38 terms

nursing process

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
intellectual autonomy
= 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
- what someone says
- primary = patient
- secondary = anyone else
- using interviewing skill, listening
- this can be very important, always asking more questions
- aka symptom
- observed or measured, can quantify
- multiple sources
- vitals, Urine, CAT scan, etc
- aka sign
telling/what you are told
aka subjective
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
- more holistic
- unhealthy response to health/illness
- nursing treatment, can do w/o doctor
- changes pending response
- 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)
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
= reverse of problem
-patient centered
-singular factor
-measurable (sometimes tell how to measure)
Ex. Problem = abdominal pain. Outcome = no abdominal pain by end of shift. patient indicated no pain
- 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
- performed by nurse
- carry out plan
- Do & document
- skills = cognitive, technical, interpersonal, legal/ethical
- components = reassessment, continuation, documentation
- supervise delegated interventions
- 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