Chapter 2 Nursing Process

1. Chapter 2Nursing Process Bader EL Safadi BSN , MSc

2. Definition of the Nursing Process • A process: "A set of actions leading to a particular goal". • Nursing Process ”AnOrganized 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 Bader EL Safadi BSN , MSc

3. Characteristics of the Nursing Process • Within the legal scope of nursing • Based on knowledge • Planned • Client centered • Goal directed • Prioritized • Dynamic Bader EL Safadi BSN , MSc

4. Steps of the Nursing Process Bader EL Safadi BSN , MSc

5. 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 • Example (BP , temperature, skin color) Bader EL Safadi BSN , MSc

6. Steps of the Nursing Process (cont’d) • Assessment (cont’d) • Types of data (cont’d) • Subjective data: information only client feels and can describe (and sometimes family’s); called symptoms • Example (pain , nausea, fatigue) • Sources of data: • primary source: client; • secondary sources: client’s family, reports, or discussion with other health care professionals Bader EL Safadi BSN , MSc

7. 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. Bader EL Safadi BSN , MSc

8. 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 Bader EL Safadi BSN , MSc

9. 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 • Serves as reference for comparing all future data Bader EL Safadi BSN , MSc

10. 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 Example ( postoperative surgical assessment) Bader EL Safadi BSN , MSc

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12. Question • Which of the following is a primary source for information? a. Client’s family b. Client c. Medical records d. Test results Bader EL Safadi BSN , MSc

13. 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 Bader EL Safadi BSN , MSc

14. Steps of the Nursing Process (cont’d) • Assessment (cont’d) • Organization • Interpreting the data is easier if the information is organized. • Organization involves grouping related information. • Nurses: organize assessment data; cluster related data using knowledge and past experiences Bader EL Safadi BSN , MSc

15. Example • Assessment Findings: Headache, distended abdomen, dry hard passed stool with difficulty, fever, weak cough, thick sputum. • RelatedClusters : • Fever, Headache. • Weak cough, thick sputum. • Distended abdomen, dry hard passed stool with difficulty. Bader EL Safadi BSN , MSc

16. Steps of the Nursing Process (cont’d) • Diagnosis • Second step of the nursing process. • Identification of health-related problems. • In this step there are: • Analyzing data. • Identifying NSG collaborative problems. • Nursing diagnosis “ Health issue that can be prevented, reduced, resolved, or enhanced through independent nursing measures.” Bader EL Safadi BSN , MSc

17. Nursing Diagnosis Questions • Are there problems here? • If so, what are the specific problems? • What are some possible causes? • Is there a situation involving risk factors? • What are the risk factors? • What are the client’s strengths? • What data are available to answer these questions? • Is more data needed? • If so, what are the possible sources of further data? Bader EL Safadi BSN , MSc

18. Categories of Nursing Diagnosis: Bader EL Safadi BSN , MSc

19. Categories of Nursing Diagnosis (cont’d) : Bader EL Safadi BSN , MSc

20. Steps of the Nursing Process (cont’d) • Nursing diagnosis (cont’d) • Diagnostic statement:an actual nursing diagnostic Statement contains one to three parts: • Name of the health related issue or problem as identified in the NANDA list) North American Nursing Diagnosis Association( • Etiology (its cause). (Physiological, psychological, situational, cultural, environmental….). • Signs and symptoms : phrase “as manifested (or evidenced) by” Bader EL Safadi BSN , MSc

21. Steps of the Nursing Process (cont’d) Diagnostic statement: Example: Parts of Nursing Diagnosis: • Sleep pattern disturbance = Problem. • Related to excessive intake of coffee = Etiology. • That manifested by difficulty in falling a sleep, feeling tiered and irritability with others =Signs and Symptoms. Bader EL Safadi BSN , MSc

22. Steps of the Nursing Process (cont’d) Example • Medical diagnosis • Infection with AIDS virus • Possible Consequences • Decreased blood cells that fight infection • Collaborative Problems • Immunodeficiency • Collaborative problem • Physiologic complications require both nurse- and physician-prescribed interventions Bader EL Safadi BSN , MSc

23. Steps of the Nursing Process (cont’d) • Planning • Third step of the nursing process • Setting priorities • Prioritization involves ranking from those that are most serious or immediate to those of lesser importance (Maslow's Hierarchy of Human Needs can be used)“Physiologic, Safety and Security, Love and belonging, Esteem and self-esteem, Self-actualization” Bader EL Safadi BSN , MSc

24. Steps of the Nursing Process (cont’d) • Planning (cont’d) • Establishing goals Goal: expected or desired outcome • Short-term goals: • Outcomes achievable in a few days to 1 week. • Used more often in a cute care. Bader EL Safadi BSN , MSc

25. Steps of the Nursing Process (cont’d) • Planning (cont’d) • Establishing goals Characteristics of Short-Term Goals: • Developed from the problem portion of the diagnostic statement. • Patient centered. • Measurable. • Realistic. • Accompanied by a target date for accomplishment Bader EL Safadi BSN , MSc

26. Steps of the Nursing Process (cont’d) Example /Short-term goals: • The client will_________________ • have a bowel movement _________ • in 2 days (specify date) __________ • client–centered • identifies measurable criteria that reflect the problem portion of the diagnostic statement • identifies a target date for achievement within a realistic time frame Bader EL Safadi BSN , MSc

27. Steps of the Nursing Process (cont’d) • Planning (cont’d) • Establishing goals (cont’d) • Long-term goals • Desirable outcomes that take weeks or months to accomplish. • Are used more often in chronic health problems. • Outcome has more details than Short- Term Goals • Goals for collaborative problems • Written for the nurse • Goals for collaborative problems Bader EL Safadi BSN , MSc

28. Steps of the Nursing Process (cont’d) • Planning (cont’d) • Establishing goals (cont’d Goals versus Outcome: • Goal : ( General ) The client will be hydrated by 8/23. • Outcome : ( Specific ) The client will have adequate hydration as evidenced by an oral intake between 2,000-3,000 ml/24 hours and a urine out put +/- 500 ml of the intake amount by 8/23 Bader EL Safadi BSN , MSc

29. Steps of the Nursing Process (cont’d) • Planning (cont’d) • Selecting nursing intervention • Planning measures: to accomplish identified goals involves critical thinking • Nursing interventions are directed at eliminating the etiologies. • Planned interventions: must be safe; within legal scope of nursing practice; and compatible with medical orders Bader EL Safadi BSN , MSc

30. 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:( directions for patient's care ) performing nursing interventions; providing specific instructions Bader EL Safadi BSN , MSc

31. 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 Bader EL Safadi BSN , MSc

32. 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 Bader EL Safadi BSN , MSc

33. 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 Bader EL Safadi BSN , MSc

34. Outcomes Form Evaluation Bader EL Safadi BSN , MSc

35. Question • Is the following statement true or false? Evaluation is the fifth and final step in the nursing process. Bader EL Safadi BSN , MSc

36. 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. Bader EL Safadi BSN , MSc

37. 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 Bader EL Safadi BSN , MSc

38. 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

39. 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

40. Concept Map Diagram Samples