week 2 nursing process
TRANSCRIPT
Unit 2
Nursing ProcessReporting
Client Teaching
Key WordsKey WordsActual nursing diagnosisAnalysisAssessmentAssessment modelAssumptionsBiasComprehensive assessment
Critical pathwaysData clusteringDefining characteristicsDelegationDependent nursing interventionsDischarge planningEtiologyEvaluation
Assessment
Diagnosis
Planning & Outcome Identification
Evaluation
Implementation
NursingNursing
ProcessProcess
North American Nursing Diagnosis Association (NANDA)
NANDA-International is recognized as the leader in development and classification of nursing diagnoses
[http://www.nanda.org/html/about.html]
Nursing Process
AssessmentFirst step in the nursing process
Involves several stepsData collectionConfirm the data is accurateOrganize the dataInterpret the data
Nursing Process - Assessment
Three types:
1. Comprehensive – provides baseline client data2. Focused – limited in scope, targets a particular
need or health care concern3. Ongoing – systematic monitoring & observation
related to specific problems
Nursing Process - Assessment
Two methods of Assessment1. Subjective – client’s perspective
Examples: Report of fainting, complaint of dizziness, nausea, headache
2. Objective – observable & measurableExamples: Vomiting, unsteady gait, pale skin, rapid breathing
Nursing Process: Data Collection
Data collection occurs in 3 phases:
1. Before you see the client2. When you see the client3. After you see the client
Nursing ProcessOrganizing the Data
Assessment models
Maslow’s Hierarchy of Needs
Body Systems Model
Human response model
Neuman's System’s Model
Identification of Patterns
Distinguish between relevant and irrelevant data
Determine whether and when there are gaps in the data and
Identify patterns of cause & effect
Nursing Diagnosis
A clinical judgment about individual, family, or community responses to actual or potential health problems/life processes. A nursing diagnosis provides the basis for selection of nursing interventions to achieve outcomes for which the nurse is accountable.
Focuses on the client’s responses to actual or potential health problems
Focuses on the illness, injury, or disease process
Changes as the client's response and/or health changes
Remains constant until a cure is effected
Nursing DiagnosisMedical Diagnosis
Identifies situations the nurse is licensed and qualified to treat
Identifies conditions the MD is licensed & qualified to treat
Strep ThroatBody Temperature, Risk for Altered
AmputationBody Image Disturbance
Cerebrovascular accident (CVA)
Activity Intolerance
AppendectomyPain
Medical DiagnosisNursing Diagnosis
Chronic obstructive pulmonary disease
Breathing Pattern, Ineffective
Development of the Nursing Diagnosis
Two-part Statement1. Problem statement – describes the client’s
response to an actual or potential health problem (diagnostic label)
2. Etiology – cause of the problem3. The diagnostic label & etiology are linked by
the terminology Related to (R/T)Example:
Ineffective breathing pattern R/T neuromuscular impairment.
Development of the Nursing Diagnosis
Two-part Statement1. Problem statement 2. Link3. Etiology neuromuscular impairment.
Ineffective breathing pattern
R/T (related to)
Example:
Nursing ProcessThree-part-statement
1. Problem statement – describes the client’s response to an actual or potential health problem (diagnostic label)
2. Etiology – cause of the problem3. The diagnostic label & etiology are linked by
the terminology Related to (R/T)4. Defining characteristics
Development of the Nursing Diagnosis
Three-part Statement1. Problem statement 2. Link3. Etiology 4. Defining
characteristics (signs & symptoms)
neuromuscular impairment.
Ineffective breathing patternR/T (related to)
Example:
as evidenced by C-6 spinal cord injury, poor chest expansion
Nursing Diagnosis
Decreased cardiac output, related to alterations in rate, rhythm, electrical conduction, as evidenced by diminished peripheral pulses.
Decreased cardiac output, related to alterations in rate, rhythm, electrical conduction
Activity intolerance related to prolonged bed rest/immobility as evidenced by fatigue and weakness
Activity intolerance related to prolonged bed rest/immobility
Three-Part StatementTwo-Part Statement
Types of Nursing Diagnoses
Actual nursing diagnosis – a problem exists. Composed of the problem statement, related factors and signs & symptoms
Risk nursing diagnosis – indicates the problem doesn’t exist but has special risk factors
Wellness nursing diagnosis – indicates the client’s desire to attain a higher level of wellness in some area of function.
