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The Nursing Process

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The Nursing Process The Nursing Process Presentation Transcript

  • THE NURSING PROCESS
  • Objectives:
    • At the end of 3 hours, the student should be able to:
    • Define nursing process
    • State importance of nursing process in nursing profession
    • State and define interrelated phases of nursing process
    • Be able to identify subjective and objective data gathered
    • Be able to formulate nursing diagnosis according to NANDA using the nursing process
  • NURSING PROCESS
    • The cornerstone of the nursing profession
    • Includes: ADOPIE – Assessment, Diagnosis, Outcome identification, Planning, Implementation and Evaluation
    View slide
    • NURSING PROCESS IS:
    • ORGANIZED & SYSTEMATIC
      • 6 sequential and interrelated steps
    • HUMANISTIC
      • The plan of care is developed and implemented with great consideration to the unique needs and concerns of the individual client
      • It is individualized
      • It involves aspect of human dignity
    View slide
    • EFFICIENT
      • Relevant to the needs of the client
      • Promotes client satisfaction and progress
    • EFFECTIVE
      • Utilizes resources wisely in terms of human, time, cost resources
    • THE HEART OF THE NURSING PROCESS
      • Knowledge – broad, varied
      • Skills
    K – knowledge; S – skills; C - caring A. MANUAL B. INTELLECTUAL C. INTERPERSONAL TECHNICAL SKILLS
    • CRITICAL THINKING
    • careful deliberate, goal-directed – to solve problems/make decisions
    • check for evidence
    • Keeping an open mind
    • Avoid jumping into conclusions
    TO ESTABLISH POSITIVE INTERPERSONAL RELATIONSHIPS, WITH CLIENT, CO-WORKERS (REQUIRES COMMUNICATION SKILLS)
    • CARING – WILLINGNESS AND ABILITY TO CARE
    • UNDERSTANDING OURSELVES
    • To be able to understand others
    • To be more objective / non-judgmental
    • Requires ability to listen empathetically
    • Listen with intent
    • Enter into another’s way of thinking and viewing the world
    • Connecting with another’s feelings and perception
    • Identify with another’s struggles, frustrations and desires
    • Being able to detach from feelings and returning to our own frame of reference
    • WILLINGNESS TO CARE
    • Keep the focus on what is best for the patient
    • Respect beliefs / values of others
    • Stay involved
    • Maintain a healthy lifestyle
    • CARING BEHAVIORS
    • Inspiring someone / instilling hope and faith
    • Demonstrating patience, compassion and willingness to persevere
    • Offering companionship
    • Helping someone stay in touch with positive aspect of the life
    • Demonstrating thoughtfulness
    • Bending the rules when it really counts
    • Doing the little things
    • Keeping someone informed
    • Showing your human side by sharing “stories”
  •  
  • ASSESSMENT
    • Collecting, validating, organizing and recording data about the client’s health status (individual, family, community)
    • PURPOSE: To establish a data base
    • ACTIVITIES:
      • COLLECTING DATA:
      • Gathering information.
      • Include the physical, psychological, emotional, socio-cultural, and spiritual factors
      • TYPES OF DATA:
      • SUBJECTIVE DATA (SYMPTOMS)
      • - experienced by the client
      • - EX. Pain, dizziness,
      • OBJECTIVE DATA (SIGNS)
      • - those that can be observed and measured
      • - EX. Pallor, diaphoresis, blood pressure, reddish urine, body temp.
      • METHODS OF COLLECTING DATA:
      • INTERVIEW. Planned purposeful conversation
      • OBSERVATION. (use of senses, lab results interpretation, physical examination)
      • SOURCE OF DATA:
      • PRIMARY: Patient/ Client
      • SECONDARY: Family members, S.O., patient’s chart/record, health team members, related literature
      • VERIFYING / VALIDATING DATA. Make sure your information is accurate.
      • ORGANIZING DATA. Cluster facts into groups of information (subjective and objective information)
  • Let’s review!
    • SUBJECTIVE OR OBJECTIVE???
    • Headache
    • Temp 37.9 C
    • RR: 20 bpm
    • Toothache
    • Client states, “ I haven’t moved my bowel since Friday (3 days).”
    • Cyanosis
    • Urine output: 60ml
    • Ate only half of the food served
  • DIAGNOSING
    • Is a process which results to a diagnostic statement or nursing diagnosis
    • The clinical act of identifying problems
    • It means to analyze assessment and derive meaning from this analysis.
    • PURPOSE: To identify the client’s health care needs and to prepare diagnostic statements
    • NURSING DIAGNOSIS
      • Is a statement of client’s potential or actual alteration of health status.
      • Uses critical thinking and skills analysis
      • Uses PRS/PES format
        • P- PROBLEM
        • R-RELATED TO FACTORS
        • S- SIGNS AND SYMPTOMS
        • P-PROBLEM
        • E-ETIOLOGY
        • S-SIGNS AND SYMPTOMS
    • ACTIVITIES DURING DIAGNOSING:
      • Organize cluster or group data. Ex. Pallor, dyspnea, weakness, fatigue – pertain to problems with oxygenation
      • Compare data against standards (accepted norms). Ex. Amber, clear urine VS cloudy urine or tea colored urine.
      • Analyze data after comparing with standards
      • Identify gaps and inconsistencies in data
      • Determine the client’s health problems, health risks, strengths
      • Formulate Nursing Diagnosis statements
    • Examples of Nursing Diagnoses:
      • Anxiety related to insufficient knowledge regarding surgical experience
      • Ineffective airway clearance related to tracheobronchial infection as manifested by weak cough, adventitious breath sounds, and copious green sputum production.
