Nursing Process

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Nursing Processes

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  • Figure 14-1. Five-step nursing process model.
  • Figure 16-1. Critical thinking and the nursing diagnostic process.
  • Nursing Process

    1. 1. The Nursing Process
    2. 2. Nursing Process The Nursing Process is a framework that helps organize and deliver nursing care. It:  Is orderly, systematic.  Is central to all nursing care.  Is used to identify, prevent and treat actual or potential health problems and promote wellness.  Encompasses all steps taken by the nurse in caring for individuals, families, groups, and communities.  Must be used by nurses
    3. 3. Definition of the Nursing Process  An organized sequence of problem- solving steps used to identify and to manage the health problems of clients  It is accepted for clinical practice established by the American Nurses Association
    4. 4. Benefits of Nursing Process  Provides an orderly & systematic method for planning & providing care  Enhances nursing efficiency by standardizing nursing practice  Facilitates documentation of care  Provides a unity of language for the nursing profession  Is economical  Stresses the independent function of nurses  Increases care quality through the use of deliberate actions
    5. 5. The Nursing Process Utilizes The Following Assessment Nursing Diagnosis Planning Implementation Evaluation
    6. 6. Characteristics of the Nursing Process  Within the legal scope of nursing  Based on knowledge-requiring critical thinking  Planned-organized and systematic  Client-centered  Goal-directed  Prioritized  Dynamic
    7. 7. Being Accountable  Using critical thinking before taking actions  Being responsible for your actions  Entering the professional role  Working at the level of your peers  Using the nursing process
    8. 8. Something to think about:  Nurses are responsible for a unique dimension of healthcare – “ the diagnosis and treatment of human responses to actual or potential health problems”
    9. 9. The Nursing Process Is:  Cyclic and dynamic  Goal directed and client centered  Interpersonal and collaborative  Universally applicable  Systematic
    10. 10. NURSING PROCESS
    11. 11. Nursing Process 1. Assessment – The nurse gathers subjective & objective information from the client & other sources in order to understand the client’s situation. 2. Nursing Diagnosis –Organizes (in collaboration with the client), interprets the data and makes nursing diagnosis/diagnoses, which is nursing’s perspective on the appropriate focus for client nursing care. 3.Planning- Sets, in collaboration with client, mutually agreed upon goals of care, desired outcomes strategies to achieve goals of care & the identification & prioritization of appropriate nursing actions.
    12. 12. Nursing Process 4.Intervention- Perform the nursing actions identified in planning. 5.Evaluation- Determine if the goals are met and outcomes achieved.
    13. 13. Advantages of using the Nursing Process  Continuity of care  Prevention of duplication  Individualized care  Promotes critical thinking & safety ■ Increased client participation ■ Collaboration of care ■ Application of Standards of care.
    14. 14. Critical Thinking  CRITICAL THINKING - is an active, organized cognitive process used to examine one’s own thinking.  It is a time for making decisions and reflecting, and taking nothing for granted.  Nurses use critical thinking as they begin to question “WHY”? What else? Why not??? What?
    15. 15.  A nurse who is a good critical thinker & uses the nursing process as intended, faces problems without forming a quick simple solution, but considers the value of all reasonable options.
    16. 16. Step #1 NURSING ASSESSMENT Information Gathering & Processing
    17. 17. Standards for Nursing Practice CRNNS
    18. 18. What Is the Nursing Assessment?  Assessment is the first step of the Nursing Process. It includes the collection & analysis of subjective & objective data pertinent to a client.
    19. 19. Nursing Assessment  Initially, the nurse must determine if the assessment should be a quick overview (consider the client’s presenting priorities, specialty area of practice) or a detailed examination of the client’s case.  In facilities, data is usually collected on standardized nursing assessment forms, designed to collect targeted relevant data.  Forms may differ depending on agency and setting.
    20. 20. Nursing Assessment  After the initial assessment the nurse focuses on the client’s potential problems by conducting a more comprehensive assessment.
