Nursing Process • Specific to the nursing profession • A framework for critical thinking • It’s purpose is to: “Diagnose and treat human responses to actual or potential health problems”
Nursing Process • Organized framework to guide practice • Problem solving method - client focused • Systematic- sequential steps • Goal oriented- outcome criteria • Dynamic-always changing, flexible • Utilizes critical thinking processes
Advantages of Nursing Process • Provides individualized care • Client is an active participant • Promotes continuity of care • Provides more effective communication among nurses and healthcare professionals • Develops a clear and efficient plan of care • Provides personal satisfaction as you see client achieve goals • Professional growth as you evaluate effectiveness of your interventions
5 Steps in the Nursing Process • Assessment • Nursing Diagnosis • Planning • Implementing • Evaluating
Assessment • First step of the Nursing Process • Gather Information/Collect Data • Primary Source - Client / Family • Secondary Source - physical exam, nursing history, team members, lab reports, diagnostic tests….. • Subjective -from the client (symptom) • “I have a headache” • Objective - observable data (sign) • Blood Pressure 130/80
Assessment To elicit as many symptoms as possible, the nurse should use open-ended rather than yes/no questions. Examples: “Describe what you are feeling” “How long have you been feeling this way?” “When did the symptoms start?” “Describe the symptoms” This type of questions will encourage the client to give more information about his or her situation. Listen carefully for cues and record relevant information.
Assessment-collecting data • Nursing Interview (history) • Health Assessment -Review of Systems • Physical Exam • Inspection • Palpation • Percussion • Auscultation
Assessment-collecting data • Make sure information is complete & accurate • Validate prn • Interpret and analyze data Compare to “standard norms” • Organize and cluster data
Example ofAssessment • Obtain info from nursing assessment, history and physical (H&P) etc…... • Client diagnosed with hypertension • B/P 160/90 • 2 Gm Na diet and antihypertensive medications were prescribed • Client statement “ I really don’t watch my salt” “ It’s hard to do and I just don’t get it”
Nursing Diagnosis • Second step of the Nursing Process • Interpret & analyze clustered data • Identify client’s problems and strengths • Formulate Nursing Diagnosis (NANDA : North American Nursing Diagnosis Association)-Statement of how the client is RESPONDING to an actual or potential problem that requires nursing intervention
Diagnosis Statement A working of nursing diagnosis may have two or three parts. The three-part system consists of the nursing diagnosis, the “related to” statement, and the defining characteristics. PES system: P (problem) - The nursing diagnosis, the label; a concise term or phrase that represent a pattern of related cues E (etiology) – “Related to” phrase or etiology; related cause or contributor to the problem S (symptoms) –Defining characteristics phrase; symptoms that the nurse identified in the assessment
Nsg Dx vs MD Dx • Within the scope of nursing practice • Identify responses to health and illness • Can change from day to day • Within the scope of medical practice • Focuses on curing pathology • Stays the same as long as the disease is present
Example of Nursing Dx • Ineffective therapeutic regimen management R/T difficulty maintaining lifestyle changes and lack of knowledge AEB B/P= 160/90, dietary sodium restrictions not being observed, and client statements of “ I don’t watch my salt” “It’s hard to do and I just don’t get it”.
Types of Nursing Diagnoses • ActualImbalanced nutrition; less than body requirements RT chronic diarrhea, nausea, and pain AEB height 5’5” weight 105 lbs. • RiskRisk for falls RT altered gait and generalized weakness • WellnessFamily coping: potential for growth RT unexpected birth of twins.
Case study: A 73-year-old man has been admitted to the unit with a diagnosis of chronic obstructive pulmonary disease (COPD). He states that he has “difficulty breathing when walking short distances”. He also states that his “heart feels like it is racing” at the same time. He states that he is “tired all the time”, and while talking to you he is continually wringing his hands and looking out the window.
Step II: Nursing DiagnosisPart 1 (Problem) Interpretation of information: • “difficulty breathing when walking short distances”= dyspnea • “heart feels like it is racing”= dysrythmia • “tired all the time”= fatigue In Section II we can find the nursing diagnosis Activity intolerance listed with these symptoms.
Step II: Nursing Diagnosis To validate that the diagnosis Activity intoleranceis appropriate for the client, we have to read NANDA definition of the nursing diagnosis. When reading, ask Does this definition describe the symptoms demonstrated by the client? If the appropriate nursing diagnosis has been selected, the definition should describe the condition that has been observed.
Activity intolerance • NANDA Definition Insufficient physiological or psychological energy to endure or complete required or desired daily activities. • Defining Characteristics Verbal report of fatique or weakness; abnormal heart rate or blood pressure response to activity; exertional discomfort or dyspnea; electrocardiografic changes reflecting dysrhytmias or ischemia • Related factors (r/t) Bed rest or immobility; generalized weakness,; sedentary lifestyle; imbalance between oxygen supply and demand
Part 2 (Etiology)“Reated to” Phrase This phrase states what may be causing or contributing to the nursing diagnosis, commonly referred to as the etiology. Ideally the etiologe, or cause, of the nursing diagnosis is something that can be treated by a nurse. When this is the case, the diagnosis is identified as an independent nursing diagnosis. If medical Intervention is also necessary, it might be identified as a collabarative diagnosis. For each suggested nursing diagnosis, the nurse should refer to the statements listed under the heading “Related Factors”
Part 3 (Symptoms)Defining Characteristic phrase • It consist of the signs and symptoms that have been gathered during the assessment phase. Signs and symptoms are labeled as defining characteristics in Section III. The use of identifying defining characteristics is similar to the process the physician uses when making a medical diagnosis
Writing a Nursing Diagnosis Statement P - Activity intolerance E – “Related to” imbalance between oxygen supply and demand S – Verbal reports of fatique, exertional dyspnea (“difficulty breathing when walking”), and dysrythmia (“racing heart ”)
Collaborative Problems • Require both nursing interventions and medical interventions EXAMPLE: Client admitted with medical dx of pneumonia Collaborative problem = respiratory insufficiency Nsg interventions: Raise HOB, Encourage C&DB MD interventions: Antibiotics IV, O2 therapy
Planning Third step of the Nursing Process • This is when the nurse organizes a nursing care plan based on the nursing diagnoses. • Nurse and client formulate goals to help the client with their problems • Expected outcomes are identified • Interventions (nursing orders) are selected to aid the client reach these goals.
