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Chapter 2 Nursing Process
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Chapter 2 Nursing Process

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  1. Chapter 2Nursing Process

  2. Definition of the Nursing Process • Organized sequence of problem-solving steps • Used to identify and manage the health problems of clients • Accepted standard for clinical practice: American Nurses Association (ANA) • Framework for nursing care

  3. Characteristics of the Nursing Process • Within the legal scope of nursing • Based on knowledge • Planned • Client centered • Goal directed • Prioritized • Dynamic

  4. Steps of the Nursing Process • Assessment • First step of nursing process • Systematic collection of facts or data • Types of data • Objective data: observable and measurable facts, referred to as signs of disorder

  5. Steps of the Nursing Process (cont’d) • Assessment (cont’d) • Types of data (cont’d) • Subjective data: information only client feels and can describe; called symptoms • Sources of data: primary source–client; secondary sources–client’s family, reports, or discussion with other health care professionals

  6. Question • Is the following statement true or false? Objective data, consisting of information that only the client feels and can describe, are called symptoms. An example is pain.

  7. Answer False. Objective data are observable and measurable facts and are referred to as signs of a disorder. Subjective data consists of information that only the client feels and can describe, and are called symptoms

  8. Steps of the Nursing Process (cont’d) • Assessment (cont’d) • Types of assessment • Data base assessment • Initial information: client’s physical, emotional, social, and spiritual health • Obtained during admission interview and physical examination

  9. Steps of the Nursing Process (cont’d) • Assessment (cont’d) • Types of assessment (cont’d) • Focus assessment • Information: details about specific problems; expands original data base • Repeated frequently or on a scheduled basis

  10. Question • Which of the following is a primary source for information? a. Client’s family b. Client c. Medical records d. Test results

  11. Answer b. Client The primary source for information is the client. The client’s family, test results, and medical records are secondary sources of information.

  12. Steps of the Nursing Process (cont’d) • Assessment (cont’d) • Organization • Involves grouping related information • Nurses: organize assessment data; cluster related data using knowledge and past experiences

  13. Steps of the Nursing Process (cont’d) • Diagnosis • Second step of the nursing process • Identification of health-related problems • Nursing diagnosis • Health issue that can be prevented, reduced, resolved, or enhanced through independent nursing measures

  14. Steps of the Nursing Process (cont’d) • Diagnosis (cont’d) • Nursing diagnosis (cont’d) • Categorized into 5 groups: actual; risk; possible; syndrome; wellness • The NANDA list • Authoritative organization for developing and approving nursing diagnoses

  15. Steps of the Nursing Process (cont’d) • Diagnosis (cont’d) • Nursing diagnosis (cont’d) • Diagnostic statement • Contains 3 parts: • Name of health-related issue or problem identified in the NANDA list

  16. Steps of the Nursing Process (cont’d) • Diagnosis (cont’d) • Nursing diagnosis (cont’d) • Diagnostic statement (cont’d) • Etiology (its cause): phrase “related to” • Signs and symptoms: phrase “as manifested (or evidenced) by”

  17. Steps of the Nursing Process (cont’d) • Diagnosis (cont’d) • Nursing diagnosis (cont’d) • Diagnostic statement (cont’d) • Potential diagnoses: “risk for” • Uncertainty: “possible” • Wellness diagnoses: “potential for enhanced”

  18. Steps of the Nursing Process (cont’d) • Diagnosis (cont’d) • Nursing diagnosis (cont’d) • Diagnostic statement (cont’d) • Potential nursing diagnoses: signs or symptoms not manifested • Possible nursing diagnoses: data incomplete

  19. Steps of the Nursing Process (cont’d) • Diagnosis (cont’d) • Nursing diagnosis (cont’d) • Diagnostic statement (cont’d) • Syndrome diagnoses and wellness diagnoses are one-part statements; they are not linked with an etiology or signs and symptoms

  20. Steps of the Nursing Process (cont’d) • Diagnosis (cont’d) • Nursing diagnosis (cont’d) • Collaborative problem • Physiologic complications require both nurse- and physician-prescribed interventions • Written using the abbreviation potential complication (PC)

  21. Steps of the Nursing Process (cont’d) • Planning • Third step of the nursing process • Setting priorities • Determine which problems require most immediate attention • Establishing goals • Goal: expected or desired outcome

  22. Steps of the Nursing Process (cont’d) • Planning (cont’d) • Establishing goals (cont’d) • Short-term goals: • Outcomes achievable in a few days to 1 week • Characteristics: developed from; client-centered

  23. Steps of the Nursing Process (cont’d) • Planning (cont’d) • Establishing goals (cont’d) • Short-term goals (cont’d) • Characteristics (cont’d) • Measurable • Realistic • Target date for accomplishment

  24. Steps of the Nursing Process (cont’d) • Planning (cont’d) • Establishing goals (cont’d) • Short-term goals (cont’d) • Characteristics (cont’d) • Predicted time • Time line for evaluation

  25. Steps of the Nursing Process (cont’d) • Planning (cont’d) • Establishing goals (cont’d) • Long-term goals • Desirable outcomes take weeks or months to accomplish • Goals for collaborative problems • Written for the nurse

  26. Steps of the Nursing Process (cont’d) • Planning (cont’d) • Establishing goals (cont’d) • Goals for collaborative problems (cont’d) • Focus: what the nurse will monitor, report, record, or do to promote early detection and treatment

  27. Steps of the Nursing Process (cont’d) • Planning (cont’d) • Selecting nursing intervention • Planning measures: to accomplish identified goals involves critical thinking • Planned interventions: must be safe; within legal scope of nursing practice; and compatible with medical orders

  28. Steps of the Nursing Process (cont’d) • Planning (cont’d) • Documenting plan of care • Plan of care: written by hand; standardized form; computer generated; based on an agency’s written standards or clinical pathways • Nursing order: performing nursing interventions; providing specific instructions

  29. Steps of the Nursing Process (cont’d) • Planning (cont’d) • Documenting plan of care (cont’d) • Standardized care plan: preprinted; computer generated • Agency-specific standards for care and clinical pathways: indicate activities provided to ensure quality, consistent care

  30. Steps of the Nursing Process (cont’d) • Planning (cont’d) • Communicating the plan of care • Nurses share plan with nursing team members, client, and the client’s family • Permanent part of client’s medical record placed in client’s chart; nurses refer to it, review it, and revise it

  31. Steps of the Nursing Process (cont’d) • Implementation • Fourth step in the nursing process: carrying out the plan of care • Implementation of: • Medical records: legal evidence • Record: quantity and quality of client response

  32. Steps of the Nursing Process (cont’d) • Evaluation • Fifth and final step of the nursing process: nurses determine whether client has reached the goal • Analyze client’s response

  33. Question • Is the following statement true or false? Evaluation is the fifth and final step in the nursing process.

  34. Answer True. Evaluation, the fifth and final step in the nursing process, is the way by which nurses determine whether a client has reached a goal. The other steps in the nursing process are assessment, diagnosis, planning, and implementation.

  35. Use of the Nursing Process • Standard for clinical nursing practice • Nurse practice act • Holds nurses accountable for demonstrating all the steps in the nursing process • To do less implies negligence

  36. Concept Mapping • Method of organizing information in graphic or pictorial form • Formats used: spider diagram, hierarchy, linear flow chart • Uses: • Enables students to integrate previous knowledge with newly acquired information

  37. Concept Mapping (cont’d) • Uses (cont’d): • Increases critical thinking and clinical reasoning skills • Enhances retention of knowledge • Correlates theoretical knowledge with nursing practice • Helps students recognize information • Promotes better time management