Planning & Outcome Identification
Planning is formulation of the actual nursing actions
Three types of planning:Initial planning – developing the preliminary plan of careOngoing planning – updates of care based on reassessmentDischarge planning – anticipation & planning of client needs after discharge
Planning PhasePrioritizing the nursing diagnosesIdentifying long & short term goalsDeveloping nursing interventionsRecording the nursing care plan in the client’s medical record
Prioritizing Nursing Diagnoses
Maslow’s hierarchy of needs
Physiological Needs
Safety & Security Needs
Love & Belonging Needs
Self-Esteem Needs
Self-
Actualization
Needs
Physiological Needs
Prioritizing Nursing Diagnoses
Betty Neuman's System Theory
Five system variables:
PhysiologicalPsychologicalSocioculturalDevelopmentalSpiritual
Protected by the lines of defense & resistance to keep the system stable
Basic structure &
Energy Resources
Identification of OutcomesProvides guidelines for individualized nursing interventions
Establishes goals & evaluation criteria to measure effectiveness of the nursing care plan
Short-term goals – 1 weekLong-term goals – weeks to months
Goals
Verbalizes comfortVerbalizes the presence of pain
Identifies factors that influence the pain experience
Long termShort term
Nursing Interventions
An action performed by the nurse that helps the client achieve the results specified by the goals and expected outcomes.
Refer directly to the nursing diagnoses.
Nursing InterventionsIndependent nursing interventions – nursing actions that are initiated by the nurse.
Interdependent nursing interventions –actions that are implemented by the nurse in conjunction with other health care professionals
Dependant nursing interventions – requires a physician order
InterventionsSpecific order – written in the medical record
or nursing care plan by a physician or nurse
Standing order – a standardized intervention
Protocol - a series of standing orders or procedures that should be followed under certain specific conditions.
Nursing Care Plan
A written guide, organizing client data into a formal statements of strategies to assist the client to optimal health
Implementation4th step in the nursing process
Involves putting the nursing care plan into action.
Nursing activities (interventions) to meet the goals set with the client begin.
Documentation Data to be recorded:
Client’s condition prior to the interventionIntervention performedClient’s response to the interventionClient outcomes
ReportingActivities completed & those yet to be completed
Current problems
Abnormal findings or changes in the client assessmentTreatment results
Diagnostic tests completed with results (if available) or tests scheduled
Evaluation5th step in the nursing process
Determines if client goals are met or not
Determination of continued or cessation of plan
Critical ThinkingThe rational examination of ideas, inferences, assumptions, principles, arguments, conclusions, issues, statements, beliefs and actions.
Making a decision is the end point of using critical thinking.
Decision MakingRecognizing and defining a problem
Gathering relevant information
Generating possible conclusions
Testing possible conclusions
Evaluating Conclusions
Decision Making & The Nursing Process
Recognizing and defining a problemGathering relevant informationGenerating possible conclusionsTesting possible conclusionsEvaluating Conclusions
AssessmentAssessmentDiagnosisPlanning & outcome identificationImplementationEvaluation
Class ActivityUse the steps in nursing process to
Describe how one would decide to purchase a new carDescribe how one would select a restaurantDescribe how one would plan a weddingDescribe how one would select a petDescribe how one would select a health insuranceDescribe how one would select a career
Documentation
Chapter 10
Documentation Defined
The interactions between and among health professionals, clients, their families, and health care organizationsThe administration of tests, procedures, treatments, and client education; andThe results of, or client’s response to, diagnostic tests and interventions (Eggland & Heinemann, 1994)
Effective Documentation
Follow the nursing processEntries are made chronologically
Date & timeObservationInterventionEvaluation
Use of healthcare facility approved vocabulary and abbreviations.SignatureAccurate
Methods of Documentation
Narrative charting: describes the client’s status, interventions and treatments in a story form.
Source-oriented charting: narrative charting by individual disciplines on separate records.
Methods of DocumentationProblem-oriented charting: problem-oriented medical record (POMR)
SOAP charting: Subjective, Objective, Assessment, Plan
SOAPIE/SOAPIER charting:Subjective, Objective, Assessment, Plan, Implementation, Evaluation/Revision
PIE charting: problem, intervention and evaluation
FOCUS charting: uses a columnar format to chart data, action and response (DAR)
Charting by Exception (CBE): documentation of deviations for the baseline or established norms
Computerized documentation: electronic medical record
Methods of Documentation
Forms
Kardex – a summary worksheet reference of basic client care information that traditionally is not part of the medical record.
