nursing process
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Nursing Process. 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 - PowerPoint PPT PresentationTRANSCRIPT
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Nursing Process
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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”
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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
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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
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5 Steps in the Nursing Process
AssessmentNursing
DiagnosisPlanningImplementingEvaluating
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Assessment
First step of the Nursing Process
Gather Information/Collect Data
Primary Source - Client / Family
Secondary 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
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Assessment
To elicit as many symptoms as possible, the nurse should use open-ended rather than yes/no questions.
Examples:
“Describe what you are feeling”
“How long have you been feeling this way?”
“When did the symptoms start?”
“Describe the symptoms”
This type of questions will encourage the client to give more information about his or her situation.
Listen carefully for cues and record relevant information.
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Assessment-collecting data Nursing Interview (history)
Health Assessment -Review of Systems
Physical Exam
Inspection
Palpation
Percussion
Auscultation
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Assessment-collecting data
Make sure information is complete & accurate
Validate prn
Interpret and analyze data Compare to “standard norms”
Organize and cluster data
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Example ofAssessment
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”
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Nursing 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
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Diagnosis Statement
A working of nursing diagnosis may have two or three parts.
The three-part system consists of the nursing diagnosis, the “related to” statement, and the defining characteristics.
PES system:P (problem) - The nursing diagnosis, the label; a
concise term or phrase that represent a pattern of related cues
E (etiology) – “Related to” phrase or etiology; related cause or contributor to the problem
S (symptoms) –Defining characteristics phrase; symptoms that the nurse identified in the assessment
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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
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Example of Nursing Dx
Ineffective therapeutic regimen management
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”.
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Types of Nursing Diagnoses
ActualImbalanced 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
WellnessFamily coping: potential for growth RT unexpected birth of twins.
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Case study:
A 73-year-old man has been admitted to the unit with a diagnosis of chronic obstructive pulmonary disease (COPD). He states that he has “difficulty breathing when walking short distances”. He also states that his “heart feels like it is racing” at the same time. He states that he is “tired all the time”, and while talking to you he is continually wringing his hands and looking out the window.
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Step II: Nursing DiagnosisPart 1 (Problem)
Interpretation of information:
“difficulty breathing when walking short distances”= dyspnea
“heart feels like it is racing”= dysrythmia
“tired all the time”= fatigue
In Section II we can find the nursing diagnosis Activity intolerance listed with these symptoms.
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Step II: Nursing Diagnosis
To validate that the diagnosis Activity intolerance is appropriate for the client, we have to read NANDA definition of the nursing diagnosis.
When reading, ask Does this definition describe the symptoms demonstrated by the client? If the appropriate nursing diagnosis has been selected, the definition should describe the condition that has been observed.
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Activity intolerance
NANDA Definition
Insufficient physiological or psychological energy to endure or complete required or desired daily activities.
Defining Characteristics
Verbal report of fatique or weakness; abnormal heart rate or blood pressure response to activity; exertional discomfort or dyspnea; electrocardiografic changes reflecting dysrhytmias or ischemia
Related factors (r/t)
Bed rest or immobility; generalized weakness,; sedentary lifestyle; imbalance between oxygen supply and demand
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Part 2 (Etiology)“Reated to” Phrase
This phrase states what may be causing or contributing to the nursing diagnosis, commonly referred to as the etiology.
Ideally the etiologe, or cause, of the nursing diagnosis is something that can be treated by a nurse. When this is the case, the diagnosis is identified as an independent nursing diagnosis. If medical Intervention is also necessary, it might be identified as a collabarative diagnosis.
For each suggested nursing diagnosis, the nurse should refer to the statements listed under the heading “Related Factors”
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Part 3 (Symptoms)Defining Characteristic phrase
It consist of the signs and symptoms that have been gathered during the assessment phase. Signs and symptoms are labeled as defining characteristics in Section III.
The use of identifying defining characteristics is similar to the process the physician uses when making a medical diagnosis
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Writing a Nursing Diagnosis Statement
P - Activity intolerance
E – “Related to” imbalance between oxygen supply and demand
S – Verbal reports of fatique, exertional dyspnea (“difficulty breathing when walking”), and dysrythmia (“racing heart ”)
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Collaborative Problems
Require both nursing interventions and medical interventions
EXAMPLE: Client admitted with medical dx of pneumonia
Collaborative problem = respiratory insufficiency
Nsg interventions: Raise HOB, Encourage C&DB
MD interventions: Antibiotics IV, O2 therapy
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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.
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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
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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.
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Planning- Types of goals
Short term goals
Long term goals
Cognitive goals
Psychomotor goals
Affective goals
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Goals are patient-centered and
SMART Specific
Measurable Attainable Relevant Time Bound
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Goals
PT. will walk 50 ft.
Pt. will eat 75% of meals
Pt. will be OOB 2-4 Hrs.
Pt. will maintain HR <100
To will state pain level is acceptable 6 (0-10)
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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.
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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
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Implemention
The fourth step in the Nursing Process
This is the “Doing” step
Carrying out 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
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Implementing- “Doing”
Monitor VS q4h
Maintain prescribed diet (2 Gm Na)
Teach client amount of 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
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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.
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Evaluation- To determine effectiveness of NCP
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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Evaluation
Outcome criteria met? Problem resolved!
Outcome criteria not fully met? Continue plan of care- ongoing.
Outcome criteria unobtainable- review each previous step of NCP and determine if modification of the NCP is needed.
Were the nsg interventions appropriate/effective?
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Evaluation
Factors that impede goal attainment:
Incomplete database
Unrealistic client outcomes
Nonspecific nsg interventions
Inadequate time for clients to achieve outcomes.
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Checkpoint
Identify which stage of the nursing process
is being described below:
The nurse writes nursing interventionsA goal is agreed uponThe nurse performs a physical assessmentA revision is made to the NCPThe nurse administers antibiotic
medicationA statement is written that outlines the
clients response to a potential health problem
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S and O Data Quiz
RR 22/min, even unlabored“I can only walk 3 blocks before my
legs start to hurt”Pain rated 3 on a scale of 0-10Skin pink, warm and dryUrine output 300mL/8 hr“My wife doesn’t come to visit very
often”Dressing clean, dry and intact.
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NCLEX Time
The nurse records the following subjective data in the client’s medical record:
A.Breath sounds clear to auscultation
B.Amber urine in sufficient quantities
C.Pain intensity 8 out of 10
D.Skin warm and dry
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NCLEX Time
When interviewing a client, the nurse uses the following open-ended style sentence:
A.Do you have any concerns right now?
B.Is your family worried about you being in the hospital?
C.How many times do you get up to go to the bathroom at night?
D.What do you mean when you say, “I don’t feel quite right?”
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NCLEX Time
In order for an actual nursing diagnosis to be valid it must have one or more supporting:
A.Laboratory results
B.Diagnostic data
C.Defining characteristics
D.Medical diagnoses
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NCLEX Time
Nursing diagnoses are aimed at identifying client problems that are treatable by _______.
A.The physician
B.The nurse
C.Invasive techniques
D.Complementary strategies