nursing process lecture notes

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NURSING PROCESS - systematic, rational method of planning and providing nursing care. -refers to a series of phases describing the practice of nursing. PURPOSES: 1. To identify client’s health status and actual or potential health care problems or needs. 2. To establish plans to meet the identified needs, and to 3. Deliver specific nursing intervention to meet those needs. 5 PHASES/ STEPS OF NURSING PROCESS (ADPIE) 1. A-SSESSMENT 2. D-IAGNOSIS/ ANALYSIS 3. P-LANNING 4. I- MPLEMENTATION/ INTERVENTION/ INTERVENING 5. E-VALUATION CHARACTERISTICS OF NURSING PROCESS A) KOZIER (C2 UFI U) *C-yclic and Dynamic- each phase provide input into the next phase >CYCLIC- regularly repeated events >DYNAMIC- continuously changing *C-lient centered- organize plan of care according to client’s problem *U-niversally Applicable- used as framework for nursing care *F-ocus on problem solving *I- nterpersonal collaborative- communicate in client, families, etc. *U-se of critical thinking- very important in nursing process B) UDAN (GOSH EE)

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Page 1: Nursing Process Lecture Notes

NURSING PROCESS- systematic, rational method of planning and providing nursing care.-refers to a series of phases describing the practice of nursing.

PURPOSES:1. To identify client’s health status and actual or potential health care problems or needs.2. To establish plans to meet the identified needs, and to3. Deliver specific nursing intervention to meet those needs.

5 PHASES/ STEPS OF NURSING PROCESS (ADPIE)1. A-SSESSMENT2. D-IAGNOSIS/ ANALYSIS3. P-LANNING4. I- MPLEMENTATION/ INTERVENTION/ INTERVENING5. E-VALUATION

CHARACTERISTICS OF NURSING PROCESSA) KOZIER (C2 UFI U)*C-yclic and Dynamic- each phase provide input into the next phase>CYCLIC- regularly repeated events>DYNAMIC- continuously changing*C-lient centered- organize plan of care according to client’s problem*U-niversally Applicable- used as framework for nursing care*F-ocus on problem solving*I- nterpersonal collaborative- communicate in client, families, etc.*U-se of critical thinking- very important in nursing process

B) UDAN (GOSH EE)*G-oal oriented*O-rganized*S-ystematic composed of sequential and interrelate steps*H-umanistic- individualized plan of care EFFICIENT AND EFFECTIVE NURSING CARE

1. ASSESSMENT (COVD)-collection, organization, validation and documentation of data.-is a continuous process carried out during all phases of the nursing process.

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* 4 TYPES OF ASSESSMENT (IPET)

TYPE TIME PURPOSE EXAMPLEI-NITAL ASSESSMENT-after admission -complete database -nursing admission

assessment

P-ROBLEM FOCUSED-ongoing process -determine specific -hourly I&O in pt problem status in ICU

E-MERGENCY –during physiologic/ -identify life -assess ABC psychologic crisis threatening problems -suicidal tendencies

T-IME LAPSED-several months after -compare current -reassessment initial assessment status to baseline data

a) C-ollection of Data-gathering info. about a client’s health status*DATABASE- all information about a clientincludes: -nursing health history (Biographical Data, Present Health/ Illness, Past History, Family History, Psychosocial History, Review of Body Systems) -physical assessment -primary care providers history and physical examination -results of laboratory and diagnostic tests -material contributed by other health personnel

*TYPES OF DATA (SOCV)1. S-UBJECTIVE DATA- also called as Symptoms/ Covert Data-verified only by the patientex. pain, itching, feelings of worry, sensation, feelings, values, beliefs, attitudes2. O-BJECTIVE DATA- also called as Signs/ Overt Data-measurable and observableex. discoloration of the skin, BP 120/80, Temperature 41 degree Celsius3. C-ONSTANT DATA- does not change over timeex. blood type, race4. V-ARIABLE DATA- can change quicklyex. vital signs, age, level of pain

*SOURCES OF DATA1. Primary Source- client best source of data2. Secondary support people, client records, healthcare professionals, literature

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*Support People- useful if pt is too young, too ill, confused*Client Records-medical records, therapy and laboratory records*Healthcare professionals- nurses, social workers, primary health providers <sharing information among professionals ensure continuity of care*Literature- review of nursing/ related literature, journals

*DATA COLLECTION METHODS (OIE)1. O-bservation –gather data by using sensesVision- overall appearance, facial/ body gestures, skin color/lesionsSmell- body/ breathe odorsHearing- lung sounds, heart sounds, bowel sounds, ability to communicateTouch- skin temperature, skin moisture, muscle strength, pulse rate, palpatory lesions

