nursing process

Created by mcostakis 

Upgrade to
remove ads

nursing process definition

a systematic, patient-centered, goal-oriented method of caring that provides a framework for nursing practice

nursing process: 4 skills

cognitive, technical, interpersonal, legal/ethical

nursing process steps

1. assessment
2. diagnosis
3. outcome identification
4. planning
5. implementation
6. evaluation

characteristics of the nursing process

cyclic/dynamic nature, patient centered, focus on problem solving, focus on decision making, interpersonal, collaborative, universally applicability, outcome oriented, use of critical thinking skills

critical thinking character traits

intellectual humility
intellectual courage
intellectual empathy
intellectual perseverance
intellectual integrity
confidence in reason
fair-mindedness
intellectual autonomy

assessment

= systematic continuous collection, validation & communication of data
-identify the priority area (purpose of assess & pt condition
-determine types of data needed
-establish database (history, physical exam, patient record, consult w/team)
-analyze the data
-followup on cues
-analyze patient symptoms
-can't delegate the assessment
-RN to validate the info, report negative outcomes/refusal to let RN assess

types of assessments: initial

Timing = performed w/in a specific time after arriving
Purpose = establish a complete database
Example = nursing admission assessment

types of assessments: problem-focused

Timing = ongoing, integrate w/nursing care
Purpose = to determine status of specific problem
Example = hourly assessment of fluid intake & output

types of assessments: emergency

Timing = during any physiologic/psychologic crisis
Purpose = identify life threatening problems & identify new problems
Example = rapid assessment of airway, breathing & circulation during cardiac arrest

types of assessments: time lapsed

Timing = several months after initial assessment
Purpose = to compare current health to prior health, monitoring & evaluating how things are going

types of assessments: Human dimensions

physical, intellectual, spiritual, economic, socio

types of assessments: Maslow

low levels of assessment of needs to High
low ones need to be met 1st --> then High

types of assessments: Health wellness continum

low --> High (death)
are they at a high level or a low level (death)

types of assessments: adaptation

how are they adapting, coping mechanisms, self-concept, what is their role in society, what are their behaviors

types of assessments: Gordon functional

assessing based on "how they can function"

Clinical skills used in assessment (4)

1. Observation = notice patient cues, constantly observing, look, feel, touch
2. interviewing
3. physical examination
4. intuition

subjective

- what someone says
- primary = patient
- secondary = anyone else
- using interviewing skill, listening
- this can be very important, always asking more questions
- aka symptom

objective

- observed or measured, can quantify
- multiple sources
- vitals, Urine, CAT scan, etc
- aka sign

symptom

telling/what you are told
aka subjective

sign

what you see/observe, measuring
aka objective

data validation steps (3)

1. identification of cues
2. make inferences about cues
3. validate cues & inferences

How to validate cues & inferences (5)

1. compare cues to knowledge base of normal function
2. refer to textbooks, journals, research
3. check consistency of cues
4. clarify patients statements
5. seek consensus w/peers about inferences

diagnosis definition

- clinical judgment of about individual, family or community responses to actual or potential health problems/life experiences.
- diagnosis provides the basis for selection of nursing interventions to achieve outcomes for which the nurse has accountability
- they are universal
-actual or potential health problems that can be prevented or resolved by nurses alone

nursing diagnosis vs medical

Nursing:
- more holistic
- unhealthy response to health/illness
- nursing treatment, can do w/o doctor
- changes pending response
Doctor:
- identify disease
- doctor treatment
-constant with disease

types of nursing diagnosis

1. Actual/individual or Risk/individual (risk = no actual data - subjective/objective)
2. Actual - Family/home or Risk - Family/home
3. health promotion/wellness = something that will put them at a better level
4. collaborative problems/risk for complications (RC)

Actual diagnosis components

3 part statement
1. problem (NANDA label)
2. Related to --> etiology, cause of problem, no medical diagnosis. Can use medical diagnosis as secondary to data
3. AEB = data, subjective & objective
Ex. acute pain, R/T unknown cause, patient states pain 8 out of 10, doubled over in posture.
Ex. acute pain, R/T inflammation secondary to appendicitis, AEB _______

Risk diagnosis components

2 part statement - you have no data (no AEB)
1. NANDA
2. Related to (directs intervention)
Ex. Risk for caregiver role strain R/T discharge of family member w/significant healthcare needs, economic instability, lack of respite care available

Health promotion/Wellness components

1 part "potential"
- need desire & effective function
Ex. Readiness of enhanced knowledge: smoking cessation
Ex. Potential for enhanced parenting

collaborative problems components

= you cannot do/meet outcomes by yourself. need someone else. usually a doctor for medication

risk for complications (RC) components

= medical diagnosis statements.
Ex. RC dsyrthymia
Ex. RC Hypoxemia (can't do by myself, b/c can't order O2)

prioritization: High

1. life threatening
2. immediate attention
3. patient important
Ex. RC Hypoxemia

prioritization: Medium

1. unhealthy consequences but not likely to threaten life

prioritization: low

1. resolve easily with minimal intervention
2. little dysfunction potential
Ex. quit smoking after 20 years

outcome/Goal

= reverse of problem
-patient centered
-singular factor
-observable
-measurable (sometimes tell how to measure)
-time-limited
-mutual
-realistic
Ex. Problem = abdominal pain. Outcome = no abdominal pain by end of shift. patient indicated no pain

planning

- select EB nursing interventions to reach goal.
- derived from nursing diagnosis, specifically etiology/cause of problem
- nurse directed/oriented --> ideally for the patient
- who, what, when where how, amount, time, frequency
- communicate, collaborate, individualize

implementation

- performed by nurse
- carry out plan
- Do & document
- skills = cognitive, technical, interpersonal, legal/ethical
- components = reassessment, continuation, documentation
- supervise delegated interventions

evaluation

- everyone is involved in the process
- do i need to go back, change things, how did it work
- continuous mutual (patient/nurse) measurement if outcome is achieved

EBP Model: ACE

1. Discovery = knowledge generation based on fundamental research
2. summary =synthesize info from research (meta-analysis, synthesis, state of art)
3. Translation = apply to practice
4. integration = actually using in practice new info that has been summarized & translated
5. evaluation = the outcomes of using the EBP in practice

Please allow access to your computer’s microphone to use Voice Recording.

Having trouble? Click here for help.

We can’t access your microphone!

Click the icon above to update your browser permissions above and try again

Example:

Reload the page to try again!

Reload

Press Cmd-0 to reset your zoom

Press Ctrl-0 to reset your zoom

It looks like your browser might be zoomed in or out. Your browser needs to be zoomed to a normal size to record audio.

Please upgrade Flash or install Chrome
to use Voice Recording.

For more help, see our troubleshooting page.

Your microphone is muted

For help fixing this issue, see this FAQ.

Star this term

You can study starred terms together

NEW! Voice Recording

Create Set