  • Types of Nsg. Diagnoses:
    • ACTUAL NURSING DIAGNOSIS
      • A judgment about the client’s response to a health problem that is present at the time of nursing assessment
      • Based on the presence of signs and symptoms
      • Ex. - ALTERED COMFORT: PAIN
      • - PAIN: SEVERE HEADACHE RELATED TO FEAR OF ADDICTION TO NARCOTICS
    • RISK NURSING DIAGNOSIS
      • A clinical judgment that a problem does not exist, but the presence of risk factors indicates that a problem is likely to develop
      • Ex. RISK FOR INFECTION
      • RISK FOR CONSTIPATION
    • POSSIBLE NURSING DIAGNOSIS
      • Is one in which evidence about a health problem is unclear or the causative factors are unknown.
      • Requires more data either to support or to refute it.
      • Ex. Possible Social Isolation related to unknown etiology
  • COMPONENTS of a NANDA NURSING DIAGNOSIS
    • PROBLEM (diagnostic label) and DEFINITION
      • Describes the client’s health status clearly and concisely in a few words
      • Qualifiers:
        • Deficient – inadequate in amount, quality, or degree; not sufficient
        • Impaired – made worse, weakened, damaged
        • Ineffective – not producing the desired effect
    • ETIOLOGY (related factors & risk factors)
      • Identifies one or more probable causes of health problem
      • Gives direction to what health needs to attend to.
    • DEFINING CHARACTERISTICS
      • A cluster of signs and symptoms that indicate the presence of a particular diagnostic label
      • ACTUAL DX: signs and symptoms
      • HIGH RISK/ RISK: factors that cause the client to be more vulnerable to the problem
      • Ex. ACTIVITY INTOLERANCE RELATED TO IMMOBILITY as manifested by verbal reports of fatigue or weakness during leg exercises
    • Formulating statements:
      • Problem – Etiology format
      • Problem – etiology – signs and symptoms format
  • OUTCOME IDENTIFICATION
    • Refers to formulating and documenting measurable, realistic, client – focused goals.
    • Provides the basis for evaluating nursing diagnosis and interventions.
    • ACTIVITIES INCLUDE:
      • ESTABLISH PRIORITIES.
        • Life-threatening should be given highest priority
        • ABC’s (airway, breathing, circulation)
        • Maslow’s hierarchy of needs (physiologic needs over psychosocial)
        • Unstable clients vs. clients with stable conditions
        • Actual problems vs. potential concerns
      • ESTABLISH GOALS & OUTCOME CRITERIA
        • GOALS: broad statements
          • SHORT-TERM GOAL (STG)
          • LONG-TERM GOAL (LTG)
        • OUTCOME CRITERIA: specific, measurable, realistic statements of goal attainment
          • S – M – A – R – T
          • Specific, measurable, attainable, time-framed
    • Ex.
    • GOAL: The client will be able to improve mobility and the ability to bear weight on left leg
    • DESIRED OUTCOMES:
      • By the end of the week, client will be able to ambulate with crutches
      • By end of the month, client will be able to stand without assistance
  • PLANNING
    • Involves determining beforehand the strategies or course of actions to be taken before implementation of nursing care.
    • Involve the client and his family
    • Begins with the first client contact until client is discharged from the facility
    • Activities:
      • Plan nursing interventions (also called nursing orders); may be dependent, independent, interdependent.
      • Write nursing care plan
      • a written summary of the care that a client is to receive.
      • the “blueprint” of the nursing process
      • the plan of care is a step-by-step process evidenced by the following:
        • Sufficient data are collected to support nsg. Diagnoses
        • At least one goal must be stated for each nsg. dx
        • Outcome criteria must be identified for each goal
        • Each intervention should be supported by scientific rationale
        • Evaluation. To assess whether goals are met or unmet.
    • TYPES OF PLANNING
    • Initial planning
      • Starts upon initial assessment/admission
    • Ongoing planning
      • Done by all nurses who work with the client to:
        • Determine change in the health status.
        • Set priorities for the client’s care during the shift.
        • Decide which problems to focus on during the shift.
        • Plan nursing activities during the shift.
    • Discharge planning
      • The process of anticipating and planning for needs after discharge.
      • Includes: ff. up care, referrals, medications, diet modifications, significant other/care provider, health teachings, which signs and symptoms to watch for.
  • IMPLEMENTATION
    • Putting the nursing care plan into action
    • Purpose: to carry out planned nursing interventions to help the client attain goals and achieve optimal level of health
    • Activities:
      • Set priorities. To determine the order in which nsg interventions are carried out.
      • Perform nsg. Interventions
      • Record actions. SOMETHING THAT IS NOT WRITTEN IS CONSIDERED NOT DONE!!!
  • EVALUATION
    • Is assessing the client’s response to nsg intervention and then comparing the response to predetermined standards or outcome criteria.
    • Purpose:
      • To appraise the extent to which goals and outcome criteria of nsg care have been achieved
    • Activities:
      • Collect data about the client’s response
      • Compare response to goals and outcome criteria
      • Assess whether goals are met (partially/completely) or unmet
      • Analyze reasons for outcomes
      • Modify care plan as needed
    • BENEFITS OF THE NURSING PROCESS FOR THE CLIENT
    • Quality client care. It meets standards of care.
    • Continuity of care.
    • Participation by the clients in their health care.
    • BENEFITS OF THE NURSING PROCESS FOR THE NURSE
    • Consistent and systematic nursing education
    • Job satisfaction
    • Professional growth
    • Avoidance of legal action
    • Meeting professional nsg standards
    • Meeting standards of accredited hospitals