65 terms

Nursing Process

Nursing Process
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Define the nursing process
a systematic problem solving approach toward providing individualized nursing care.
What is NANDA-I
North American Nursing
Diagnosis Association International
What are the characteristics of the nursing process?
1-framework for care to indiv, families, & communities 2-orderly & systematic 3-interdependent 4-provides specific care for the indiv, fam, & comm 5- client centered 6-appropriate for use throughout lifespan 7-used in ALL settings
What are the steps of the nursing process?
ADPIE A=assessment D=diagnosis P=planning I=implementation E=evaluation
How does the nurse obtain assessment info?
1- initial (or admission assessment) 2- focused assessment 3- emergency assesment
How does the nurse obtain assessment info?
past medical hx - family hx - reason for admission - current meds - previous hospitalizations & surgeries - psychosocial assessment - nutrition - complete physical assessment
focused assessment
Collects data about a problem that has already been identified. This type of assessment determines whether
the problem still exists, or any changes.
focused assessment questions
‐ What are your symptoms?
‐ When did they start?
‐ What activity were you doing ?
‐ What makes it better or worse?
‐ What are you doing to relieve the symptom?
Emergency assessment
Performed to identify a life‐threatening problem (choking, stab wound, heart attack).
subjective data
Information verbalized or stated by the client.
objective data
‐ Observable and measurable information.
‐ Remember to include your senses: smell, hearing, touch and sight.
sign
An objective finding perceived by the examiner ex. (fever, rash, etc.)
symptom
Subjective findings verbalized or stated by the client ex. ("I have a headache" " I feel sick in my stomach.")
signs are
objective
symptoms are
subjective
2 sources of data
primary & 2ndary
primary source of data
‐Information obtained from the patient (only)
secondary sources of data
‐ Family members
‐ Significant others
‐ Past & current health records, laboratory tests,diagnostic procedures, consultations from other healthcare professionals.
collect the data then BLANK the data
VALIDATE
‐Confirm and verify the information.
‐ Keep it free from errors, bias, or misinterpretation.
Data is 1,2,3
collected, validated, then clustered
clustering of data often contains
defining characteristics which are specific assessment findings that support a
nursing diagnosis.
during the clustering of data what is used
critical thinking is used to analyze and synthesize the information that is
collected. The data is then put into specific clusters that describe a specific client problem.
identify sources of data for obtaining information from the client
subjective & objective, primary & secondary, people, healthcare professionals, medical chart, test & lab results etc
identify how you develop a nursing diagnosis
As you cluster data, you begin to consider various diagnoses that may relate to the client. You must remember that if certain defining characteristics do not exist for a specific diagnosis, then you must not use the diagnosis.
identify how you develop a nursing diagnosis (what is first / next etc)
1. Complete thorough assessment of the patient.
2.Highlight or underline relevant symptoms (defining
characteristics).
3. Make a list of symptoms.
4. Cluster and interpret the symptoms.
5. Analyze and interpret the symptoms.
6. Select a nursing diagnosis based on the definition
found in the nursing diagnosis manual by Doenges,
Moorhouse and Murr.
7. Remember to prioritize the identified problems.
what is the difference between a medical and nursing dx
A medical diagnosis describes a disease process. A nursing diagnosis describes an individual, family or
group response to an actual or potential problem.
medical dx
‐Identification of a disease condition based on specific
findings such as diagnostic tests and procedures.
‐ Remains the same as long as the disease is present.
nursing dx
‐ Clinical judgment in response to actual or potential
health problems.
‐ Provides a basis for providing nursing care through
various interventions to achieve outcomes.
‐ Changes possibly from day to day as the patient's
response changes.
what are the 4 types of NANDA-I dx
1. Actual diagnosis
2. Risk diagnosis
3. Health promotion diagnosis
4. Wellness diagnosis
actual dx
Represents a problem that has been validated by the
presence of defining characteristics (signs and
symptoms).
risk dx
Is defined by NANDA‐I , "describes human responses to health conditions/life processes that may develop in a vulnerable individual, family, or community. It is supported by risk factors that contribute to increased
vulnerability" (NANDA, 2007). Ex. infection after surgery
health promotion dx
Clinical judgment of a person, family, or community desire to enhance their well being and readiness to implement health behaviors of a higher level. Ex. nutrition
wellness dx
Describes the human responses to levels of wellness in an individual, family or community that have readiness to enhance well being. Ex.Coping, readiness of enhanced related to successful cancer treatment.
