Date post: | 22-Sep-2014 |
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The Nursing Process
Nursing Process
The Nursing Process is a framework that helps organize and deliver nursing care. It:
Is orderly, systematic. Is central to all nursing care. Is used to identify, prevent and treat actual or potential
health problems and promote wellness. Encompasses all steps taken by the nurse in caring for
individuals, families, groups, and communities. Must be used by nurses
Definition of the Nursing ProcessAn organized sequence of problem-
solving steps used to identify and to manage the health problems of clients
It is accepted for clinical practice established by the American Nurses Association
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 the nursing
profession Is economical Stresses the independent function of nurses Increases care quality through the use of
deliberate actions
The Nursing Process Utilizes The Following
AssessmentNursing DiagnosisPlanningImplementationEvaluation
Characteristics of the Nursing Process
Within the legal scope of nursingBased on knowledge-requiring critical
thinkingPlanned-organized and systematicClient-centeredGoal-directedPrioritizedDynamic
Being Accountable
Using critical thinking before taking actions
Being responsible for your actions Entering the professional role Working at the level of your peers Using the nursing process
Something to think about:
Nurses are responsible for a unique dimension of healthcare – “ the diagnosis and treatment of human responses to actual or potential health problems”
The Nursing Process Is:
Cyclic and dynamic Goal directed and client centered Interpersonal and collaborative Universally applicable Systematic
NURSING PROCESS
Nursing Process
1. Assessment – The nurse gathers subjective & objective information from the client & other sources in order to understand the client’s situation.
2. Nursing Diagnosis –Organizes (in collaboration with the client), interprets the data and makes nursing diagnosis/diagnoses, which is nursing’s perspective on the appropriate focus for client nursing care.
3.Planning- Sets, in collaboration with client, mutually agreed upon goals of care, desired outcomes strategies to achieve goals of care & the identification & prioritization of appropriate nursing actions.
Nursing Process
4.Intervention- Perform the nursing actions identified in planning.
5.Evaluation- Determine if the goals are met and outcomes achieved.
Advantages of using the Nursing Process Continuity of care Prevention of
duplication Individualized
care Promotes critical
thinking & safety
■ Increased client participation
■ Collaboration of care
■ Application of Standards of care.
Critical Thinking
CRITICAL THINKING - is an active, organized cognitive process used to examine one’s own thinking.
It is a time for making decisions and reflecting, and taking nothing for granted.
Nurses use critical thinking as they begin to question “WHY”? What else? Why not??? What?
A nurse who is a good critical thinker & uses the nursing process as intended, faces problems without forming a quick simple solution, but considers the value of all reasonable options.
Step #1 NURSING ASSESSMENT
Information Gathering & Processing
Standards for Nursing Practice CRNNS
What Is the Nursing Assessment?
Assessment is the first step of the Nursing Process. It includes the collection & analysis of subjective & objective data pertinent to a client.
Nursing Assessment
Initially, the nurse must determine if the assessment should be a quick overview (consider the client’s presenting priorities, specialty area of practice) or a detailed examination of the client’s case.
In facilities, data is usually collected on standardized nursing assessment forms, designed to collect targeted relevant data.
Forms may differ depending on agency and setting.
Nursing Assessment
After the initial assessment the nurse focuses on the client’s potential problems by conducting a more comprehensive assessment.
How Is Data Obtained?
Data are obtained through:Interviews- patient, nurses, support
persons, HCPsPhysical examinationsObservationsReview of records and diagnostic
reportsCollaboration with colleagues
Data Collection: Sources of Data
Client-usually the best source of information, pay attention to your client, act interested.
Family and Significant Others- used as primary sources of information about infants, children, and critically ill, intellectually disabled, disoriented, or unconscious clients. Can be used as secondary sources of information.
Health Care Team /nurse caring for patient -change of shift report
Nurse’s Own Experience- Through experience the nurse learns to ask questions that yield important information
Medical or Other Records- medical hx, lab tests, diagnostic study tests, educational, military records ect.
Literature Review, Standards of Care, Procedures
Assessment Data Gathering Tools/Reports
Health History – Health promotion & disease prevention
behaviours, health problems & responses & risk factors (biological & environmental).
Requisites (needs): Universal SCR, Health Deviation SCR, Developmental SCR (physiological, psychological, sociological, spiritual) Other: Health practices, family and social support, goals, values, and expectations about the health care system.
Physical assessment: Head to toe assessment
During Assessment Use:
Critical thinking Broad knowledge base Effective communication skills Keen observation and physical
assessment skills
ASSESSMENT ALSO INCLUDES CLIENT’S:
• current and past health and functional status• present and past coping patterns (strengths and
limitations)• response to therapy (past/present, nursing/medical)
• risk for potential problems • desire for a higher level of wellness• health practices• support system• goals, values & expectations re health care system• need for nursing
Importance of Client Expectations
Client/patient expectations influence the nurses’ success in developing a relationship with the client that leads to a directed, purposeful and comprehensive assessment.
Subjective vs. Objective Data
Subjective data- information reported by the client. Only the client can determine this data. Ex: “I am scared, about surgery”
Objective data- observations or measurements made by nurse - i.e. vital signs, physical assessments, laboratory tests/values, changes in behavior (physical assessment)
Based on assessment data gathering tools modeled on Orem’s Self-Care Model.
Nursing Health History
The Nursing Health History is the systematic collection of subjective and objective data used to determine a clients self care requisites, functional ability and ways of coping.
