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Nursing process review

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  • 1. Defines Nursing as:the diagnosis and treatment ofhuman responses to actual orpotential health careproblems.
  • 2. a problem solving approach forgathering data, identifying aperson’s needs, selecting andimplementing approaches fornursing care and evaluatingoutcomes of care given.
  • 3. Steps of Nursing Process:1. Assessment2. Diagnosis3. Planning4. Implementation5. Evaluation
  • 4. RATIONALE FOR USING NURSING PROCESS:  requirement – national practice standards  preparation for NCLEX  promotes critical thinking  means of communication  results in an individualized plan of care
  • 5. 7
  • 6. 1. a. Interviewing patient & family – chief complaint b. Nursing History: - support system - health - ADL’s - feelings/concerns - culture - occupation - financial concerns
  • 7. 2. Observation & Measurement: A sixth sense? Or merely mindful caution?
  • 8. 3. REVIEW OF THE RECORDS1. DOCTOR’S ORDERS2. PROGRESS NOTE3. HISTORY/PHYSICAL4. NURSING NOTES5. CONSULTATION6. DIAGNOSTIC STUDIES7. LAB RESULTS 10
  • 9. 4. Physical Assessment /Examination GENERAL SURVEY VITAL SIGNS HEAD & NECK UPPER EXTREMITIES ANTERIOR & POSTERIOR THORAX ABDOMEN LOWER EXTREMITIES PELVIS & PERINEUM MOTOR/SENSORY/SPINE SKIN 11
  • 10. Cluster Data According To Body Systems• Visual & Auditory • Question:• Respiratory After gathering and clustering• Cardiovascular all your data, in which areas or systems are you seeing• Gastrointestinal abnormal findings? These• Nervous systems become your priority assessment areas for a• Musculoskeletal focused assessment or on-• Urinary going evaluation• Reproductive• Hematological• Endocrine• Integumentary 12
  • 11. Data Classification:#1 What are symptoms and signs: - Sign : aka - objective data – what you observe - Symptom: aka – subjective data – what the person states#2 Adaptive vs ineffective responses#3 Identify the causative factors or etiology 13
  • 12. AKA PROBLEMIDENTIFICATION 14
  • 13. CLINICAL JUDGMENT• IS AN OPINION THAT THE NURSE MAKES BASED ON THE CLINICAL DATA OBTAINED; Clinical judgment allows the nurse to identify, associate and interpret the signs and symptoms of a given condition NURSING DIAGNOSIS• IS A CLINICAL JUDGMENT ABOUT AN INDIVIDUAL’S RESPONSES TO ACTUAL ORPOTENTIAL HEALTH PROBLEMS.
  • 14. CLINICAL JUDGMENT PROCESS – Howto arrive at a Nursing Diagnosis: Reasoning Critical Nursing Thinking Diagnosis /Clinical Judgment Knowledge & experience
  • 15. NURSES ARE RESPONSIBLE FOR PROVIDING TREATMENTFOR IDENTIFIED DIAGNOSES –…. “actual or potential health problems that nurses byvalue of their education and experience are able, licensedand legally responsible and accountable to treat”. ANXIETY IMPAIRED MOBILITY
  • 16. TYPES OF NURSING DIAGNOSES1. ACTUAL GWC2. RISK FOR & HIGH RISK FOR3. POSSIBLE4. WELLNESS5. SYNDROME
  • 17. MAKING A NURSING DIAGNOSIS:A. 1. After gathering data, cluster signs and symptoms 2. Next identify causative factors for these signs and symptoms 3. Select a Nursing Diagnosis based on them V Klein
  • 18. A 32 year old woman has a fractured leg with a cast and she does not know how to use her crutches. She expresses concern that she “will be confined to bed or a chair and not be able to get around and care for her 4 year old son”. -Fractured leg - immobilized by a Cast -Does not know how to use Impaired physical mobility crutches- Verbalizes concern that she will be confined and not be able to care for her 4 year old son Ineffective Role Performance V Klein
  • 19. MAKING A NURSING DIAGNOSIS: cont.B. Confirm by checking with Carpenito 1. Read the definition 2. Read the defining characteristics – at least one major
  • 20. MAKING A NURSING DIAGNOSIS: cont.C. Factors that cause or contribute to the problem are called Related Factors in Carpenito – divides them into 4 groups 1. pathophysiological 2. treatment related 3. situational (personal or environmental) 4. maturational V Klein
  • 21. Fractured leg cast Pathophysiological Treatment related Impaired physical mobility Situational Maturational Lack of noneknowledge
  • 22. MAKING A NURSING DIAGNOSIS: cont.D. Look at all the causes (aka related factors) and determine which is the primary cause of the problem. The primary cause or related factor becomes the second part of the diagnosis which is called the “related to”(note: the R/T must be something theNurse can treat independently) V Klein
  • 23. CONNECT THE PROBLEM WITH THE PRIMARY RELATED FACTOR USING THE LETTERS R/T: IMPAIRED PHYSICAL MOBILITY R/TINSUFFICIENT KNOWLEDGE OF ADAPTIVE TECHNIQUES IN USE OF CRUTCHES FOR AMBULATION.