how do you formulate an actual nursing dx; what does it consist of
A nursing diagnosis consists of 3 parts or what is referred to PES format:
P= Problem
E =Etiology
S =Signs and Symptoms
what is the purpose of the problem
to identify the health status or
problem of the individual using the approved NANDA - I list. Ex.Pain, acute
what is the etiology
the cause ; Identifies the physiologic, psychological, sociologic, spiritual, or environmental factors assumed to be the
cause of the problem or a contributing factor.
the etiology is linked to the problem with the phrase
"related to" ; The etiology cannot be related to a medical diagnosis.
signs & symptoms
Identified as subjective and/or objective data that supports the problem.
‐ Identified by the nurse from the clustering of
significant data including assessment findings.
signs & symptoms are linked to the etiology by the phrase
"as evidenced by"
how do you formulate a risk dx? what does a risk dx consist of?
consist of a problem and the etiology only - there are NO signs & sypmtoms because it hasn't happened yet
what does the planning phase of the nursing process consist of
develop a plan of care.This is accomplished by developing client centered goals
and expected outcomes. - use critical thinking to develop nursing interventions to resolve the client's problem and achieve the goals.
3 helpful guides in prioritizing needs
1-Maslow 2- Pt preference what does the pt think is important 3-Anticipation or future problems
Maslow
Maslow's Hierarchy of Needs
a. physiological needs
b. safety needs
c. love and belonging needs
d. self‐esteem needs
e. self‐actualization needs
prioritizing nursing dx ex 1
1 -airway 2- urinary 3- sexual 4- skin integrity
prioritizing nursing dx ex 2
1-gas exchange 2-hypothermia 3-knowledge defecit 4- infection
prioritizing nursing dx ex 3
1-pain 2-mobility 3- social isolation 4-self esteem
define a goal
" a broad statement that describes the desired change in a client's condition or behavior."
components of a correctly written goal
include expected outcomes or
measurable criteria to evaluate the achievement of the goal.
short term goal
an objective behavior or response
you expect the client to achieve in a short period of time usually less than one week.
long term goal
An objective behavior or response you expect the client to achieve in a longer period of time possibly over several days, weeks, or months.
what is an expected outcome
An outcome is a measurable change in the client's status that you expect to occur related to the implemented care.
guidelines to remember when writing goals
1-client centered 2-singular 3-observable 4-measurable 5-time limited 6-mutual 7-realistic
what are nursing interventions
Are actions or treatments based on knowledge or judgment that the nurse performs to meet the patient outcomes.
what are the 3 types of nursing interventions - provide examples
1-independent ex. positioning 2-dependent ex. med admin 3-collaborative or interdependent ex. OT
what are frequent errors when writing nursing interventions
1-Failure to be precise or fully indicate the nursing action. 2-Failure to indicate frequency 3-Failure to indicate quantity 4-Failure to indicate method
what is the purpose of scientific rationale for student nurses
is the reason for choosing the particular intervention based on supportive evidence
from textbooks, journals, and/or online nursing
references (so we know why we are doing the task we are doing)
what is the implementation phase of the nursing process
This step begins after the care plan has been developed by the nurse. This is the step of the nursing process where the nurse performs the interventions as a means
of achieving the goals.
interventions can be BLANK or BLANK
direct (performed through interaction with the client) or indirect (without the client but on their behalf)
the implementation process takes into account 5 activities
1-reassessing 2-review/revise existing nursing dx & care plan 3-organizing resources & delivery of care 4-Anticipating/preventing any complications 5-Implementing interventions
Implementing Interventions: requires 3 skills
1-cognitive 2-personal 3-psychomotor
Implementing Interventions :cognitive skills
critical thinking ; good decisions
Implementing Interventions: personal skills
communication ; therapeutic interactions
Implementing Interventions ; psychomotor skills
proper performance and knowledge of skills
what is the evaluation phase of the nursing process
Evaluation is the final stage of the nursing process. You as the nurse determine if the patient has achieved the expected outcomes not if the nursing interventions were completed.
the evaluation phase has 5 components
1. Identifying criteria and standards.
2. Collecting data to determine if the criteria or
standards are met.
3. Interpreting and summarizing findings.
4. Documenting findings and any clinical judgment.
5. Terminating, continuing or revising the care plan.
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