2. Interviewing -planned communication -conversation with a purpose get information, identify problem, teach, provide support and therapy and counseling

*2 TYPES OF INTERVIEW1. Directive- nurse controls, get specific information - used when time is limited (emergency situation)2. Non Directive- rapport building interview - client control the interview*RAPPORT- understanding between two or more people

*TYPES OF INTERVIEW QUESTION (CONL)1. Closed Questions- require only yes or no -give short, factual answers giving specific information >W questions Who? What? When? Where?2. Open Ended Question- invite client to discover, explore, elaborate feelings and thoughts>What? How?3. Neutral Question-client can answer without direction and pressure; open-ended and non directive>How? Why?4. Leading Question-client has less opportunity to decide weather the answer is true or not; closed ended/directive>Aren’t you? Won’t you?

*PLANNING THE INTERVIEW AND SETTING (TP SA DL)

CONSIDER: TIME, PLACE, SEATING ARRANGEMENT, DISTANCE, LANGUAGE

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1. TIME- when client is physically comfortable and free from pain-minimal interruptions

2. PLACE- well lighted, well ventilated-free of distractions-place where others cannot overhear or see client

3. SEATING ARRANGEMENT- *client in bed- 45 degree angle to bed *initial admission- overbed table between

*standing and looking down at a client can be intimidating

4. DISTANCE- neither too small or too far-pts feel uncomfortable when talking to someone who is too close or too far away-2 to 3 feet during interview-also varies in ethnicity8-12 inches- Arab 24 inches- Britain18 inches- US 36 inches- Japan

5. LANGUAGE-convert medical terminology into common English usage-interpreters/ translators if nurse don’t speak the same language or dialect

*STAGES OF AN INTERVIEW (OB C)

1. Opening-most important part-establish RAPPORT that will create trust and goodwill (greeting, self-introduction)-orient the interviewee (purpose, what info. needed, how long it will take, how info. will be used)

2. Body- client communicates what he/she thinks, feels, knows, perceives-nurse use communication techniques that make both parties feel comfortable

3. Closing-terminates interview when needed information has been obtained-important for maintaining trust/ rapport and for facilitating future interactions

TECHNIQUES TO CLOSE THE INTERVIEW1. Offer to answer questions (do you have any questions?)2. Conclude ( Well, that’s all I need to know for now)3. Thank the client (Thank you for your time and help)4. Express concern (Take care of yourself)5. Plan for next meeting (I’ll be here to see you on Monday)6. Summary/ Summarize (Lets review what we have just covered in this interview…)

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3. Examining-systematic data collection method that uses observation to detect health problems-major method used in physical health assessment

TECHNIQUES: (IPPA)

I-nspection assessing by the use of sense of sightP-alpation examining by sense of touch using fatpads of the fingerP-ercussiontapping body part to produce soundsA-uscultationlistening to body sounds with the use of stethoscope

3 WAYS OF EXAMINING

1. Cephalocaudal- “head to toe approach”head-neck-thorax-abdomen-extremities-toes2. Body System- respiratory system, circulatory system, nervous system, etc.3. Screening examination- “review of systems”-brief review of essential functioning (nursing admission assessment form)

b) O-rganizing data-nurses use an organized assessment framework.

*11 Typology of Functional Health Pattern (Gordon)1.Health perception/ Health Management-describes the clients perceived pattern of health and well-being and how health is managed.2.Nutritional/ Metabolic Pattern-describes client’s pattern of food and fluid consumption.3.Elimination Pattern-describes pattern of excretory function (bowel, bladder and skin).4.Activity-Exercise Pattern-describes pattern of exercise, activity, leisure and recreation.5.Sleep-Rest Pattern-describes pattern of sleep, rest and relaxation6.Cognitive-Perceptual Pattern-describes sensory-perceptual and cognitive patterns.7.Self Perception/ Self Concept Pattern-describes client’s self concept and perception of self pattern (self-worth, comfort, body image, feeling state).8.Role-relationship Pattern-describes pattern of participation and relationship.9.Sexuality-reproductive Pattern-describes client’s pattern of satisfaction and dissatisfaction with sexuality patterns; describes reproductive patterns.10.Coping/ Stress- tolerance Pattern-describes client’s general coping pattern and effectiveness of pattern in terms of stress tolerance.

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11.Values-beliefs Pattern-describes patterns of values, beliefs and goal that guide the client’s choices or decisions.