  • 24. A Nursing Diagnosis is one that nurses cantreat independently and one that does notrequire medical interventionCollaborative problems are certainphysiologic complications that nursesmonitor to detect onset or change instatus; collaborative problems requirenursing and medical intervention
  • 25. Nurses cannot prevent a collaborative problem but they can detect it early to reduce its seriousness - eg monitoring a dressing closely for signs of bleeding.Nurses can prevent certain physiological problems and thesecan be identified as Risk for Nursing Diagnoses -egs: Pressure Ulcers - Risk for Impaired Skin Integrity Aspiration - Risk for AspirationProblems that nurses can treat independently are identifiedas Nursing Diagnoses – egs Ineffective cough - Ineffective Airway Clearing Stage 1 & 2 pressure ulcers - Impaired Skin Integrity
  • 26. JUST CHECKING TO SEE IF YOU ARE AWAKE  V Klein
  • 27. 1. When a medical diagnosis is a related factor, avoid writing it as your R/T ( remember your R/T must be something you can treat independently as a nurse)Eg. Anxiety R/T CancerInstead ask what/how has the medical diagnosis caused or contributed to the problem V Klein
  • 28. WRITTEN CORRECTLY: Anxiety R/T perceived/actual losses secondary to cancer(Treatment related – loss of hair; financialetc) V Klein
  • 29. 2. When writing the R/T avoid using signs and symptoms – they result from the problem rather than cause or contribute.Eg. Disturbed sleep pattern R/T difficulty falling asleep. V Klein
  • 30. CORRECT DIAGNOSIS:Disturbed sleep pattern R/T environmentalchanges due to hospitalization – noise, frequentinterruptions V Klein
  • 31. 3. Do not use a goal as your R/T.Impaired parenting R/T parents shouldspend more time holding infantCORRECT DIAGNOSIS:Impaired parenting R/T a lack ofknowledge regarding infant care andneeds.
  • 32. CORRECTLY WRITTEN ??Disturbed Body Image R/T Breast CancerDisturbed Body Image R/T changes inappearance secondary to Chemo therapy OrDisturbed Body Image R/T a change inappearance secondary to loss of left breast
  • 33. CORRECTLY WRITTEN ?Grieving R/T crying and inability to sleep Grieving R/T losses associated with death of …. ( companionship, financial etc) V Klein
  • 34. CORRECTLY WRITTEN ?Ineffective Airway Clearance R/T rhonci bilaterallyIneffective Airway Clearance R/T inability to maintain anupright position ORIneffective Airway Clearance R/T thick , tenacious secretionssecondary to inadequate fluid intake.
  • 35. CORRECTLY WRITTEN ? Imbalanced Nutrition: Less than body requirements R/T ChemotherapyImbalanced Nutrition: Less than body requirements R/Tdecreased desire to eat secondary to side effects of chemotherapy ORR/T mouth discomfort associated with Chemotherapy V Klein
  • 36. WHAT IS WRONG WITH THIS DIAGNOSIS??Risk for Constipation R/T reports of hard dry stool “ Reports of hard dry stool” is a symptom – therefore it no longer is a Risk for problem If the symptom did not exist and the patient had risk factors : Risk for constipation R/T side effects of analgesics Risk for constipation R/T effects of anesthesia and surgical manipulation. R/T effects of immobility on peristalsis
  • 37. C. PLANNING – AKA GOAL SETTING WHEN WRITING GOALS,THE FOCUS IS ON CHANGING THE ABNORMAL SIGNS & SYMPTOMSClient goals are used to: 1. direct interventions 2. evaluate the effectiveness of the interventions
  • 38.  S SPECIFIC M MEASURABLE A ATTAINABLE R REALISTIC T TIMELY
  • 39. RULES FOR WRITING GOALS:1. a. Start out with the phrase: The client will demonstrate…. b. The first part of the goal needs to reflect the nursing diagnosis2. This is followed by AEB and 2-3 goal criteria. a. Goal criteria must reflect desired changes in the signs and symptoms listed. b. Criteria must be observable and/or measureable3. Always end with one realistic time frame
  • 40. Disturbed sleep pattern R/T environmentalchanges due to hospitalization – noise,frequent interruptions Symptoms/Subjective Data : “I can’t fall asleep here and when I do someone or something always wakes me up.” Signs/Objective Data: Refuses to participate in self-care measures. Irritable and sarcastic when talking to family members and staff
  • 41. Client will demonstrate an improved sleep patternAEB: Verbalizing that he/she was able to fall and stay asleep throughout the night Participating in morning hygiene – teeth hair, shower Communicating in a pleasant manner with family members and staff - within 48 hours
  • 42. D. Implementation- AKA interventionsThree components: 1. must use an action verb 2. state where, what, how, how much and how far 3. time element – when, how often and how longTypes: Assess, Care, Manage, Teach
  • 43. E. EVALUATION- results/effectsThe final step is to determine if your patient’s goal has been met.Look at your goal criteria to do this.If criteria not met, remember that the Nursing Process is a circular process – it begins and ends with assessment.
  • 44. THEEND V Klein