    21. 21. How Is Data Obtained?  Data are obtained through: Interviews- patient, nurses, support persons, HCPs Physical examinations Observations Review of records and diagnostic reports Collaboration with colleagues
    22. 22. Data Collection: Sources of Data  Client-usually the best source of information, pay attention to your client, act interested.  Family and Significant Others- used as primary sources of information about infants, children, and critically ill, intellectually disabled, disoriented, or unconscious clients. Can be used as secondary sources of information.  Health Care Team /nurse caring for patient -change of shift report  Nurse’s Own Experience- Through experience the nurse learns to ask questions that yield important information  Medical or Other Records- medical hx, lab tests, diagnostic study tests, educational, military records ect.  Literature Review, Standards of Care, Procedures
    23. 23. Assessment Data Gathering Tools/Reports  Health History –  Health promotion & disease prevention behaviours, health problems & responses & risk factors (biological & environmental).  Requisites (needs): Universal SCR, Health Deviation SCR, Developmental SCR (physiological, psychological, sociological, spiritual) Other: Health practices, family and social support, goals, values, and expectations about the health care system.  Physical assessment: Head to toe assessment
    24. 24. During Assessment Use:  Critical thinking  Broad knowledge base  Effective communication skills  Keen observation and physical assessment skills
    25. 25. ASSESSMENT ALSO INCLUDES CLIENT’S: • current and past health and functional status • present and past coping patterns (strengths and limitations) • response to therapy (past/present, nursing/medical) • risk for potential problems • desire for a higher level of wellness • health practices • support system • goals, values & expectations re health care system • need for nursing
    26. 26. Importance of Client Expectations  Client/patient expectations influence the nurses’ success in developing a relationship with the client that leads to a directed, purposeful and comprehensive assessment.
    27. 27. Subjective vs. Objective Data  Subjective data- information reported by the client. Only the client can determine this data. Ex: “I am scared, about surgery”  Objective data- observations or measurements made by nurse - i.e. vital signs, physical assessments, laboratory tests/values, changes in behavior (physical assessment) Based on assessment data gathering tools modeled on Orem’s Self-Care Model.
    28. 28. Nursing Health History  The Nursing Health History is the systematic collection of subjective and objective data used to determine a clients self care requisites, functional ability and ways of coping.
    29. 29. Purpose of the Subjective Component of the Nursing Health History  Provides subjective data on the client’s health care experiences and current health and lifestyle habits. i.e. patient’s level of wellness, present and past family history, changes in life patterns, review of systems etc
    30. 30. Nursing Health History  Nurses need to …document all relevant information on time… Pay attention to facts and be as descriptive as possible.
    31. 31. What Are Your Responsibilities?  Recognize health problems.  Anticipate complications.  Initiate actions to ensure appropriate and timely treatment. Begin to think CRITICALLY !!!!!!
    32. 32. Critical Thinking  MENTAL OPERATIONS –decision making & reasoning  KNOWLEDGE-having the facts & understanding the reason behind the knowledge  ATTITUDES- curious/open-minded/non- judgmental….
    33. 33. Assessment of Well-Being  According to the World Health Organization is well-being in these domains: Emotional Physical Social Spiritual
    34. 34. TYPES OF INTERVIEWS  DIRECTED  NON-DIRECTED THINGS THAT IMPAIR COMMUNICATION:  PRESENTING QUICK SOLUTIONS  UNWARRANTED CHEERFULNESS  FALSE REASSURANCE  GIVING ADVICE  CHANGING THE SUBJECT
    35. 35. CULTURAL DIVERSITY  MUST PROVIDE CARE CONGRUENT WITH A CLIENT’S EXPECTATIONS  “This is not about you” ?  Respect INDIVIDUAL’S DIFFERENCES, What is the significance of the problem or illness to the client?  What does it mean in the family/community?