Flowsheets – columnar format makes documenting dates and times of particular assessments easier to track.
Review of Medical Record Forms
After reviewing the different healthcare organization’s document, discuss the method of documentation for each (flow chart, computerized, FOCUS charting, etc.)
Reporting
Based on the nursing process a verbal report of the client’s health status, needs, treatments, outcomes and responses is communicated to other members of the health care team.
Client TeachingTeaching-learning process is a planned interaction that supports behavioral change that is not a result of maturation or coincidence.
Formal teaching – planned and goal directed
Informal teaching – initiated at any time a learning need is identified
Client Teaching
Learning – a process whereby an individual integrates information that results in a behavioral change.
Learning DomainsCognitive – intellectual understanding (learning the technique for giving a clean catch urine specimen)
Affective – related to attitudes, beliefs and emotions (recognizing the value of diet)
Psychomotor – motor skills (learning to perform blood sugar testing)
Adult Leaner: Basic Assumptions
Personality develops from dependence to independence
Learning readiness is affected by developmental stage and sociocultural factors
Previous learning experiences can be used as a foundation
Opportunities to use the new knowledge reinforces the new knowledge
Learning Principles
RelevanceMotivationReadinessMaturation
ReinforcementParticipationOrganizationRepetition
Learning Styles
Visual learner –processing information sight
Auditory learner –processing listening
Kinesthetic learner-experiencing the information through touching, feeling & doing
Barriers to the Teaching-Learning Process
Physiological
Psychological
Environmental
Sociocultural
Teaching MethodsDiscussions
Formal lecture
Question and answer sessions
Role play
Games/computer activities
Class Activity
Assignment: Break into 3 groups (Children, adolescents, older adults). Present to the class the:
MOST significant factors that influence learning for your assigned developmental stageTypes of learning needsStrategies to enhance learning at each stage
VITAL SIGNS
Temperature
Pulse
Respirations
Blood Pressure
The “Signs of Life”
Temperature [T]
Routes:OralRectalAxillarySkinTympanic membrane
Temperature [T] –ReadingsVariationsNormal ReadingRoute
37ºC or 98.6ºFOral
37.5ºC or 99.6ºFRectal
>38ºC or 100.4ºF Pyrexia
37ºC or 98.6ºFTympanic
<36ºC or 96.8ºF Hypothermia
36.5ºC or 97.6ºF
Axillary
Pulse [P]
Terms to knowPulse rateBradycardiaTachycardiaPulse rhythmPulse amplitudePulse deficit
Pulse [P]
TemporalCarotidApical Femoral Dorsalis pedis
BrachialUlnarRadialPoplitealPosterior Tibial
Pulse Points
Pulse - Readings
<60 Bradycardia
60-100 beats/minute
[P]
>100 Tachycardia
VariationsNormal Reading
Vital Sign
Respirations [R]
Terms to Know:EupneaBradypneaHypoventilationTachypneaHyperventilationDyspnea
Respirations - Readings
<60 Bradycardia
16-20 respirations/
minute
[R]
>100 Tachycardia
VariationsNormal Reading
Vital Sign
Blood Pressure (B/P)Measures the force exerted by the blood against the walls of the blood vessels. Dependent upon the Cardiac output –volume of blood per minute pumped by the left ventricle; Peripheral Resistance – pressure within a vessel that resists the flow of blood.
Blood Pressure - Terms
Arterial pressureDiastolic blood pressureSystolic blood pressurePulse pressureOrthostatic hypotension
Blood Pressure - Readings
<90/60 Hypotension
90/60 –140/90
[B/P or BP]
>140/90 Hypertension
VariationsNormal Reading
Vital Sign
Unit 3: Health Promotions
Chapter 15: Wellness Concepts
Key Terms
HealthWellness
Health Promotion
Class discussion:What is a eudaemonistic approach to health?What is the Healthy People 2000? 2010?What are the leading cases of death associated with lifestyle factors that can be controlled?
The EndNext class topics for review:Prevention as InterventionBasic NutritionDiet TherapyNutritional SupportExcretion/EliminationNursing Process & Client NutritionRest & Sleep & the Nursing ProcessAssignment: Keypoints to teaching body mechanics due Sept. 16, 2003