*Abraham Maslow’s Hierarchy of Needs

Self-actualization

Self esteem

Love and belongingness

Safety and Security

Physiologic Needs- FONBERS (fluid, oxygen, nutrition, body temperature, elimination, rest & sleep)

c) V-alidating Data- double checking or verifying data to ensure that it is accurate and factual(C2 D2 R)C-ompare- subjective vs. objectiveC-larify- ambiguous/ vague statementD-ouble check- extremely abnormal dataD-etermine factors that may interfere accurate measurementR-eferences- explain phenomena*differentiate CUES from INFERENCES!CUES- are subjective or objective data that can be directly observed by the nurseINFERENCES-are the nurse’s interpretation or conclusion based on the cues

d) D-ocumenting Data-data are recorded in a factual manner and not interpreted by the nurse.-for example, the nurse must record the client’s intake as “coffee 240 ml, juice 120 ml, 1 egg and 1 slice of toast” rather than as “appetite good” or “normal appetite” a judgment.F-actualA-ctualT-imely

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2. DIAGNOSIS/ DIAGNOSING- statement or conclusion regarding the nature of phenomena.- provides basis for the selection of nursing intervention.

NANDA (North American Nursing Diagnosis Association)-define, refine and promote a taxonomy of nursing diagnostic terminology of general use to

professional nurses. A taxonomy is a classification system or set of categories arranged based on a single principle or set of principles.

*DIAGNOSTIC LABELS-standardized NANDA names for diagnoses*DIAGNOSING-reasoning process*NURSING DIAGNOSIS- diagnostic label + etiology

***TYPES OF NURSING DIAGNOSIS (WARPS)

TYPE DESCRIPTION EXAMPLEW-ellness Dx -describes human responses to

level of wellness in an individual, family or community that have a readiness for enhancement

-Readiness for Enhanced Spriritual Well-being-Enhanced Family Coping

A-ctual Dx -problem is present (+) signs/ symptoms

-Ineffective Breathing Pattern-Anxiety

R-isk Dx -problem does not exist, but the present of risk factors indicates a problem is likely to develop unless nurses intervene

-Risk for infection

P-ossible Dx -health problem is incomplete or unclear

-Possible Social Isolation r/t unknown etiology

S-yndrome Dx -associated with a cluster of other diagnosis

-Impaired Physical Mobility-Risk for Disuse Syndrome-Risk for Impaired Tissue Integrity

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***COMPONENTS OF NURSING DIAGNOSIS (PED)

P-roblem (diagnostic label)- describes client’s health problem or response for nursing theraphy given. PURPOSE: to direct the formation of client’s goals and desired outcomes.Qualifiers- word that have been added to NANDA labels to give additional meaning. (DIDIC)

D-eficient (inadequate in amount, quality or degree; not sufficient; incomplete)I- mpaired (made worse, weakened, damaged, reduced, deteriorated)D- ecreased ( lesser in size, amount, degree)I- neffective ( not producing the desired effect)C- ompromised ( to make vulnerable to threat)

E-tiology (related factors/ risk factors)-identifies one or more probable causes of health problem, gives direction to the required nursing theraphy and enables the nurse to individualized nursing care.

D-efining Characteristics-cluster of signs and symptoms that indicate the presence of a particular diagnostic label

***DIAGNOSTIC PROCESS-uses critical thinking skills of analysis and synthesis*Critical Thinking- cognitive process during which a person reviews data and considers explanation before forming an opinion.*Analysis- separation into components; breaking down of the whole into its parts ( deductive reasoning)*Synthesis- putting together parts into whole (inductive reasoning)

3 STEPS OF DIAGNOSTIC PROCESS ( AIF)1. A-nalyze Data2. I-dentifying health problems, risk, strengths3. F-ormulating Diagnostic Statements

1. A-nalyzing DataA) Compare data against standardsB) Cluster CuesC) Identify gaps and inconsistencies

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A) Compare data against standard and norms

TYPE OF CUE CLIENT CUES STANDARD/NORMDeviation from population norms

F- 5’2 in height, 240 lbs F- 5’2 in height -108-121 lbs (ideal weight)

Dysfunctional behavior Teen (16 y/o) not left the room for 2 days as verbalized by the mother

Adolescents usually liked to be with their peers

Developmental Delay Child 17 months old, still cannot speak as verbalized by the parent

Children usually speak their first word by 10-12 months

Changes in usual health status

States “I’m not hungry these days”

Client usually eats three balanced meals per day

Changes in usual behavior Reports that his husband angers easily

Husband usually relaxed and easygoing

B) Cluster Cues- combining data from different assessment areas to form a pattern and organizing subjective and objective data into appropriate categories- nurse interprets meaning of cues, label the cue clusters with tentative diagnostic hypothesis

