5.nursingprocess

8/13/2019 5.NursingProcess

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3 INTERRELATED PROCESSES

INVOLVED IN A COMPETENTNURSING PRACTICE:

CRITICAL THINKING

PROBLEM SOLVING

DECISION MAKING

CREATIVITY - thinking that results in thedevelopment of new ideas and products; abilityto develop and implement new and bettersolutions


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CRITICAL THINKING – a discipline specific,reflective reasoning process that guides a nurse in

generating, implementing and evaluatingapproaches for dealing with client care andprofessional concerns

PROBLEM SOLVING – process of obtaininginformation that clarifies the nature of theproblem and suggest possible solutions thenchoosing from the possible solutions the best one

to implement DECISION MAKING – process for choosing the

best actions to meet a desired goal


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NURSING PROCESS A SYSTEMATIC, RATIONAL METHOD OF

PLANNING AND PROVIDING NURSING CARE

The “cornerstone of nursing practice” Is:

ORGANIZED

SYSTEMATIC

GOAL-ORIENTED HUMANISTIC CARE

EFFICIENT AND EFFECTIVE


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CHARACTERISTIC

CYCLIC and DYNAMICClient centered

Orderly, planned, step by step (systematic)

Decision making s involved in every phaseof the nursing process

Interpersonal and collaborative

Permits creativity among nurses and clients

Universal


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BENEFITS FOR THE CLIENT Quality client care

Meets standards of care

Continuity of care Participation by the clients in their health care

Reflects respect for human dignity


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BENEFITS FOR THE NURSE Consistent and systematic nursing education

Job satisfaction

Professional growth Avoidance of legal action

Meeting professional nursing standards

Meeting standards of accredited hospitals


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PHASES ASSESSMENT

DIAGNOSIS (NURSING DIAGNOSIS)

PLANNING and OUTCOMEIDENTIFICATION

IMPLEMENTATION

EVALUATION


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ASSESSMENT ASSESSMENT

Collecting, validating, organizing, andrecording/documenting data about the client’s healthstatus

PURPOSE: to establish data base (all the informationabout the client)

Activities during assessment

Collection of data

Verifying/validating data

Organizing data


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Types of ASSESSMENT INITIAL ASSESSMENT

- Performed within specified time after admission to ahealth care agency

- Establish a complete database for problem

identification, reference and future comparison

- Ex: nursing admission assessment

PROBLEM-FOCUSED ASSESSMENT

- Ongoing process integrated with nursing care- Determine the status of a specific problem identified in

an earlier assessment

- Ex: I&O Q1; assessment of pt’s ability to perform self -

care


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Types of ASSESSMENT

EMERGENCY ASSESSMENT- Done during any physiologic r psychologic crisis of the

client

- Identify life-threatening problems; identify new and

overlooked problems- Ex: assessment of ABCs during arrest, suicidal

tendencies

TIME-LAPSED ASSESSMENT

- Done several months after initial assessment- Compare the client’s current status to baseline data

previously obtained

- Ex: reassessment on a home care or outpatient client


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ASSESSMENT COLLECTION OF DATA

Gathering information about the client, considering,psychological, emotional, socio-cultural, and spiritualfactors that may affect his/her health status

Types of data

Subjective (symptoms/ covert) – data that can be describedonly by the person experiencing it

Objective (signs/ overt) – data that can be observed andmeasured


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ASSESSMENT• COLLECTION OF DATA

– Methods of data collection

• Interview – planned purposeful conversation

• Observation – use of senses, use of units of measure, physicalexamination techniques, interpretation of laboratory results

– Sources of data

• Primary – patient/ client

• Secondary – family members, significant others, patient’srecord/chart, health team members, related literature


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ASSESSMENT ORGANIZING DATA – the nurse use a

written/computerized format that organizes datasystematically

Often referred to as “nursing health history”, “nursingassessment”, “nursing database form”

Ex: Conceptual Models/Framework

Wellness Models

- Assist clients to identify health risks and to explore lifestyle

habits and health behaviors, beliefs, values and attitudes thatinfluence levels of wellness

Nonnursing Models

- Erikson’s stages of development

- Piaget’s stages of development


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ASSESSMENT

VALIDATING DATA – act of “double-checking” or verifying data to confirm that it is accurate andfactual

