nursing process review
TRANSCRIPT
Defines Nursing as:
the diagnosis and treatment of
human responses to actual or
potential health care
problems.
a problem solving approach for
gathering data, identifying a
person’s needs, selecting and
implementing approaches for
nursing care and evaluating
outcomes of care given.
Steps of Nursing
Process:
1. Assessment
2. Diagnosis
3. Planning
4. Implementation
5. Evaluation
RATIONALE FOR USING NURSING PROCESS:
requirement – national practice standards
preparation for NCLEX
promotes critical thinking
means of communication
results in an individualized plan of care
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1. a. Interviewing patient & family
– chief complaint
b. Nursing History:
- support system
- health
- ADL’s
- feelings/concerns
- culture
- occupation
- financial concerns
2. Observation & Measurement:
A 'sixth sense?' Or merely mindful caution?
3. REVIEW OF THE RECORDS
1. DOCTOR’S ORDERS
2. PROGRESS NOTE
3. HISTORY/PHYSICAL
4. NURSING NOTES
5. CONSULTATION
6. DIAGNOSTIC STUDIES
7. LAB RESULTS
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4. Physical Assessment /Examination
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GENERAL SURVEY VITAL SIGNS HEAD & NECK UPPER EXTREMITIES ANTERIOR & POSTERIOR THORAX ABDOMEN LOWER EXTREMITIES PELVIS & PERINEUM MOTOR/SENSORY/SPINE SKIN
Cluster Data According To Body Systems
• Visual & Auditory
• Respiratory
• Cardiovascular
• Gastrointestinal
• Nervous
• Musculoskeletal
• Urinary
• Reproductive
• Hematological
• Endocrine
• Integumentary
• Question:
After gathering and clustering all your data, in which areas or systems are you seeing abnormal findings? These systems become your priority assessment areas for a focused assessment or on-going evaluation
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Data Classification:
#1 What are symptoms and signs:
- Sign : aka - objective data –
what you observe
- Symptom: aka – subjective data –
what the person states
#2 Adaptive vs ineffective responses
#3 Identify the causative factors or
etiology
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AKA
PROBLEM
IDENTIFICATION
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CLINICAL JUDGMENT
• IS AN OPINION THAT THE NURSE MAKES BASED ON THE CLINICAL DATA OBTAINED;
Clinical judgment allows the nurse to identify, associate and interpret the signs and symptoms of a given condition
NURSING DIAGNOSIS
• IS A CLINICAL JUDGMENT ABOUT AN INDIVIDUAL’S RESPONSES TO ACTUAL OR POTENTIAL HEALTH PROBLEMS.
CLINICAL JUDGMENT PROCESS – How to arrive at a Nursing Diagnosis:
Reasoning Critical Thinking
Nursing Diagnosis/Clinical Judgment
Knowledge & experience
ANXIETY IMPAIRED MOBILITY
NURSES ARE RESPONSIBLE FOR PROVIDING TREATMENT
FOR IDENTIFIED DIAGNOSES –
…. “actual or potential health problems that nurses by
value of their education and experience are able, licensed
and legally responsible and accountable to treat”.
TYPES OF NURSING DIAGNOSES
1. ACTUAL
2. RISK FOR & HIGH RISK FOR GWC
3. POSSIBLE
4. WELLNESS
5. SYNDROME
V Klein
MAKING A NURSING DIAGNOSIS:
A. 1. After gathering data, cluster signs
and symptoms
2. Next identify causative factors
for these signs and symptoms
3. Select a Nursing Diagnosis based
on them
A 32 year old woman has a fractured leg with
a cast and she does not know how to use her
crutches. She expresses concern that she
“will be confined to bed or a chair and not be
able to get around and care for her 4 year
old son”.
-Fractured leg
- immobilized by a Cast
-Does not know
how to use
crutches
- Verbalizes concern that
she will be confined and not be able to
care for her 4 year old son
Impaired physical mobility
Ineffective Role
Performance
V Klein
MAKING A NURSING DIAGNOSIS: cont.
B. Confirm by checking with Carpenito
1. Read the definition
2. Read the defining characteristics –
at least one major
MAKING A NURSING DIAGNOSIS: cont.
C. Factors that cause or contribute to the
problem are called Related Factors in
Carpenito – divides them into 4 groups
1. pathophysiological
2. treatment related
3. situational (personal or
environmental)
4. maturational
V Klein
Impaired
physical
mobility
cast
Fractured
leg
Pathophysiological
Maturational
none
Situational
Lack of
knowledge
Treatment
related
MAKING A NURSING DIAGNOSIS: cont.
D. Look at all the causes (aka
related factors) and determine
which is the primary cause of
the problem.
The primary cause or related factor becomes
the second part of the diagnosis which is called
the “related to”
(note: the R/T must be something the Nurse can treat independently)
V Klein
CONNECT THE PROBLEM WITH THE PRIMARY RELATED FACTOR USING THE
LETTERS R/T:
IMPAIRED PHYSICAL MOBILITY R/T INSUFFICIENT KNOWLEDGE OF ADAPTIVE
TECHNIQUES IN USE OF CRUTCHES FOR AMBULATION.