C) Identifying Gaps and Inconsistencies in Data- Final check to ensure that data are complete and correct.Possible sources: measurement error, expectations, and inconsistent or unreliable reports.E.g. Nursing history- not seen doctor in 15 years, stated my doctor takes my BP every year

2. I-dentifying Health Problems, Risk and Strengths*Determining Health Problem and Risk- after grouping and clustering data, nurse- client together identify problemEx. 1. Decreased urinary frequency and amount for two days possible urinary problem 2. Deficient Fluid Volume (urinary problem- eliminated)*Determining Strengths-when problem is already identified, taking inventory of strengths promotes self-concept and self-image.-this strengths aid in mobilizing health and regenerative processEx. normal weight/ height, absence of allergies, being a non-smoker

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3. F-ormulating Diagnostic Statementsa) One- part statement (Problem) -consist of NANDA label only-Wellness diagnosis, Syndrome diagnosise.g. Rape-Trauma Syndrome, Readiness for Enhanced Spiritual Well Being

b) Two- part statement (Problem + Etiology) -are joined by the words Related toe.g. Constipation related to prolonged laxative use, Severe anxiety related to threat to physiologic integrity; possible cancer

c) Three- part statement (Problem + Etiology + Signs/ Symptoms) -are joined by the word related to; and manifested by for the signs/ symptomse.g. Non Compliance ( Diabetic Diet) related to unresolved anger about diagnosis as manifested by:S- “ I forget to take my pills” “ I can’t live without sugar in my food”O- Weight 98 kg (215 lbs) BP- 190/ 100

VARIATIONS OF BASIC FORMAT1. Unknown Etiology- does not know the causee.g. Noncompliance (Medication Regimen) related to unknown etiology

2. Complex Factors- too many etiologic factorse.g. Chronic Low Self- Esteem related to complex factors

3. Possible- nurse believes more data are needed about clients problem/ needse.g. Possible Low Self-Esteem related to loss of job and rejection by family

4. Secondary to-divide etiology in 2 parts; more descriptive, useful; often pathophysiologic or disease process or medical diagnosise.g. Risk for Impaired skin integrity related to decreased peripheral circulation secondary to diabetes

3. PLANNING- A deliberative, systematic phase of nursing process that involves decision making and problem solving.

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NURSE refers client’s assessment data and diagnostic statementsformulating client’s goals designing interventions prevent, reduce or eliminate the client’s health problem

-product NCP “blueprint of nursing process

***TYPES OF PLANNING (IOD)I- NITIAL PLANNING - admission assessment-initial comprehensive plan of careO -NGOING PLANNING - done by all nurses who work with the client, occurs at the beginning of the shift as the nurse plans the care to be given that day.PURPOSES:1. To determine whether the client’s health status has changed2. To set priorities for the client’s care during the shift3. To decide which problems to focus on during the shift4. To coordinate the nurse’s activities so that more than one problem can be addressed at each client contact

D -ISCHARGE PLANNING - the process of anticipating and planning for the needs after discharge

THE PLANNING PROCESS (SESI)1. S-etting Priorities2. E-stablishing Client’s Goal3. S-electing Nursing Intervention4. I-ndividualized Nursing Care Plan Writing

1. S-etting priorities-a process of establishing a preferential sequence for addressing nursing diagnosis and intervention.*High Priority- life- threatening*Medium Priority- delayed development or causes physical and emotional changes*Low Priority-arises from normal developmental needs or that requires minimal nursing supportEx. Loss of cardiac function, Loss of respiratory function Acute illness, Decreased coping ability

Often use HIERARCHY OF NEEDS of Abraham Maslow

FACTORS TO CONSIDER:

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1. Client’s Values and Beliefs- values concerning health may be more important to the nurse than to the client.2. Client’s Priorities- involving client in prioritizing and care planning enhances cooperation.3. Resources Available4. Urgency of Health problem

2. E-stablishing Client’s GoalGOAL (broad) Improve nutritional statusDESIRED OUTCOME (specific) Gain 5 lbs by Dec. 15, 2009

GOAL (broad) Improve knowledge regarding disease (Hypertension)

DESIRED OUTCOME (specific) Be able to discuss the factors that affect the disease (Hypertension)

2 TYPES OF GOALS1. SHORT TERM GOAL- can achieve in a short period of time (days/ less than a week)(useful: pts that require healthcare for short time,pts frustrated with long termgoals)

2. LONG TERM GOAL- can achieve for weeks or months(useful: who lives at home, with chronic problems, pts in nursing extended care facilities, rehabilitation centers)