Ensure that the assessment information is complete

Ensure that objective and related subjective data agree

Obtain additional information that may have beenoverlooked

Differentiate between cues and inferences CUES – subjective or objective data

INFERENCES – nurses’ interpretation or conclusions madebased on the cues


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ASSESSMENT DOCUMENTING/RECORDING DATA – includes

all data collected about the client’s status

Data are recorded in a factual manner and not asinterpreted by the nurse

Nurses records subjective data in the client’sown words, using quotation marks


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DIAGNOSING Process which results to a diagnostic statement or

NURSING DIAGNOSIS

Clinical act of identifying problems Means analyzing assessment information and derive

meaning from this analysis

PURPOSE: identify the client’s health care needs and

to prepare diagnostic statements


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DIAGNOSING Statement of the client’s potential or actual alteration

of health status

Uses the critical-thinking skills of the analysis andsynthesis

Uses PRS/PES

P –problem; R – related factors; S – signs and symptoms

P – problem; E – etiology; S – signs and symptoms


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DIAGNOSING PROBLEM (DIAGNOSTIC LABEL)

Describes the client’s health problem or response fro which nursing therapy is given

Describes the client’s health status clearly and conciselyin a few words

Follows a “NANDA” label

QUALIFIERS – words hat have been added to someNANDA labels to give additional meaning to thediagnostic statement


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DIAGNOSING QUALIFIERS:

DEFICIENT – inadequate in amount, quality, or degree;not sufficient; incomplete

IMPAIRED – made worse, weakened, damaged, reduced,deteriorated

DECREASED – lesser in size, amount or degree

INEFFECTIVE – not producing the desired effect COMPROMISED – to make vulnerable to threat


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DIAGNOSING ETIOLOGY – identifies one or more probable causes of

the health problem

DEFINING CHARACTERISTICS –cluster of signs andsymptoms that indicate the presence of a particulardiagnostic label


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DIAGNOSING Activities during diagnosing:

Organize cluster or group data

Compare data against standards

Analyze data after comparing with standards

Identify gaps and inconsistencies in data

Determine the client’s health problems, health risks and

strengths Formulate NURSING DIAGNOSIS STATEMENTS


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Types of Nursing Diagnosis ACTUAL DIAGNOSIS – a client problem that is

present at the time of the nursing assessment; basedon associated signs and symptoms

RISK NURSING DIAGNOSIS – clinical judgment thata problem does not exist but the presence of riskfactors indicates that the client is likely to developunless the nurse intervenes

WELLNESS DIAGNOSIS – describes human responsesto levels of wellness in an individual, family orcommunity that have a readiness for enhancement


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Types of Nursing Diagnosis POSSIBLE NURSING DIAGNOSIS – one in which

evidence about a health problem is incomplete orunclear

SYNDROME DIAGNOSIS – a diagnosis that isassociated with a cluster of diagnosis


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PLANNING

AND

OUTCOME IDENTIFICATION


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PLANNING

Involves determining beforehand the strategies orcourse of actions to be taken before implementation ofnursing care

PURPOSE:

Identify the client’s goals and appropriate nursingintervention

Direct client care activities

Promote continuity of care

Focus charting requirements Allow for delegation of specific activities


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Types of PLANNING INITIAL PLANNING – done after initial assessment

ONGOING PLANNING – occurs at the beginning of ashift towards the end of the shift

Determine whether the client’s health status haschanged

Set priorities for the client’s care during the shift

Decides which problems to focus on during the shift

Coordinate the nurse’s activities so that more than oneproblem can be addressed at each client contact

DISCHARGE PLANNING – process of anticipating andplanning for needs after discharge


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PLANNING Plan nursing intervention:

Direct activities to be carried out in the implementationphase

NURSING INTERVENTIONS – any treatment, basedupon clinical judgment and knowledge, that a nurseperforms to enhance client outcomes

NURSING ORDERS

INDEPENDENT, DEPENDENT,INTERDEPENDENT/COLLABORATIVE activities that nursescarry out to provide client care


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PLANNING NURSING CARE PLAN

A written summary of the care that a client is to receive

The “blueprint” of the nursing process

Nursing centered

Step-by-step process TYPES:

INFORMAL NCP – strategy that exists in the nurse’s mind

FORMAL NCP – written or computerized guide that organizesinformation about the client’s care

STANDARDIZED CARE PLAN – specifies the nursing care forgroups of clients with common needs

INDIVIDUALIZED CARE PLAN – tailored to meet the uniqueneeds of a specific client


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PLANNING PROTOCOLS – preprinted to indicate the actions

commonly required for a particular group of client

POLICIES and PROCEDURES – develop to govern thehandling of frequently occurring situations

