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The Nursing Process


Resources 

Andrea Ackermann, Mount St. Mary College, Critical-thinking-the-nursingprocess 2001. http://www.umanitoba.ca/nursing/courses/128,(20 ) Sara-jo Wiscombe, Nursing Process ,Wallace Community College ,May 22,2001. Tucker C, MODULE A INTRODUCTION TO NURSING Process, August 21, 2002 .


The Nursing Process An

organizational framework for the practice of nursing Orderly, systematic Central to all nursing care Encompasses all steps taken by the nurse in caring for a patient


Definition of the Nursing Process  An

organized sequence of problemsolving steps used to identify and to manage the health problems of clients  It is accepted for clinical practice established by the American Nurses Association


Benefits of Nursing Process       

Provides an orderly & systematic method for planning & providing care Enhances nursing efficiency by standardizing nursing practice Facilitates documentation of care Provides a unity of language for the nursing profession Is economical Stresses the independent function of nurses Increases care quality through the use of deliberate actions


The Nursing Process Utilizes The Following Assessment Nursing

Diagnosis Planning Implementation Evaluation


Characteristics of the Nursing Process  Within

the legal scope of nursing  Based on knowledge-requiring critical thinking  Planned-organized and systematic  Client-centered  Goal-directed  Prioritized  Dynamic


Benefits of using the nursing process    

Continuity of care Prevention of duplication Individualized care Standards of care

Increased client participation

Collaboration of care


Being Accountable Using critical thinking before taking actions  Being responsible for your actions  Entering the professional role  Working at the level of your peers  Using the nursing process 


Something to think about: 

Nurses are responsible for a unique dimension of healthcare – “ the diagnosis and treatment of human responses to actual or potential health problems”


MARTHA ROGERS, NURSE THEORIST “When

an apple is cut, others see seeds in the apple. We, as nurses, see apples in the seeds.”


What Are Your Responsibilities?   

Recognize health problems. Anticipate complications. Initiate actions to ensure appropriate and timely treatment.

Begin to think CRITICALLY !!!!!!


Critical Thinking 

MENTAL OPERATIONS –decision making & reasoning

KNOWLEDGE-having the facts & understanding the reason behind the knowledge

ATTITUDES- curious/open-minded/nonjudgmental….


Critical Thinking Critical thinking in nursing is an essential component of professional accountability and quality nursing care.





Critical thinking is careful, deliberate, and goal directed.


Assessment of Well-Being  According

to the World Health Organization is well-being in these domains:  Emotional  Physical  Social  Spiritual


Lets Get Started :        

Nurse collects background info from previous charts Ensure environment is conducive Arrange seating Allow adequate time Nurse introduces self Identifies purpose of interview Ensure confidentiality of information Provide for patient needs before starting


TYPES OF INTERVIEWS  

DIRECTED NON-DIRECTED

THINGS THAT IMPAIR COMMUNICATION:  PRESENTING QUICK SOLUTIONS  UNWARRANTED CHEERFULNESS  FALSE REASSURANCE  GIVING ADVICE  CHANGING THE SUBJECT


ASSESSMENT  Observation  Interview

 Types

of questions  Environment (physical and emotional) Spiritual conciderations  Examination


Types of Data To Collect:  Objective

data-observable and measurable facts (Signs)  Subjective data-information that only the client feels and can describe (Symptoms)


CULTURAL DIVERSITY MUST PROVIDE CARE CONGRUENT WITH A CLIENT’S EXPECTATIONS  “This is not about you” ?  Respect INDIVIDUAL’S DIFFERENCES, What is the significance of the problem or illness to the client?  What does it mean in the family/community? 


COMMON Challenges: Defense Mechanisms COMPENSATION  DENIAL  DISPLACEMENT RATIONALIZATION 

   

PROJECTION REPRESSION SUPPRESSION REGRESSION


Continued THE NURSING PROCESS HELPS NURSES UNDERSTAND THE STRATEGIES CLIENTS USE IN their attempt at coping: This knowledge will help you FURTHER INDIVIDUALIZE THEIR CARE 


Resources      

Client Other individuals Previous records Consultations Diagnostics studies Relevant literature


Assessment 

Data base assessment – comprehensive information you gather on initial contact with the person to assess all aspects of health status. Focus assessment – the data you gather to determine the status of a specific condition.


Sources of Data  Primary

source: Client  Secondary source: Client’s family, reports, test results, information in current and past medical records, and discussions with other health care workers


Disease Prevention 

Primary prevention – protection from a disease while still in a healthy state. Secondary prevention – early detection and treatment of disease. Tertiary prevention – prevent complications and to maintain health once the disease process has occurred.


Verifying Data        

Essential in critical thinking!!!!! Measurable data Double check personal observations Double check equipment Check with experts and team members Recheck out-liers Compare objective and subjective data Clarify statements


Planning  Establish

the goals, interventions and outcomes


General Guidelines for Setting Priorities 1. 2. 3. 4.

Take care of immediate life-threatening issues. Safety issues. Patient-identified issues. Nurse-identified priorities based on the overall picture, the patient as a whole person, and availability of time and resources.


