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Nursing Process

Terms in this set (59)

Critical Thinking :
Nurses use clinical reasoning and clinical decision making
to practice safe and effective nursing care
to improve clinical decision making
to decrease errors in clinical judgment
The Nursing Process
Systematic, rational method of planning and providing individualized care
Assessing
Diagnosing
Planning
Implementing
Evaluating
Assessing
*Data (information) gathered systematically
*Importance of assessment
*Components of a nursing health history
*Collect, organize, validate, and document data
Types of Assessments
Initial
Emergency
Time-lapsed
Problem-Focused
Focused Initial shift
Emergency Assessment
Identifies life-threatening problems
Identifies new or overlooked problems
Time-lapsed Assessment
Occurs several months after initial
Compares current status to baseline
Problem-Focused Assessment
Determines status of a specific problem
Focused Initial shift assessment:
...
Initial Assessment:
Performed within a specified time period
Comprehensive
Collecting Data
Gathering information about patient's health status
Must be systematic and continuous
Includes past history and current problem
Subjective or objective
Primary or secondary source
Establishes baseline
Subjective Data
Symptoms
Covert data
Can be described only by person affected
Includes sensations, feelings, values, beliefs, attitudes, and perception of personal health status and life situations
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
Sources of Data
Primary source
-The patient

Secondary sources
-All other sources of data
-Validate if possible
Methods of Data Collection
**Observing
**General Survey
*Interviewing
*examining
Interviewing
planned communication or a conversation with a purpose
Used to:
Get or give information
Identify problems of mutual concern
Evaluate change
Teach
Provide support
Provide counseling or therap
General survey
"General Survey"
Components
Physical appearance, mental status, mobility
Environment
Patient status
Observing
Gathering data using the senses
Used to obtain following types of data:
Skin color (vision)
Body or breath odors (smell)
Lung or heart sounds (hearing)
Skin temperature (touch)
Examining (physical examination)
Systematic data-collection method
Uses observation and inspection, auscultation, palpation, and percussion
Vital signs, height and weight
Cephalocaudal approach
Screening examination (review of systems)
Diagnosing
Diagnostic labels are standardized NANDA names

Nursing diagnosis - problem statement consisting of diagnostic label plus etiology
Analyze Data
Identify health problems, risks, and strengths
Formulate diagnostic statements
Types of Nursing Diagnoses
Actual diagnosis
Health promotion diagnosis
Risk diagnosis
Wellness diagnosis
Actual diagnosis
Problem presents at the time of assessment
Health promotion diagnosis
Preparedness to implement behaviors to improve their health condition
Risk diagnosis
Problem does not exist
Wellness diagnosis
Describes human responses to levels of wellness in individual, family, or community
Components of a Nursing Diagnosis
*Problem statement (diagnostic label)
-Describes the patient's health problem or response

*Etiology (related factors and risk factors)
-Identifies one or more probable causes of the health problem
-Not stated as a medical diagnosis

