ppt chapter 02
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Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins
Chapter 2
Nursing Process
Chapter 2
Nursing Process
Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins
Definition of the Nursing Process Definition of the Nursing Process
• Organized sequence of problem-solving steps
• Used to identify and manage the health problems of clients
• Accepted standard for clinical practice: American Nurses Association (ANA)
• Framework for nursing care
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Characteristics of the Nursing ProcessCharacteristics of the Nursing Process
• Within the legal scope of nursing
• Based on knowledge
• Planned
• Client centered
• Goal directed
• Prioritized
• Dynamic
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• Assessment
– First step of nursing process
o Systematic collection of facts or data
Types of data
Objective data: observable and measurable facts, referred to as signs of disorder
Steps of the Nursing ProcessSteps of the Nursing Process
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Steps of the Nursing Process (cont’d)Steps of the Nursing Process (cont’d)
• Assessment (cont’d)
– Types of data (cont’d)
o Subjective data: information only client feels and can describe; called symptoms
– Sources of data: primary source–client; secondary sources–client’s family, reports, or discussion with other health care professionals
Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins
QuestionQuestion
•Is the following statement true or false?
Objective data, consisting of information that only the client feels and can describe, are called symptoms. An example is pain.
Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins
AnswerAnswer
False.
Objective data are observable and measurable facts and are referred to as signs of a disorder. Subjective data consists of information that only the client feels and can describe, and are called symptoms
Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins
Steps of the Nursing Process (cont’d)Steps of the Nursing Process (cont’d)
• Assessment (cont’d)
– Types of assessment
o Data base assessment
Initial information: client’s physical, emotional, social, and spiritual health
Obtained during admission interview and physical examination
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Steps of the Nursing Process (cont’d)Steps of the Nursing Process (cont’d)
• Assessment (cont’d)
– Types of assessment (cont’d)
o Focus assessment
Information: details about specific problems; expands original data base
Repeated frequently or on a scheduled basis
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Steps of the Nursing Process (cont’d)Steps of the Nursing Process (cont’d)
• Assessment (cont’d)
– Types of assessment (cont’d)
o Functional assessment
Comprehensive
• Performance of ADLs
• Cognitive abilities
• Social functioning
Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins
QuestionQuestion
•Which of the following is a primary source for information?
a. Client’s family
b. Client
c. Medical records
d. Test results
Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins
AnswerAnswer
b. Client
The primary source for information is the client. The client’s family, test results, and medical records are secondary sources of information.
Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins
Steps of the Nursing Process (cont’d)Steps of the Nursing Process (cont’d)
• Diagnosis
– Second step of the nursing process
o Identification of health-related problems
o Nursing diagnosis
Health issue that can be prevented, reduced, resolved, or enhanced through independent nursing measures
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Steps of the Nursing Process (cont’d)Steps of the Nursing Process (cont’d)
• Diagnosis (cont’d)
– Nursing diagnosis (cont’d)
– Categorized into 5 groups: actual; risk; possible; syndrome; wellness
o The NANDA list
Authoritative organization for developing and approving nursing diagnoses
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• Diagnosis (cont’d)
– Nursing diagnosis (cont’d)
o Diagnostic statement
Contains 3 parts:
Name of health-related issue or problem identified in the NANDA list
Steps of the Nursing Process (cont’d)Steps of the Nursing Process (cont’d)
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Steps of the Nursing Process (cont’d)Steps of the Nursing Process (cont’d)
• Diagnosis (cont’d)
– Nursing diagnosis (cont’d)
o Diagnostic statement (cont’d)
Etiology (its cause): phrase “related to”
Signs and symptoms: phrase “as manifested (or evidenced) by”
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Steps of the Nursing Process (cont’d)Steps of the Nursing Process (cont’d)
• Diagnosis (cont’d)
– Nursing diagnosis (cont’d)
o Diagnostic statement (cont’d)
Potential diagnoses: “risk for”
Uncertainty: “possible”
Wellness diagnoses: “potential for enhanced”
Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins
• Diagnosis (cont’d)
– Nursing diagnosis (cont’d)
o Diagnostic statement (cont’d)
Potential nursing diagnoses: signs or symptoms not manifested
Possible nursing diagnoses: data incomplete
Steps of the Nursing Process (cont’d)Steps of the Nursing Process (cont’d)
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• Diagnosis (cont’d)
– Nursing diagnosis (cont’d)
o Diagnostic statement (cont’d)
Syndrome diagnoses and wellness diagnoses are one-part statements; they are not linked with an etiology or signs and symptoms
Steps of the Nursing Process (cont’d)Steps of the Nursing Process (cont’d)
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• Diagnosis (cont’d)