Planning – Begin by prioritizing client problems • Prioritize list of client’s nursing diagnoses using Maslow • Rank as high, intermediate or low • Client specific • Priorities can change
PlanningDeveloping a goal and outcome statement • Goal and outcome statements are client focused. • Worded positively • Measurable, specific observable, time-limited, and realistic • Goal = broad statement • Expected outcome = objective criterion for measurement of goal • Utilize NOC as standard EXAMPLE • Goal: Client will achieve therapeutic management of disease process…. • Outcome Statement: AEB B/P readings of 110-120 / 70-80 and client statement of understanding importance of dietary sodium restrictions by day of discharge.
Planning- Types of goals • Short term goals • Long term goals • Cognitive goals • Psychomotor goals • Affective goals
Goals are patient-centered andSMART Specific Measurable Attainable Relevant Time Bound
Goals • PT. will walk 50 ft. • Pt. will eat 75% of meals • Pt. will be OOB 2-4 Hrs. • Pt. will maintain HR <100 • To will state pain level is acceptable 6 (0-10)
Planning-select interventions • Interventions are selected and written. • The nurse uses clinical judgment and professional knowledge to select appropriate interventions that will aid the client in reaching their goal. • Interventions should be examined for feasibility and acceptability to the client • Interventions should be written clearly and specifically.
Interventions – 3 types • Independent ( Nurse initiated )- any action the nurse can initiate without direct supervision • Dependent ( Physician initiated )-nursing actions requiring MD orders • Collaborative- nursing actions performed jointly with other health care team members
Implemention • The fourth step in the Nursing Process • This is the “Doing” step • Carrying out nursing interventions (orders) selected during the planning step • This includes monitoring, teaching, further assessing, reviewing NCP, incorporating physicians orders and monitoring cost effectiveness of interventions • Utilize NIC as standard
Implementing- “Doing” • Monitor VS q4h • Maintain prescribed diet (2 Gm Na) • Teach client amount of sodium restriction, foods high in sodium, use of nutrition labels, food preparation and sodium substitutes • Teach potential complications of hypertension to instill importance of maintaining Na restrictions • Assess for cultural factors affecting dietary regime
Implementing – “Doing” • Teach the client- hypertension can’t be cured but it can be controlled. • Remind the client to continue medication even though no S/S are present. • Teach client importance of life style changes: (weight reduction, smoking cessation, increasing activity) • Stress the importance of ongoing follow-up care even though the patient feels well.
Evaluation- To determine effectiveness of NCP • Final step of the Nursing Process but also done concurrently throughout client care • A comparison of client behavior and/or response to the established outcome criteria • Continuous review of the nursing care plan • Examines if nursing interventions are working • Determines changes needed to help client reach stated goals.
Evaluation • Outcome criteria met? Problem resolved! • Outcome criteria not fully met? Continue plan of care- ongoing. • Outcome criteria unobtainable- review each previous step of NCP and determine if modification of the NCP is needed. • Were the nsg interventions appropriate/effective?
Evaluation Factors that impede goal attainment: • Incomplete database • Unrealistic client outcomes • Nonspecific nsg interventions • Inadequate time for clients to achieve outcomes.
Checkpoint Identify which stage of the nursing process is being described below: • The nurse writes nursing interventions • A goal is agreed upon • The nurse performs a physical assessment • A revision is made to the NCP • The nurse administers antibiotic medication • A statement is written that outlines the clients response to a potential health problem
S and O Data Quiz • RR 22/min, even unlabored • “I can only walk 3 blocks before my legs start to hurt” • Pain rated 3 on a scale of 0-10 • Skin pink, warm and dry • Urine output 300mL/8 hr • “My wife doesn’t come to visit very often” • Dressing clean, dry and intact.
NCLEX Time • The nurse records the following subjective data in the client’s medical record: • A.Breath sounds clear to auscultation • B.Amber urine in sufficient quantities • C.Pain intensity 8 out of 10 • D.Skin warm and dry
NCLEX Time • When interviewing a client, the nurse uses the following open-ended style sentence: • A.Do you have any concerns right now? • B.Is your family worried about you being in the hospital? • C.How many times do you get up to go to the bathroom at night? • D.What do you mean when you say, “I don’t feel quite right?”
NCLEX Time In order for an actual nursing diagnosis to be valid it must have one or more supporting: • A.Laboratory results • B.Diagnostic data • C.Defining characteristics • D.Medical diagnoses
NCLEX Time Nursing diagnoses are aimed at identifying client problems that are treatable by _______. • A.The physician • B.The nurse • C.Invasive techniques • D.Complementary strategies