*Defining characteristics
-Cluster of existing signs and symptoms
Nursing Diagnosis
Describes human response, the patient's physical, sociocultural, psychological, and spiritual responses to an illness or health problem
A clinical judgment about a patient's response to a health problem
Steps in Diagnostic Process
Analyze data
-Compare data against standards
-Cluster cues
-Identify gaps and inconsistencies
Identify health problems, risks, and strengths
Formulate diagnostic statements
Recognizing Cues
A deviation from population norms
Changes in usual health patterns are not explained by developmental or situational changes
Indications of delayed growth & development
Changes in usual behaviors in roles or relationships
Nonproductive or dysfunctional behavior
How does the nursing diagnosis relate to the patient goal and the nursing interventions?
*The Problem suggests the Patient Goals
The nursing diagnosis (problem) describes a health status that needs to be changed
The Goals then suggest what the nurse needs to do (interventions)
The aim of the interventions is to ALTER the factors that contribute to the problem (the cause or etiology)
The Planning Process
*Consists of following activities:
Setting priorities
Establishing patient 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)
Patient Goals/Outcomes
*Statement of what the patient will be able to do
*Goal should be:
Achievable
Reasonable
Specific
Meaningful
Agreed upon between the Patient and Nurse
SMART stands for
S = Specific
M = Measurable
A = Attainable
R = Relevant
T = Time-Oriented
Types of Patient Goals
*Cognitive
Increases patient knowledge
*Affective
Changes in feelings, values, beliefs, and attitudes
*Psychomotor
Patient's ability to perform skills
*Body appearance and function
Changes in body systems and functions
Components of Patient Goals
Subject (the patient)
Verb (action to perform)
Conditions (circumstances under which the action is to be performed)
Criterion of desired performance (speed, accuracy, distance, quality, etc)
Examples of correctly stated goal
Poor nutritional status
Resident will increase food intake to ____ calories per day by (date)
Resident will consume at least 75% of each meal by (date)
Resident will maintain weight between ___ and ___ pounds by (date)
Examples of correctly stated goal
Constipation
Resident will have a bowel movement at least every 2 days without use of laxatives or enemas by (date)
Resident will consume one glass of fruit juice with each meal by (date)
Examples of correctly stated goal
Impaired mobility
Resident will increase ambulation to ___ feet twice daily by (date)
Resident will be free from contractures and skin breakdown by (date)
Examples of correctly stated goal
Pain
Resident will rate pain at 3 or less (on a scale of 10) by (date)
Types of Nursing Care Plans
*Informal nursing care plan
A strategy for action that exists in nurse's mind
*Formal nursing care plan
Written or computerized guide
*Standardized care plan
A formal plan that specifies actions for a group of patients with common needs
*Individualized care plan
Tailored to meet the unique needs of a specific patient
implementing/interventions
*Reassessing the client
*Determining the nurses needs for assistance
*Implementing the nursing interventions
*Supervising the delegated care
*Documenting nursing activities
*Actions nurse performs to help the patient achieve goals
*Focus on eliminating or reducing cause of nursing diagnosis
*Treat signs and symptoms and defining characteristics
*Interventions for risk nursing diagnoses should focus on reducing patient's risk factors
Types of Interventions
Independent
Dependent
Callaborative
Independent Interventions
Activities nurses are licensed to initiate (i.e., physical care, ongoing assessment)
Dependent Interventions
Activities carried out under primary care provider's orders or supervision, or according to specified routines
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 patient's age, health, and condition
Achievable with the resources available
Congruent with the patient's values, beliefs, and culture
Based on nursing knowledge and experience or knowledge from relevant sciences
Within established standards of care
Individualizing Interventions
What
Who
Whe
How
***Be Specific!!!
To implement care successfully, nurses need:
Cognitive skills
Interpersonal skills
Technical skills
5 Activities of the Implementing Phase
Reassessing the patient
Determining nurse's need for assistance
Implementing nursing interventions
Supervising delegated care
Documenting nursing activities
Delegating Implementation
*Delegation occurs during planning
Who does each task decided upon?
*Nurse is responsible for correct implementation of task delegated, analysis of data, and evaluation of outcome
...
Collecting data r/t desired outcomes
Comparing data w/ desired outcomes
Relating nursing activities to outcomes
Drawing conclusions about problem status
Continuing, modifying, or terminating the nursing care plan
Goal Met
Goal Partially Met
-What needs to be done?
Goal Not Met
-What needs to be done?
The nurse changes a patient's dry sterile dressing. How is the nurse functioning when performing this task?
Dependently
A nurse is interviewing a patient. Which patient statement is an example of objective data?
"I ate half my lunch"
The concept that is the cornerstone of the Nursing Process is that it:
Is dynamic rather than static
A nurse teaches a patient to use visualization to cope with chronic pain. Which step of the Nursing Process is associated with this nursing intervention?
Implementation
Which human response identified by the nurse is an example of objective data?
Irregular radial pulse of 50 beats per minute
A nurse responds to a patient's call bell. Which patient statement is subjective data?
"My pain feels like a 5 on a scale of 0 to 5."
What is an appropriately worded goal for a patient who is at risk for falling? "The patient will be:
Free from trauma."
A nurse teaches a patient to use visualization to cope with chronic pain. Which step of the nursing process is associated with this nursing intervention?
Implementation
A nurse collects data about a patient. What should the nurse do next?
Determine significance of the information
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