copyright © 2010 wolters kluwer health | lippincott williams & wilkins ms 1 program group 3-30...

Copyright © 2010 Wolters Kluwer Health | Lippincott Williams & Wilkins

MS 1 Program Group 3-30

MS 1 Program Group 3-30

Chapter 03:

The Nursing Process


Steps of the Nursing ProcessSteps of the Nursing Process

• Introduction

– Provision of healthcare: Process of problem-solving

– Purpose of nursing process: Provides a systematic method to plan and implement client care to achieve desired outcomes

– Includes: Collecting information; identifying problems; developing an outcome-based plan; carrying out plan; evaluating results

– Framework for nursing care


QuestionQuestion

Is the following statement true or false?

The purpose of nursing process is intentional, contemplative, and outcome-directed thinking.


AnswerAnswer

False

The purpose of nursing process is to provide a systematic method for nurses to plan and implement client care to achieve desired outcomes.

Critical thinking is intentional, contemplative, and outcome-directed thinking.



• Introduction

– Begins: Client enters healthcare system

– Five steps

• Assessment

• Diagnosis (nursing)

• Planning

• Implementation

• Evaluation


Steps of the Nursing ProcessSteps of the Nursing Process• Introduction

Figure 3-1Five steps of the nursing Process, pg 18



• Assessment

– Client’s health status: Careful observation; evaluation

– Collect information: Determine abnormal function, risk factors, client strengths

– Recurring nursing activity

– Client database: Medical and nursing history; physical examination; diagnostic studies

– Baseline data: Comparison for future signs and symptoms


QuestionQuestion


Nursing diagnoses are different from medical diagnoses.


AnswerAnswer

True

In nursing diagnoses, the nurse reports or analyzes data to identify health problems that independent or physician-prescribed nursing actions can prevent or solve. Medical diagnoses identify medical conditions. It violates licensure for nurses to assign medical diagnoses.



• Assessment (cont’d)

– Reference for determining improvement in client’s health

– Initial and ongoing assessment: Provision of nursing care

• Nursing Diagnosis

– Report or analyze data: Identify and define problems

– LPNs report information: Actual or potential health problems


Steps of the Nursing ProcessSteps of the Nursing Process• Nursing Diagnosis

– RNs examine and analyze client database: Formulate nursing diagnoses

– Identify and define health problems nursing actions can prevent or solve

– NANDA-approved nursing diagnoses (pg 19)

– Nursing diagnostic statement

• Problem: Name; cause; signs and symptoms or data indicate the problem

• Phrases used: Cause “related to” or “secondary to” (figure 3-2)




– Data link: “As manifested by” or “as evidenced by”

– Actual diagnoses: Identify existing problems

– Risk diagnoses: Identify potential problems; stem “risk for”

– Possible diagnoses: Stem “possible”

– Collaborative problems: Denote complications with physiologic origin; manage problems using physician-prescribed and nursing-prescribed interventions (potential complication – PC)




– Wellness diagnoses: Stem “potential for enhanced”

– Syndrome diagnoses: Identify diagnosis associated with a cluster of other diagnoses

– Five syndrome diagnoses: NANDA

• Planning

– Setting priorities; defining expected (desired) outcomes; determining specific nursing interventions; recording plan of care



• Planning (cont’d)

– Respect client’s right to participate in healthcare; involve client and family

– Establishing priorities

• Prioritize client’s multiple problems

• Framework used for prioritizing: Maslow’s hierarchy of human needs

• First-level needs: Baseline survival needs; highest priority

• Problem that poses threat to physiologic functioning: Rank first


Steps of the Nursing ProcessSteps of the Nursing Process• Planning

– Establishing priorities (cont’d)

• Nursing diagnoses that affect

• First level, physiologic needs: Ineffective breathing pattern, deficient fluid volume

• Second level, safety and security: Anxiety, risk for injury

• Third level, love and belonging: Parental role conflict, social isolation

• Fourth level, esteem and self-esteem: Powerlessness, ineffective coping



• Planning

– Establishing priorities

• Nursing diagnoses that affect (cont’d)

• Fifth level, self-actualization: Delayed growth and development, spiritual distress

– Defining expected outcomes

• Client and family: Include in establishing outcomes

• Outcomes: Specific, realistic, measurable



– Determining specific interventions

• Plan of care: Identifies interventions or actions for achieving outcomes

• Relieving cause of problem: Directs interventions

• Identify specific interventions to decrease effects of the problem

(Examples of expected outcomes – Table 3-3, pg 21)



– Recording the plan of care

• RN: Assigns interventions in written plan as nursing orders

• Nursing orders: Specific nursing directions; clear; appropriate; compatible with medical orders

• Preprinted or computer-generated care plans: Saves time

• Complete plan of care: Communication; basis for continuity of care

• REVIEW: Nursing Care plan, 3-1, pg 23



• Implementation

– Carrying out written plan of care

– Performing interventions; monitoring client’s status; assessing and reassessing client before, during, and after treatments

– Involvement of client, family, community, and members of healthcare team

– Documentation; discuss importance of accurate and thorough documentation in medical record

– (Important element)


Steps of the Nursing ProcessSteps of the Nursing Process• Implementation (cont’d)

– Functions: Communication; client status; legal document; validation for reimbursement; evaluation

– Document permanent record: All nursing actions, observations, client responses

– Record of nursing action: Mirror image of the written plan

– Appropriate documentation: Maintains communication; ensures that client’s progress is monitored


Steps of the Nursing ProcessSteps of the Nursing Process• Evaluation

– Assessment; review: Quality, suitability of care given, client’s responses

– Actual outcomes compared with expected outcomes

– Conclusions during evaluation: Outcome achieved, not met, or not achieved

– Reasons for client’s lack of progress: Unrealistic expectations, incorrect diagnosis, additional problems, ineffective nursing measures, premature target date


QuestionQuestion


Three possible conclusions can be drawn during the evaluation phase of the nursing process.


AnswerAnswer

True

Three possible conclusions can be drawn during the evaluation phase of the nursing process: Outcome achieved, outcome not met, or outcome not achieved.


The Nursing Process and Critical ThinkingThe Nursing Process and Critical Thinking

• Critical Thinking

– Intentional, contemplative, and outcome-directed thinking

– Critical thinking is used in the nursing process

– Nurse’s role when caring for clients: Continuous assessment of clients’ needs; dealing with situations that involve multiple interventions

– Good critical thinking skills: Make nurses more efficient and effective


The Nursing Process & Critical ThinkingThe Nursing Process & Critical Thinking

• Critical thinking (cont’d)

– Use of the nursing process: Combines critical thinking with problem-solving methods

– Nursing process: Helps nurses acquire critical thinking and problem-solving skills; dynamic, continuous process

– Identify specific cognitive and mental activities to use when thinking critically

– Requirement for developing critical thinking skills: Knowledge, practice, experience.


NCLEX Questions

&Question Time!!

copyright © 2010 wolters kluwer health | lippincott williams & wilkins ms 1 program group 3-30...

Documents