    36. 36. COMMON Challenges: Defense Mechanisms  COMPENSATION  DENIAL  DISPLACEMENT RATIONALIZATION  PROJECTION  REPRESSION  SUPPRESSION  REGRESSION
    37. 37. Continued  THE NURSING PROCESS HELPS NURSES UNDERSTAND THE STRATEGIES CLIENTS USE IN their attempt at coping: This knowledge will help you FURTHER INDIVIDUALIZE THEIR CARE
    38. 38. Resources  Client  Other individuals  Previous records  Consultations  Diagnostics studies  Relevant literature
    39. 39. Assessment  Data base assessment – comprehensive information you gather on initial contact with the person to assess all aspects of health status.  Focus assessment – the data you gather to determine the status of a specific condition.
    40. 40. Sources of Data  Primary source: Client  Secondary source: Client’s family, reports, test results, information in current and past medical records, and discussions with other health care workers
    41. 41. Disease Prevention  Primary prevention – protection from a disease while still in a healthy state.  Secondary prevention – early detection and treatment of disease.  Tertiary prevention – prevent complications and to maintain health once the disease process has occurred.
    42. 42. Verifying Data  Essential in critical thinking!!!!!  Measurable data  Double check personal observations  Double check equipment  Check with experts and team members  Recheck out-liers  Compare objective and subjective data  Clarify statements
    43. 43. Planning  Establish the goals, interventions and outcomes
    44. 44. General Guidelines for Setting Priorities 1. Take care of immediate life-threatening issues. 2. Safety issues. 3. Patient-identified issues. 4. Nurse-identified priorities based on the overall picture, the patient as a whole person, and availability of time and resources.
    45. 45. Nurse Identified Priorities  Composite of all patient’s strengths and health concerns.  Moral and ethical issues.  Time, resources, and setting.  Hierarchy of needs.  Interdisciplinary planning.
    46. 46. Identifying Client-centered Outcomes  State what the patient will do or experience at the completion of care.  Give direction to the patient’s overall care.  Patient behaviors not nurse behaviors!!  “The patient will…”
    47. 47. DIAGNOSIS  Sort, cluster, analyze information  Identify potential problems and strengths  Write statement of problem or strength  Risk of infection related to compromised nutrition
    48. 48. Nursing Diagnosis (cont.)  Potential for effective breastfeeding related to knowledge level and support system  Prioritize the problems  Not a medical diagnosis
    49. 49. Steps for deriving outcomes from Nursing Diagnosis  Look at the first clause of the nursing dx and restate in a statement that describes improvement, control or absence of the problem.  Risk for infection r/t surgical procedure.  The client will demonstrate no signs or symptoms of infection.
    50. 50. Components of Outcomes  Subject: who is the person expected to achieve the outcome?  Verb: what actions must the person take to achieve the outcome?  Condition: under what circumstances is the person to perform the actions?  Performance criteria: how well is the person to perform the actions?  Target time: by when is the person expected to be able to perform the actions?
    51. 51. Nursing Interventions  Road maps directing the best ways to provide nursing care.  Evidence based nursing. 1. Monitor health status. 2. Minimize risks. 3. Resolve or control a problem. 4. Assist with ADLs. 5. Promote optimum health and independence.
    52. 52. Interventions  Direct interventions: actions performed through interaction with clients.  Indirect interventions: actions performed away from the client, on behalf of a client or group of clients.
    53. 53. Nursing Diagnosis  Health issue that can be prevented, reduced, resolved, or enhanced through independent nursing measures
    54. 54. Documenting the Plan of Care  To ensure continuity of care, the plan must be written and shared with all health care personnel caring for the client.  Consists of: 1. Prioritized nursing diagnostic statements. 2. Outcomes. 3. Interventions.
