Nursing Process: Foundation for Practice

1. Nursing Process: Foundation for Practice NPN 105 Joyce Smith RN, BSN

2. What is the “Nursing Process”? • It is a systematic method that directs the nurse and patient in planning patient care, and enables you to organize and deliver nursing care • It is patient centered and outcome oriented • The steps are interrelated and dependent on the accuracy of each of the preceding steps • It is used to identify, diagnose, and treat human responses to health and illness

3. Together the nurse and the patient accomplish the following: • Assess the patient to determine need for nursing care • Determine nursing diagnoses for actual and potential health problems • Identify expected out comes and plan care • Implement care • Evaluate the results

4. Five Steps of the Nursing Process • Assessment – collection of patient data • Diagnosis – identifies patients strengths and potential problems • Planning – develop the specific holistic desired goals and nursing interventions to assist the patient • Implementation – carry out the plan of care • Evaluation – determine the effectiveness of the plan of care

6. Assessment: Phase One of the Nursing Process • Purpose: • Establish a baseline of information on the client and develop a data base • Determine client’s normal function • Determine client’s risk for dysfunction • Determine presence or absence of dysfunction • Determine client’s strengths • Provide data for diagnostic phase

7. Unique Focus of Nursing Assessment • Nursing assessments do not duplicate medical assessments • Medical assessments target data pointing to pathologic conditions • Nursing assessments focus oh the patient’s responses to health problems or potential health problems

8. Assessment • The purpose is to establish a database by: • Collecting data • Subjective versus objective • Interviewing and taking a health history • Subjective and organized • Performing a physical examination • Vital signs, patient’s behavior, diagnostic and laboratory data, medical records

9. Approaches for Data Collection • Gordon’s 11 Functional Health Patterns • Uses a series of questions which assist in formulating a nursing diagnosis • Problem focused assessment • Focuses on the patient’s problem and develop you plan of care around the problem

10. Health perception-management Nutritional-metabolic Elimination Activity-exercise Sleep-rest Cognitive -perceptual Self-perception-self-concept Role-relationship Sexuality-reproductive Coping-stress-tolerance Value-belief Gordon’s Health Patterns

11. Types of Nursing Assessments • Initial assessment • Focused assessment • Emergency assessment • Time-lapsed assessment

12. Types of Data • Subjective Data • Information perceived only the affected person • Cannot be perceived or verified by another person • Examples: feeling nervous, nauseated, chilly

13. Types of Data • Objective Data • Observable and measurable data • Data that can be see, heard or felt by someone other than the person experiencing it • Examples: elevated temperature (>101 F), moist skin, refusal to eat, vital signs

14. Characteristics of Data • Complete • Factual and accurate • Relevant

15. Components of Data Collection • Interview • Orientation phase • Working phase • Termination

16. Sources of Data • Primary • patient • Secondary • Family members • Significant other • Other healthcare professionals • Health records

17. Components of Data Collection • Nursing History • Biographical information • Reasons for seeking healthcare • Present illness or health concern • Health history • Environmental history • Psychosocial and cultural history • Review of systems or functional health patterns

18. Interpreting Assessment Data • Data interpretation and validation • Data clustering • Data documentation

19. Diagnosis: Phase 2 of the Nursing Process • Data is useless if not used • An important part of nursing practice is determining what the client needs • Developing a nursing diagnosis is the next step in planning for the care of the patient • Looking at the data, we can see both problems treated by nursing (nursing diagnosis) and treated by other disciplines (collaborative problems). • Nursing diagnosis are not medical diagnosis

20. Purpose of a Nursing Diagnosis • 1. Identify how and individual, group or community responds to an actual or potential health and life processes • 2. Identify factors that contribute to or cause health problems (etiology). • 3. Identify resources or strengths the individual, group or community can utilize to prevent or resolve problems

21. Health Problem • A condition that necessitates intervention to prevent or resolve the disease or illness or to promote coping and wellness

22. Health Problems for Nursing Focus • Monitoring for changes in health status • Promoting safety and preventing harm • Identifying and meeting learning needs • Tailoring treatment and medication regimens for each individual

23. Health Problems for Nursing Focus • Promoting comfort and managing pain • Promoting health and a sense of well being • Recognizing and addressing barriers to an independent, healthy lifestyles • Determining human responses

24. Nursing Diagnosis • A clinical judgment about individual, family, or community responses to actual and potential health problems or life processes • The goal of a nursing diagnosis is to identify actual and potential responses

25. Medical Diagnosis • Identification of a disease condition based on a specific evaluation of physical signs, symptoms, history, diagnostic tests, and procedures • The goals of a medical diagnosis is to identify the cause of a illness or injury and design a treatment plan

26. Nursing Diagnosis • Actual or potential health problems that can be prevented or resolved by independent nursing interventions

27. Nursing Diagnosis • Nursing diagnoses provide the basis for selecting nursing interventions that will achieve valued patient outcomes for which the nurse is responsible

28. NANDA • NANDA: North American Nursing Diagnosis Association • Established in 1973 to identify standards and classify health problems treated by nurses

29. NANDA • NANDA conferences are held every two years to continue progress in defining, classifying and describing diagnoses

30. NANDAS’ Definition of Nursing Diagnosis • Nursing diagnosis is a clinical judgment about individual, family, or potential health problems/life processes. Nursing diagnosis provides the basis for selection of nursing interventions to achieve outcomes for which the nurse is accountable

31. Nursing Diagnosis • Clinical judgment about individual, family or community • Response to actual or potential health or life process • Provides basis for nursing interventions • Label and action of describing functional problems • Identify and synthesize information gathered during assessment

32. Nursing Diagnosis vs. Medical Diagnosis • Medical diagnosis • Identify disease • Nursing diagnosis • Focus on unhealthy response to health or illness • Medical diagnosis • Physician directs treatment • Nursing diagnosis • Nurse treats problem within scope of independent nursing practice

33. Nursing Diagnosis vs. Medical Diagnosis • Medical Diagnosis • Remains the same as long as the disease is present • Nursing Diagnosis • May change from day to day as the patient’s responses change

34. Nursing Diagnosis • Medical Diagnosis • Myocardial infarction • Nursing Diagnosis • Fear • Altered health maintenance • Knowledge deficit • Pain • Altered tissue perfusion

35. Development of Nursing Diagnosis • Assess the patient • Review data and find actual and potential problems • Use diagnostic reasoning to identify patient needs • Arrange data in clusters or defining characteristics • Use all data available • Reach conclusions for patient needs • Determine Nursing Diagnosis according to NANDA approved diagnoses

36. Components of a Nursing Diagnosis • Diagnostic label – name of the nursing diagnosis with descriptors • Related factors – includes factors which contribute to the problem and are not the cause ,but are associated with it. THESE ARE NOT MEDICAL DIAGNOSIS. • Defining characteristics - Assessment data which supports the nursing diagnosis • Subjective data – what the patients tells you • Objective data – what you observe or data obtained • Risk factors – clues which point to potential problems

37. Nursing Diagnosis • Types of diagnoses • Actual • Risk • Wellness

38. What a Nursing Diagnosis is Not • A nursing diagnosis is NOT a medical diagnosis • A nursing diagnosis is NOT a statement of patient need

39. Legal Ramifications of Nursing Diagnosis • A nurse • Can only identify problems within the scope of practice • Cannot diagnose or treat medical disease • Must identify problems within his/her scope o practice, abilities and education