STANDING ORDER - written document aboutpolicies, rules and regulations or orders regarding

client care Gives nurses authority to carry out specific actions

under certain circumstances


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STUDENT CARE PLAN ASSESSMENT

CUES (SUBJECTIVE, OBJECTIVE)

NURSING DIAGNOSIS SCIENTIFIC EXPLANATION

NURSING INTERVENTION

RATIONALE – scientific principle given as a reason for

selecting a particular nursing intervention EVALUATION


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OUTCOME IDENTIFICATION Formulating and documenting measurable, realistic,

client-focused goals

Provides the basis for evaluating nursing diagnosis

PURPOSE:

Provide individualized care Promote client participation

Plan care that is realistic and measurable

Allow involvement of support people

PRIORITY SETTING

- Process of establishing a preferential sequence foraddressing nursing diagnosis and intervention


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OUTCOME IDENTIFICATION ACTIVITIES:

Establish PRIORITIES Life-threatening situations should be given highest

priority

Use principle of ABC

Use Maslow’s Hierarchy of Needs

Consider something that is very important to the client Client’s with unstable condition should be given priority

over those with stable conditions

Consider the amount of time, materials, equipments

required to care for clients Actual problems take precedence over potential

concerns

Attend to client before equipment


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OUTCOME IDENTIFICATION ACTIVITIES:

Nursing diagnoses are classified as high-priority,medium-priority, and low-priority

High-priority nursing diagnosis –those that arepotentially life-threatening and require immediate

action Medium-priority – those that could result in unhealthy

consequences such as physical or emotional but are notlife threatening

Low-priority – involve problems that usually can beresolved easily with minimal interventions and areunlikely to cause significant dysfunction


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OUTCOME IDENTIFICATION Establish client’s goals and outcome criteria

CLIENT GOAL – an educated guess, made as a BROADSTATEMENT, about what the client’s state will be after

the nursing intervention is carried out

Behavioral goals are written to indicate a desired state;contain an action verb and a qualifier that indicate thelevel of performance that needs to be achieved

Calculate Distinguish Participate Classify Explain Identify Define Compare


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OUTCOME IDENTIFICATION Qualifier – description of the parameter for achieving

the goal

Goals may be short-term (can be met in a relativelyshort period; within days or less than a week) or long-

term (requires more time; several weeks or months) Outcome Criteria are specific, measurable, realistic

statements of goal attainment

Answer the questions: ho, what actions, under what

circumstances, how well, when


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OUTCOME IDENTIFICATION OUTCOME CRITERIA

S – specific

M – measurable

A – attainable

R – realistic

T – time-framed


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IMPLEMENTATION Putting the nursing care plan into action

Action phase in which the nurse performs nursinginterventions

Consists of doing and documenting specific nusing

actions PURPOSE:

Carry out planned nursing interventions to help theclient attain goals and achieve optimal level of health


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IMPLEMENTATION

ACTVITIES: Reassessing the client

Determining the nurse’s need for assistance

Perform/implement nursing interventions

Supervising the delegated care

Record/document nursing actions

IMPLEMENTING SKILLS

COGNITIVE INTERPERSONAL

TECHNICAL


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IMPLEMENTATION COGNITIVE SKILLS

- Intellectual skills

- Include problem solving, decision making, criticalthinking and creativity

- For quality and safe nursing practice INTERPERSONAL SKILLS

- All activities in interaction

- Communication skills

TECHNICAL SKILLS- “hands-on” skills; tasks, procedures or psychomotor

skills


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EVALUATION “to judge” or “to appraise”

Assessing the client’s response to nursinginterventions and then comparing the response topredetermined standards or outcome criteria

PURPOSE: to appraise the extent to which goals andoutcome criteria of nursing care have been achieved

Determine the client’s progress toward achievement ofgoals/outcomes

Determine the effectiveness of the nursing care plan


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EVALUATION

ACTIVITIES: Collect data about the client’s response

Compare the client’s response to goals and outcomecriteria

4 possible judgments that may be made as follows: The goal was completely met or partially met or completely

unmet or new problems or nursing diagnosis have developed

Analyze the reasons for the outcomes

Modify care plan as needed


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A 20 year old male patient was admitted to the ER at

3pm with a compliant of body weakness , abdominalpain and 8 episodes of watery stool since 5am…uponassessment the nures noted poor skin turgor, dry and warm skin, dry lips and mucus membranes. Sunken

eyeballs. Urine is concentrated and sccanty Vitalssigns are temp 37.8. rr 29, pr 120, bb 80/60…

5.nursingprocess

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