A Nursing Diagnosis is one that nurses can
treat independently and one that does not
require medical intervention
Collaborative problems are certain
physiologic complications that nurses
monitor to detect onset or change in
status; collaborative problems require
nursing and medical intervention
Nurses cannot prevent a collaborative problem but they
can detect it early to reduce its seriousness - eg monitoring
a dressing closely for signs of bleeding.
Nurses can prevent certain physiological problems and these
can be identified as Risk for Nursing Diagnoses -egs:
Pressure Ulcers - Risk for Impaired Skin Integrity
Aspiration - Risk for Aspiration
Problems that nurses can treat independently are identified
as Nursing Diagnoses – egs
Ineffective cough - Ineffective Airway Clearing
Stage 1 & 2 pressure ulcers - Impaired Skin Integrity
V Klein
JUST CHECKING TO SEE IF YOU ARE AWAKE
V Klein
1. When a medical diagnosis is a related
factor, avoid writing it as your R/T
( remember your R/T must be
something you can treat independently
as a nurse)
Eg. Anxiety R/T Cancer
Instead ask what/how has the medical
diagnosis caused or contributed to the
problem
V Klein
WRITTEN CORRECTLY:
Anxiety R/T perceived/actual
losses secondary to cancer
(Treatment related – loss of hair; financial
etc)
V Klein
2. When writing the R/T avoid using signs
and symptoms – they result from the
problem rather than cause or
contribute.
Eg. Disturbed sleep pattern R/T difficulty
falling asleep.
V Klein
CORRECT DIAGNOSIS:
Disturbed sleep pattern R/T environmental
changes due to hospitalization – noise, frequent
interruptions
3. Do not use a goal as your R/T.
Impaired parenting R/T parents should
spend more time holding infant
CORRECT DIAGNOSIS:
Impaired parenting R/T a lack of
knowledge regarding infant care and
needs.
CORRECTLY WRITTEN ??
Disturbed Body Image R/T Breast Cancer
Disturbed Body Image R/T changes in
appearance secondary to Chemo therapy
Or
Disturbed Body Image R/T a change in
appearance secondary to loss of left breast
V Klein
CORRECTLY WRITTEN ?
Grieving R/T crying and inability to sleep
Grieving R/T losses associated with death of ….
( companionship, financial etc)
CORRECTLY WRITTEN ?
Ineffective Airway Clearance R/T rhonci bilaterally
Ineffective Airway Clearance R/T inability to maintain an
upright position
OR
Ineffective Airway Clearance R/T thick , tenacious secretions
secondary to inadequate fluid intake.
V Klein
CORRECTLY WRITTEN ?
Imbalanced Nutrition: Less than body requirements R/T
Chemotherapy
Imbalanced Nutrition: Less than body requirements R/T
decreased desire to eat secondary to side effects of chemotherapy
OR
R/T mouth discomfort associated with Chemotherapy
WHAT IS WRONG WITH THIS DIAGNOSIS??
Risk for Constipation R/T reports of hard dry stool
“ Reports of hard dry stool” is a symptom – therefore it
no longer is a Risk for problem
If the symptom did not exist and the patient had risk
factors :
Risk for constipation R/T side effects of analgesics
Risk for constipation R/T effects of anesthesia and
surgical manipulation.
R/T effects of immobility on peristalsis
C. PLANNING – AKA GOAL
SETTING
WHEN WRITING GOALS,THE
FOCUS IS ON CHANGING THE
ABNORMAL SIGNS & SYMPTOMS
Client goals are used to:
1. direct interventions
2. evaluate the effectiveness of
the interventions
S SPECIFIC
M MEASURABLE
A ATTAINABLE
R REALISTIC
T TIMELY
RULES FOR WRITING GOALS:
1. a. Start out with the phrase: The client will demonstrate….
b. The first part of the goal needs to reflect the nursing diagnosis
2. This is followed by AEB and 2-3 goal criteria.
a. Goal criteria must reflect desired changes in the signs and symptoms listed.
b. Criteria must be observable and/or measureable
3. Always end with one realistic time frame
Disturbed sleep pattern R/T environmental
changes due to hospitalization – noise,
frequent interruptions
Symptoms/Subjective Data :
“I can’t fall asleep here and when I do
someone or something always wakes
me up.”
Signs/Objective Data:
Refuses to participate in self-care
measures. Irritable and sarcastic
when talking to family members and
staff
Client will demonstrate an improved sleep pattern AEB:
Verbalizing that he/she was able to fall and stay asleep throughout the night
Participating in morning hygiene – teeth
hair, shower
Communicating in a pleasant manner with family members and staff
- within 48 hours
D. Implementation- AKA
interventions
Three components:
1. must use an action verb
2. state where, what, how, how much and how
far
3. time element – when, how often and how
long
Types:
Assess, Care, Manage, Teach
E. EVALUATION-
results/effects
The final step is to determine if
your patient’s goal has been met.
Look at your goal criteria to do this.
If criteria not met, remember that
the Nursing Process is a circular
process – it begins and ends with
assessment.
V Klein
THE
END