Purpose of the Subjective Component of the Nursing Health History
Provides subjective data on the client’s health care experiences and current health and lifestyle habits.i.e. patient’s level of wellness, present
and past family history, changes in life patterns, review of systems etc
Nursing Health History
Nurses need to
…document all relevant information on time… Pay attention to facts and be as descriptive as possible.
What Are Your Responsibilities?
Recognize health problems. Anticipate complications. Initiate actions to ensure appropriate
and timely treatment.
Begin to think CRITICALLY !!!!!!
Critical Thinking
MENTAL OPERATIONS –decision making & reasoning
KNOWLEDGE-having the facts & understanding the reason behind the knowledge
ATTITUDES- curious/open-minded/non-judgmental….
Assessment of Well-Being
According to the World Health Organization is well-being in these domains:EmotionalPhysicalSocialSpiritual
TYPES OF INTERVIEWS
DIRECTED NON-DIRECTED
THINGS THAT IMPAIR COMMUNICATION: PRESENTING QUICK SOLUTIONS UNWARRANTED CHEERFULNESS FALSE REASSURANCE GIVING ADVICE CHANGING THE SUBJECT
CULTURAL DIVERSITY
MUST PROVIDE CARE CONGRUENT WITH A CLIENT’S EXPECTATIONS
“This is not about you” ? Respect INDIVIDUAL’S DIFFERENCES,
What is the significance of the problem or illness to the client?
What does it mean in the family/community?
COMMON Challenges:Defense Mechanisms
COMPENSATION DENIAL DISPLACEMENT
RATIONALIZATION
PROJECTION REPRESSION SUPPRESSION REGRESSION
Continued
THE NURSING PROCESS HELPS NURSES UNDERSTAND THE STRATEGIES CLIENTS USE IN their attempt at coping:
This knowledge will help you FURTHER INDIVIDUALIZE THEIR CARE
Resources
Client Other individuals Previous records Consultations Diagnostics studies Relevant literature
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.
Sources of DataPrimary source: ClientSecondary source: Client’s family,
reports, test results, information in current and past medical records, and discussions with other health care workers
Disease Prevention
Primary prevention – protection from a disease while still in a healthy state.
Secondary prevention – early detection and treatment of disease.
Tertiary prevention – prevent complications and to maintain health once the disease process has occurred.
Verifying Data
Essential in critical thinking!!!!! Measurable data Double check personal observations Double check equipment Check with experts and team members Recheck out-liers Compare objective and subjective data Clarify statements
Planning
Establish the goals, interventions and outcomes
General Guidelines for Setting Priorities
1. Take care of immediate life-threatening issues.
2. Safety issues.3. Patient-identified issues.4. Nurse-identified priorities based on
the overall picture, the patient as a whole person, and availability of time and resources.
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!!
“The patient will…”
DIAGNOSIS Sort, cluster, analyze information Identify potential problems and
strengths Write statement of problem or
strength Risk of infection related to
compromised nutrition
Nursing Diagnosis (cont.)
Potential for effective breastfeeding related to knowledge level and support system
Prioritize the problems Not a medical diagnosis
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.
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?
Nursing Interventions
Road maps directing the best ways to provide nursing care.
Evidence based nursing.
1. Monitor health status.
2. Minimize risks.
3. Resolve or control a problem.
4. Assist with ADLs.
5. Promote optimum health and independence.
Interventions
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.
Nursing DiagnosisHealth issue that can be prevented,
reduced, resolved, or enhanced through independent nursing measures
Documenting the Plan of Care To ensure continuity of care, the plan
must be written and shared with all health care personnel caring for the client.
Consists of:
1. Prioritized nursing diagnostic statements.
2. Outcomes.
3. Interventions.
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
Documentation
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”
Evaluation
1. Determining outcome achievement
2. Identifying the variables affecting outcome achievement
3. 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
Diagnostic StatementsName of the health-related issue or
problem as identified in the NANDA listEtiology (its cause)Signs and SymptomsThe 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”
Collaborative Problems-Nurse’s Responsibility
Correlating medical diagnoses or medical treatment measures with the risk for unique complications
Documenting the complications for which clients are at risk
Making pertinent assessments to detect complications
Continued
Reporting trends that suggest development of complications
Managing the emerging problem with nurse- and physician-prescribed measures
Evaluating the outcomes
The Nursing Process
Nursing DiagnosisJudgment or conclusion about the risk for—
or actual—need/problem of the patientNANDA format
NANDA – North American Nursing Diagnosis Association
Identifies nursing functions Creates classification system Establishes diagnostic labels
Risk of infection related to compromised nutritional state
Potential complication of seizure disorder related to medication compliance
PlanningThe 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.
Setting PrioritiesDetermine problems that require
immediate actionMaslow’s Hierarchy of Human Needs
Short-Term GoalsOutcomes achievable in a few days or
1 week Developed form the problem portion of
the diagnostic statementClient-centeredMeasurableRealisticAccompanied by a target date
Long-Term GoalsDesirable outcomes that take weeks
or months to accomplish for client’s with chronic health problems
The Nursing Process
PlanningIdentification of goals and outcome criteriaPrioritizationTime frame
Selecting Nursing InterventionsPlanning 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.
Communicating The PlanThe 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.
EvaluationThe 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.
The Nursing Process
EvaluationOngoing part of the nursing processDetermining the status of the goals
and outcomes of care
Monitoring the patient’s response to drug therapy
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