COMPONENTS OF GOAL/ DESIRED OUTCOME STATEMENT1. Subject- a noun ( client, any part of client)2. Verb- specifies an action the client is to perform3. Conditions/ Modifiers- added to verb to explain –what, where, when, how?4. Criterion of Desired Outcome- level at which client will perform specified behavior (time, speed, accuracy, distance, quality)

Client walks the length of the hall without cane by date of discharge.(December 1, 2009)

Client performs leg ROM exercises as taught every 8 hours

3. S-electing Nursing Intervention-nurse perform to achieve client’s goals

***3 TYPES OF NURSING INTERVENTIONS1. Independent Interventions- nurses licensed to initiate

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e.g. physical care, ongoing assessment, emotional support and comfort, teaching, counseling, environmental management, making referrals to other health care professionals2. Dependent Interventions- activities carried out under physician’s order/ supervisione.g. medications. IV therapy, diagnostic tests, treatments, diet and activity3. Collaborative Interventions- nurse carries with collaboration with other health team members

CRITERIA FOR CHOOSING NURSING INTERVENTIONS

I- ndividual’s age, health, conditionT- herapiesS- afe InterventionS- how respect (values/ beliefs)A- chievable with resources availableF- irm adheranceE- evidenced based

4. Individualized NCP Writing

4. IMPLEMENTATION-is putting the nursing care plan into action.-an action phase in which nurse performs nursing intervention.Purpose: To carry out planned nursing interventions to help the client attain goals and achieve optimal level of health.

***Implementing Skills1. Cognitive- include intellectual skills like problem solving, decision-making, critical thinking and creativity. Crucial to safe, intelligent nursing care2. Interpersonal- nurse ability to communicate with others. caring, comforting, advocacy, referring, counseling/ supporting3. Technical skills- hands on skills, tasks, procedures, and psychomotor skills. manipulating equipment, giving injections, bandaging, moving, lifting4. Therapeutic use of self – is being willing and being able to care.

PROCESS IN IMPLEMENTING (RIDDS)R- eassessing clientI- mplementing nursing interventionD- etermine nurse’s need for assistanceD- ocumenting nursing activities

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S- upervising nursing activities

1. Reassessing the client- to ensure prompt attention to emerging problems.>just before implementing an intervention, nurse must reassess the client to make sure the intervention is still needed. Ex. Diagnosis ( Disturbed Sleep Pattern r/t Anxiety) during rounds you see that the pt is sleeping (X) relaxation strategy 2. Implementing nursing intervention- it is important to explain the client the ff:

What interventions will be done? What sensation to expect? What the expected outcome is?***Always ensure patient’s privacy!!!

>>>When implementing nursing intervention, nurses should follow these guidelines. (ABC RE HIP).

A- dapt activities to the individual client- client’s beliefs, values, age, health status and environment that can affect the success of a nursing action.

B- ased on scientific knowledge, research and professional standard of care-rationale, possible side effects or complicationsC- learly understand interventions to be implemented-intelligent implementation of medical and nursing planR- espect dignity of client and enhance client’s self- esteem-providing pricay and encouraging clients to make their own decisionE- ncourage patient to participate actively-enhances client sense of independence and control but it varies (because some patient may want total or little involvement.***Amount of desired involvement may be related to:

Severity of illness Client’s culture Client’s fears Client’s understanding of the illness/ intervention

H- olistic-nurse must view client as a whole and consider client’s responses in that contextI- mplement safe careP-rovide teaching, support and comfort-should explain purpose of intervention, what client will experience, how the client can participate increase responsibility for self-care

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3. Determining nurse’s need for assistance- when implementing nursing intervention, nurse may need assistance for one or more of the following reasons:NURSE: Unable to implement

Assistance decreases stress of clientsLacks knowledge/ skills

4. Documenting nursing activities-part of the agency’s permanent record for the client-after carrying out DOCUMENT!*not done before implementation

5. Supervising nursing activities-if care is delegated to other healthcare personnel, the nurse is responsible for client’s overall care and must ensure that activities have been implemented according to the care plan.COMMUNICATE- documenting the client’s record

- reporting verbally - filling out a written form

5. EVALUATION-assessing client’s response to nursing progress toward healthcare and effectiveness of nursing care plan.

TYPES OF EVALUATION

1. Ongoing Evaluation- continous

2. Initial Evaluation- specific intervals

3. Terminal Evaluation- evaluation at discharge

TYPES OF OUTCOMES

The goal was completely met. The goal was partially met. The goal was completely unmet.

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