Module 2: Basic Elements in Nursing/Intro to the Nursing Process

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Learning objectives: 1. Identify the components of critical thinking in the nursing process. 2. Discuss the concepts of the nursing process

What are the critical thinking components of the Nursing Process?

1.Assessment- subj and obj data
2.Nursing Diagnosis- data analysis, problem identification, label
3.Planning- priorities, outcomes, interventions
4.Implementation- nurse-initiated treatments, physician-initiated treatments
5.Evaluation- data, diagnoses, etiologies, plans, interventions

Assessment: What are the 2 steps?

1. Collection and Verification of data
2. Analysis of data

What is the Analysis of data?

1. Develops nursing dx
2. Identifies collaborative problems
3. Develops a plan of care

Ex of nursing dx: Risk of falling

1. Place call light near pt
2. Leave all lights on in room

Assessment: Problem-oriented approach to assessment

"back pain", "anxiety", knowledge deficit"

Types of data:

1. Subjective
2. Objective

Subjective data:

pt verbalizes what is hurting or how they're feeling
ex: pt says they're in pain.

Objective data:

This data is measurable, you can see it and describe it

Sources of data:

1. pt/client
2. family
3. health care team
4. medical records (HIPPA- Health Insurance Portability and Accountability Act of 1996)

What do I need to collect?

1. Interview/health hx
2. Bio info
3. Reason for seeking health care
4. Present illness
5. Health hx
6. Psychosocial hx
7. Review of systems (subj obs.- trouble swallowing? probs w/ heart? probs w/ teeth?)(obj obs.-physical assessment, pupils don't dilate)
8. Physical exam
9. Observation of client behavior (cues, why can't pt sit?, inferences, validation)
10. Diagnostic and lab data
11. Validating data/analysis
12. Documentation of data collection (correct terminology, factual/objective, descriptive)

What is a Nursing Diagnosis?

* A clinical judgement about individual, family or community responses to actual and potential health probs or life processes

*Client/pt centered

*Prioritize nursing diagnoses

What is a Medical Diagnosis?

Identification of a disease condition (diabetes mellitus, osteoarthritis)


*1982- North American Nursing Diagnosis Association
*ex: activity intolerance, hopelessness, risk for falls, acute pain, sleep deprivation

Nursing Diagnosis: Based on 2 parts of data collection

1. Diagnostic Label
2. Statement of a related factor
ex: acute pain R/T herniated disk? OR
acute pain R/T pressure on spinal

Planning Nursing Care: What's the plan?

* Setting goals for the client
* Setting expected outcomes
* Plans nursing interventions
* Sets priorities
* Goals must be client-centered, measurable, observable, and time-limited

Example of plan:

Nursing dx: Acute pain
Goal: pts level of comfort will improve before surgery
Expected outcome: pt will report pain less than 3 by time of surgery

Short-Term goal:

Objective behavior or response expected to resolve in less than a week

Long-Term goal:

Objective behavior or response over several days, weeks, or months

Nursing Intervention/Implementation:

* Any treatment, based upon clinical judgement and knowledge, that a nurse performs to enhance client outcomes.

* "Evidenced-based"- based upon clinical judgement and knowledge

Implementing Nursing Care:

*Interventions- based on assessment data, nursing dx, and goal and expected outcomes
Assessment: pt slowly, unable to tolerate sitting, slow, hesitant gait when walking

Nursing dx: Impaired physical mobility R/T acute pain

Goal: pt will have pain less than 3 by end of day

Interventions: pain meds, change position frequently, position in proper alignment, avoid positions that cause pain

Evaluation of Nursing Care:

You conduct evaluative measures to determine if you met expected outcomes, not if nursing interventions were completed.

Did you or did you not meet your goal?

Did you achieve your expected outcome?

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