– Nursing diagnosis (cont’d)
o Collaborative problem
Physiologic complications require both nurse- and physician-prescribed interventions
Written using the abbreviation potential complication (PC)
Steps of the Nursing Process (cont’d)Steps of the Nursing Process (cont’d)
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• Planning
– Third step of the nursing process
o Setting priorities
Determine which problems require most immediate attention
o Establishing goals
Goal: expected or desired outcome
Steps of the Nursing Process (cont’d)Steps of the Nursing Process (cont’d)
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• Planning (cont’d)
– Establishing goals (cont’d)
o Short-term goals:
Outcomes achievable in a few days to 1 week
Characteristics: developed from; client-centered
Steps of the Nursing Process (cont’d)Steps of the Nursing Process (cont’d)
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• Planning (cont’d)
– Establishing goals (cont’d)
o Short-term goals (cont’d)
Characteristics (cont’d)
Measurable
Realistic
Target date for accomplishment
Steps of the Nursing Process (cont’d)Steps of the Nursing Process (cont’d)
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• Planning (cont’d)
– Establishing goals (cont’d)
o Short-term goals (cont’d)
Characteristics (cont’d)
Predicted time
Time line for evaluation
Steps of the Nursing Process (cont’d)Steps of the Nursing Process (cont’d)
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• Planning (cont’d)
– Establishing goals (cont’d)
o Long-term goals
Desirable outcomes take weeks or months to accomplish
o Goals for collaborative problems
Written for the nurse
Steps of the Nursing Process (cont’d)Steps of the Nursing Process (cont’d)
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• Planning (cont’d)
– Establishing goals (cont’d)
o Goals for collaborative problems (cont’d)
Focus: what the nurse will monitor, report, record, or do to promote early detection and treatment
Steps of the Nursing Process (cont’d)Steps of the Nursing Process (cont’d)
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• Planning (cont’d)
– Selecting nursing intervention
o Planning measures: to accomplish identified goals involves critical thinking
o Planned interventions: must be safe; within legal scope of nursing practice; and compatible with medical orders
Steps of the Nursing Process (cont’d)Steps of the Nursing Process (cont’d)
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• Planning (cont’d)
– Documenting plan of care
o Plan of care: written by hand; standardized form; computer generated; based on an agency’s written standards or clinical pathways
o Nursing order: performing nursing interventions; providing specific instructions
Steps of the Nursing Process (cont’d)Steps of the Nursing Process (cont’d)
Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins
• Planning (cont’d)
– Documenting plan of care (cont’d)
o Standardized care plan: preprinted; computer generated
o Agency-specific standards for care and clinical pathways: indicate activities provided to ensure quality, consistent care
Steps of the Nursing Process (cont’d)Steps of the Nursing Process (cont’d)
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• Planning (cont’d)
– Communicating the plan of care
o Nurses share plan with nursing team members, client, and the client’s family
o Permanent part of client’s medical record placed in client’s chart; nurses refer to it, review it, and revise it
Steps of the Nursing Process (cont’d)Steps of the Nursing Process (cont’d)
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• Implementation
– Fourth step in the nursing process: carrying out the plan of care
– Implementation of:
o Medical records: legal evidence
o Record: quantity and quality of client response
Steps of the Nursing Process (cont’d)Steps of the Nursing Process (cont’d)
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• Evaluation
– Fifth and final step of the nursing process: nurses determine whether client has reached the goal
– Analyze client’s response
Steps of the Nursing Process (cont’d)Steps of the Nursing Process (cont’d)
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QuestionQuestion
•Is the following statement true or false?
Evaluation is the fifth and final step in the nursing process.
Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins
AnswerAnswer
True.
Evaluation, the fifth and final step in the nursing process, is the way by which nurses determine whether a client has reached a goal. The other steps in the nursing process are assessment, diagnosis, planning, and implementation.
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Use of the Nursing ProcessUse of the Nursing Process
• Standard for clinical nursing practice
• Nurse practice act
– Holds nurses accountable for demonstrating all the steps in the nursing process
– To do less implies negligence
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Concept MappingConcept Mapping
• Method of organizing information in graphic or pictorial form
• Formats used: spider diagram, hierarchy, linear flow chart
• Uses:
– Enables students to integrate previous knowledge with newly acquired information
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Concept Mapping (cont’d)Concept Mapping (cont’d)
• Uses (cont’d):
– Increases critical thinking and clinical reasoning skills
– Enhances retention of knowledge
– Correlates theoretical knowledge with nursing practice
– Helps students recognize information
– Promotes better time management
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