    55. 55. Documentation  Clear and concise  Appropriate terminology Usually on a designated form  Physical assessment Usually by Review of Systems • Overview of symptoms • Diet • Each body system
    56. 56. Documentation  Use patient’s own words in subjective data – enclose in “ ___” (quotation marks)  Avoid generalizations – be specific  Don’t make summative statements – describe - e.g. patient is being ornery should be patient resists instruction or patient states “Don’t talk to me, I don’t care about that”
    57. 57. Evaluation 1. Determining outcome achievement 2. Identifying the variables affecting outcome achievement 3. Deciding whether to continue, modify, or terminate the plan
    58. 58. Determining Outcome Achievement  Must be aware of outcomes set for the client.  Must be sure patient is ready for evaluation.  Is patient able to meet outcome criteria?  Is it: Completely met? Partially met? Not met at all?  Record in progress in notes.  Update care plan.
    59. 59. Identifying Variable Affecting Outcome Achievement  Maintain individuality of care plan: 1. Is the plan realistic for the client? 2. Is the plan appropriate at the time for this particular client? 3. Were changes made in the plan when needed? 4. How does the client feel about the plan?
    60. 60. Predict, Prevent, and Manage  Focus on early intervention  Based on research  Predict and anticipate problems  Look for risk factors
    61. 61. Diagnostic Statements  Name of the health-related issue or problem as identified in the NANDA list  Etiology (its cause)  Signs and Symptoms  The name of the nursing diagnosis is linked to the etiology with the phrase “related to,” and the signs and symptoms are identified with the phrase “as manifested (or evidenced) by”
    62. 62. Collaborative Problems- Nurse’s Responsibility  Correlating medical diagnoses or medical treatment measures with the risk for unique complications  Documenting the complications for which clients are at risk  Making pertinent assessments to detect complications
    63. 63. Continued  Reporting trends that suggest development of complications  Managing the emerging problem with nurse- and physician-prescribed measures  Evaluating the outcomes
    64. 64. The Nursing Process Nursing Diagnosis Judgment or conclusion about the risk for— or actual—need/problem of the patient NANDA format
    65. 65. NANDA – North American Nursing Diagnosis Association  Identifies nursing functions  Creates classification system  Establishes diagnostic labels  Risk of infection related to compromised nutritional state  Potential complication of seizure disorder related to medication compliance
    66. 66. Planning  The process of prioritizing nursing diagnoses and collaborative problems, identifying measurable goals or outcomes, selecting appropriate interventions, and documenting the plan of care.  The nurse consults with the client while developing and revising the plan.
    67. 67. Setting Priorities  Determine problems that require immediate action  Maslow’s Hierarchy of Human Needs
    68. 68. Short-Term Goals  Outcomes achievable in a few days or 1 week  Developed form the problem portion of the diagnostic statement  Client-centered  Measurable  Realistic  Accompanied by a target date
    69. 69. Long-Term Goals  Desirable outcomes that take weeks or months to accomplish for client’s with chronic health problems
    70. 70. The Nursing Process Planning Identification of goals and outcome criteria Prioritization Time frame
    71. 71. Selecting Nursing Interventions  Planning the measures that the client and nurse will use to accomplish identified goals involves critical thinking.  Nursing interventions are directed at eliminating the etiologies.
    72. 72. Selecting an intervention  The nurse selects strategies based on the knowledge that certain nursing actions produce desired effects.  Nursing interventions must be safe, within the legal scope of nursing practice, and compatible with medical orders.
    73. 73. Communicating The Plan  The nurse shares the plan of care with nursing team members, the client, and client’s family.  The plan is a permanent part of the record.
    74. 74. Evaluation  The way nurses determine whether a client has reached a goal.  It is the analysis of the client’s response, evaluation helps to determine the effectiveness of nursing care.
    75. 75. The Nursing Process Evaluation Ongoing part of the nursing process Determining the status of the goals and outcomes of care Monitoring the patient’s response to drug therapy
    76. 76. Documentation  Clear and concise  Appropriate terminology Usually on a designated form  Physical assessment Usually by Review of Systems • Overview of symptoms • Diet • Each body system

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