If appropriate, ask family members or significant
others to bring in special foods that patient
particularly enjoys.
• Stay with patient during meals to assist as needed
and to offer support and encouragement.
• Monitor laboratory values, and report significant
changes to physician. Laboratory values provide
objective data regarding nutritional status.
• Explain the importance of adequate nutrition and
fluid intake. Patient may have inadequate or
inaccurate knowledge regarding the contribution of
good nutrition to overall wellness.
*Desired Patient Outcomes/Discharge Criteria
1.Patient has shown a slow, progressive weight gain
during hospitalization.
2.Vital signs, blood pressure, and laboratory serum
studies are within normal limits.
3.Patient is able to verbalize importance of adequate
nutrition and fluid intake.
Nursing Care Plan 3
*Nursing diagnosis: SLEEP PATTERN DISTURBANCE
• Definition: Disruption of sleep time which causes
patient discomfort or interferes with desired lifestyle
*Possible Etiologies (related to)
• Depressed mood
• Repressed fears
• Feelings of hopelessness
• Fear of failure
• Anxiety, moderate to severe
• Hallucinations
• Delusional thinking
*Defining Characteristics (evidenced by)
• Verbal complaints of difficulty falling asleep
• Awakening earlier or later than desired
• Interrupted sleep
• Verbal complaints of not feeling well rested
• Remaining awake 30 minutes after going to bed
• Awakening very early in the morning and being
unable to go back to sleep
• Excessive yawning and desire to nap during the day
• Hypersomnia; using sleep as an escape
*Goals/Objectives
**Short-Term Goal
• Patient will be able to sleep 4 to 6 hours with the aid
of a sleeping medication within 5 days.
**Long-Terms Goal
• Patient will be able to fall asleep within 30 minutes
of retiring, and obtain 6 to 8 hours of uninterrupted
sleep each night without medication by discharge.
*Interventions with Selected Rationales
• Keep strict records of sleeping patterns. Accurate
base line data are important in planning care to assist
patient with this problem.
• Discourage sleep during the day to promote restful
sleep at night.
• Administer antidepressant medication at bedtime so
patient does not become drowsy during the day.
• Assist with measures that may promote sleep, such
as warm, non-stimulating drinks, light snacks, warm
baths, backrubs.
• Performing relaxation exercises to soft music (or
other technique) may be helpful before sleep.
• Limit intake of caffeinated drinks, such as tea, coffee,
and coals. Caffeine is a CNS stimulant that may
interfere with the patient’s ability to rest and sleep.
• Administer sedative medications, as ordered, to
assist patient achieve sleep until normal sleep
pattern is restored.
• For patient experiencing hypersomnia, set limits on
time spent in room. Plan stimulating diversionary
activities on a structured, daily schedule. Explore
fears and feelings that sleep is helping to suppress.
*Desired Patient Outcomes/Discharge Criteria
1.Patient is sleeping 6 to 8 hours per night without
medication.
2.Patient is dealing to fall asleep within 30 minutes of
retiring.
3.Patient is dealing with fears and feelings rather than
escaping from them through-excessive sleep.