nursing process nur101 fall 2010 lecture #6 and #7 k. burger, msed, msn, rn, cne ppp by: sharon...
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Nursing Process
NUR101Fall 2010Lecture #6 and #7K. Burger, MSEd, MSN, RN, CNE
PPP By: Sharon Niggemeier MSN, RN
Revised KBurger 8/06, 9/08,8/10
Nursing Process Specific to the nursing profession A framework for critical thinking It’s purpose is to:
“Diagnose and treat human responses to actual or potential health problems”
Nursing Process Organized framework to guide practice Problem solving method - client focused Systematic- sequential steps Goal oriented- outcome criteria Dynamic-always changing, flexible Utilizes critical thinking processes
What are some critical thinking characteristics necessary for application of Nursing Process? Knowledge – science & skills Standards – use of EBP standards of
practice Experience – previous client experiences Attitudes – open-mindedness, creativity,
integrity, confidence,
Scientific Method of problem solving
ID problem Collect data Form hypothesis Plan of action Hypothesis testing Interpret results Evaluate findings
Advantages of Nursing Process Provides
individualized care Client is an active
participant Promotes continuity of
care Provides more
effective communication among nurses and healthcare professionals
Develops a clear and efficient plan of care
Provides personal satisfaction as you see client achieve goals
Professional growth as you evaluate effectiveness of your interventions
Assessment First step of the Nursing Process Gather Information/Collect Data
Primary Source - Client / FamilySecondary Source - physical exam, nursing
history, team members, lab reports, diagnostic tests…..
Subjective -from the client (symptom) “I have a headache”
Objective - observable data (sign) Blood Pressure 130/80
Assessment-collecting data
Nursing Interview (history) History includes: physical, emotional, social,
spiritual, intellectual dimensions. Considerations for the older adult & cultural
diverse client. Review this section in P & P Health Assessment:
Review of Systems Inspection Palpation Percussion Auscultation
Assessment-collecting data
Make sure information is complete & accurate
Validate prn Interpret and analyze data
Compare to “standard norms” Organize and cluster data
Example of Focused Assessment
Obtain info from nursing assessment, history and physical (H&P) etc…...
Client diagnosed with hypertension B/P 160/90 2 Gm Na diet and antihypertensive
medications were prescribed Client statement “ I really don’t watch
my salt” “ It’s hard to do and I just don’t get it”
Diagnosis Second step of the Nursing Process
Interpret & analyze clustered data
Identify client’s problems and strengths
Formulate Nursing Diagnosis (NANDA : North American Nursing Diagnosis Association)-Statement of how the client is RESPONDING to an actual or potential problem that requires nursing intervention
Nsg Dx vs MD Dx
Within the scope of nursing practice
Identify responses to health and illness
Can change from day to day
Within the scope of medical practice
Focuses on curing pathology
Stays the same as long as the disease is present
Formulating a Nursing Diagnosis Composed of 3 parts: Problem statement [Diagnostic Label]
the client’s response to a problem Etiology [Related Factors]
what’s causing/contributing to the client’s problem
Signs/Symptoms [Defining Characteristics] what’s the evidence of the problem
Nursing Diagnosis
Problem ( Diagnostic Label)-based on your assessment of client…(gathered information), pick a problem from the NANDA list...
Etiology (Related Factors)- determine what the problem is caused by or related to (R/T)...
Signs/Symptoms (Defining Characteristics)- state as evidenced by (AEB) the specific facts the problem is based on...
Example of Nursing Dx
Ineffective health maintenance
R/T difficulty maintaining lifestyle changes and lack of knowledge
AEB B/P= 160/90, dietary sodium restrictions not being observed, and client statements of “ I don’t watch my salt” “It’s hard to do and I just don’t get it”.
Types of Nursing Diagnoses Actual
Imbalanced nutrition; less than body requirements RT chronic diarrhea, nausea, and pain AEB height 5’5” weight 105 lbs.
RiskRisk for falls RT altered gait and generalized weakness
WellnessReadiness for enhanced Family coping:
Health PromotionReadiness for enhanced immunization status
Planning
Third step of the Nursing Process This is when the nurse organizes a nursing
care plan based on the nursing diagnoses. Nurse and client formulate goals to help the
client with their problems Expected outcomes are identified Interventions (nursing orders) are selected
to aid the client reach these goals.
Planning – Begin by prioritizing client problems Prioritize list of
client’s nursing diagnoses using Maslow
Rank as high, intermediate or low
Client specific Priorities can change
Planning- Types of goals
Short term goals Long term goals
Cognitive goals Psychomotor
goals Affective goals
PlanningDeveloping a goal and outcome statement
Goal and outcome statements are client focused.
Worded positively Measurable, specific
observable, time-limited, and realistic
Goal = broad statement Expected outcome = objective
criterion for measurement of goal
Utilize NOC as standard
EXAMPLE
Goal:Client will achieve therapeutic management of disease process….
Outcome Statement:AEB B/P readings of 110-120 / 70-80 and client statement of understanding importance of dietary sodium restrictions by day of discharge.
Think about this….
We have talked about the difference between cognitive, psychomotor and affective goals.
What type of goal is the statement on the previous slide?
Can you think of some goal statements in the other domains?
Planning-select interventions Interventions are selected and written. The nurse uses clinical judgment and
professional knowledge to select appropriate interventions that will aid the client in reaching their goal.
Interventions should be examined for feasibility and acceptability to the client
Interventions should be written clearly and specifically.
Interventions – 3 types Independent ( Nurse initiated )- any
action the nurse can initiate without direct supervision
Dependent ( Physician initiated )-nursing actions requiring MD orders
Collaborative- nursing actions performed jointly with other health care team members
Implemention The fourth step in the Nursing Process This is the “Doing” step Carrying out or delegating nursing
interventions (orders) selected during the planning step
This includes monitoring, teaching, further assessing, reviewing NCP, incorporating physicians orders and monitoring cost effectiveness of interventions
Utilize NIC as standard
DelegationFive Rights
Right task Right circumstance Right person Right communication Right supervision
NCSBN (1995)
Implementing- “Doing” Maintain prescribed diet (2
Gm Na) Administer antihypertensive
medications per MD order Obtain registered dietician
consult to teach client about sodium restriction, foods high in sodium, use of nutrition labels, food preparation and sodium substitutes
Teach potential complications of hypertension to instill importance of maintaining Na restrictions
Assess for cultural factors affecting dietary regime
Monitor VS q4h
Implementing – “Doing”
Teach the client- hypertension can’t be cured but it can be controlled.
Remind the client to continue medication even though no S/S are present.
Teach client importance of life style changes: (weight reduction, smoking cessation, increasing activity)
Stress the importance of ongoing follow-up care even though the patient feels well.
Think about this….
We have learned about the 3 different types of nursing interventions:Independent – Dependent – Collaborative
Label each of the interventions on the previous slides as either I – D – or C
Evaluation Final step of the Nursing Process but
also done concurrently throughout client care A comparison of client behavior and/or
response to the established outcome criteria Continuous review of the nursing care plan Examines if nursing interventions are working Determines changes needed to help client
reach stated goals.
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