Nurse Identified Priorities 

   

Composite of all patient’s strengths and health concerns. Moral and ethical issues. Time, resources, and setting. Hierarchy of needs. Interdisciplinary planning.


Identifying Client-centered Outcomes 

 

State what the patient will do or experience at the completion of care. Give direction to the patient’s overall care. Patient behaviors not nurse behaviors!! “The patient will…”


DIAGNOSIS Sort, cluster, analyze information  Identify potential problems and strengths  Write statement of problem or strength  Risk of infection related to compromised nutrition 


Nursing Diagnosis (cont.) Potential for effective breastfeeding related to knowledge level and support system  Prioritize the problems  Not a medical diagnosis 


Steps for deriving outcomes from Nursing Diagnosis 

Look at the first clause of the nursing dx and restate in a statement that describes improvement, control or absence of the problem. Risk for infection r/t surgical procedure. The client will demonstrate no signs or symptoms of infection.


Components of Outcomes     

Subject: who is the person expected to achieve the outcome? Verb: what actions must the person take to achieve the outcome? Condition: under what circumstances is the person to perform the actions? Performance criteria: how well is the person to perform the actions? Target time: by when is the person expected to be able to perform the actions?


Nursing Interventions 

 1. 2. 3. 4. 5.

Road maps directing the best ways to provide nursing care. Evidence based nursing. Monitor health status. Minimize risks. Resolve or control a problem. Assist with ADLs. Promote optimum health and independence.


Interventions 

Direct interventions: actions performed through interaction with clients.



Indirect interventions: actions performed away from the client, on behalf of a client or group of clients.


Nursing Diagnosis  Health

issue that can be prevented, reduced, resolved, or enhanced through independent nursing measures


Documenting the Plan of Care 

 1.

2. 3.

To ensure continuity of care, the plan must be written and shared with all health care personnel caring for the client. Consists of: Prioritized nursing diagnostic statements. Outcomes. Interventions.


Documentation Clear and concise  Appropriate terminology 

 

Usually on a designated form

Physical assessment 

Usually by Review of Systems • Overview of symptoms • Diet • Each body system


Documentation Use patient’s own words in subjective data – enclose in “ ___” (quotation marks)  Avoid generalizations – be specific  Don’t make summative statements – describe - e.g. patient is being ornery should be patient resists instruction or patient states “Don’t talk to me, I don’t care about that” 


Evaluation 1. 2.

3.

Determining outcome achievement Identifying the variables affecting outcome achievement Deciding whether to continue, modify, or terminate the plan


Determining Outcome Achievement    

 

Must be aware of outcomes set for the client. Must be sure patient is ready for evaluation. Is patient able to meet outcome criteria? Is it: Completely met? Partially met? Not met at all? Record in progress in notes. Update care plan.


Identifying Variable Affecting Outcome Achievement 

Maintain individuality of care plan: 1. Is the plan realistic for the client? 2. Is the plan appropriate at the time for this particular client? 3. Were changes made in the plan when needed? 4. How does the client feel about the plan?


Predict, Prevent, and Manage    

Focus on early intervention Based on research Predict and anticipate problems Look for risk factors


Diagnostic Statements  Name

of the health-related issue or problem as identified in the NANDA list  Etiology (its cause)  Signs and Symptoms  The name of the nursing diagnosis is linked to the etiology with the phrase “related to,” and the signs and symptoms are identified with the phrase “as manifested (or evidenced) by”


Collaborative ProblemsNurse’s Responsibility  Correlating

medical diagnoses or medical treatment measures with the risk for unique complications  Documenting the complications for which clients are at risk  Making pertinent assessments to detect complications


Continued Reporting trends that suggest development of complications  Managing the emerging problem with nurse- and physician-prescribed measures  Evaluating the outcomes 


The Nursing Process Nursing Diagnosis  Judgment

or conclusion about the risk for— or actual—need/problem of the patient  NANDA format


NANDA – North American Nursing Diagnosis Association   

Identifies nursing functions Creates classification system Establishes diagnostic labels Risk of infection related to compromised nutritional state Potential complication of seizure disorder related to medication compliance


Planning  The

process of prioritizing nursing diagnoses and collaborative problems, identifying measurable goals or outcomes, selecting appropriate interventions, and documenting the plan of care.  The nurse consults with the client while developing and revising the plan.


Setting Priorities  Determine

problems that require immediate action  Maslow’s Hierarchy of Human Needs


Short-Term Goals  Outcomes

achievable in a few days or

1 week  Developed form the problem portion of the diagnostic statement  Client-centered  Measurable  Realistic  Accompanied by a target date


Long-Term Goals  Desirable

outcomes that take weeks or months to accomplish for client’s with chronic health problems


The Nursing Process Planning  Identification  Prioritization  Time

frame

of goals and outcome criteria


Selecting Nursing Interventions  Planning

the measures that the client and nurse will use to accomplish identified goals involves critical thinking.  Nursing interventions are directed at eliminating the etiologies.


Selecting an intervention The nurse selects strategies based on the knowledge that certain nursing actions produce desired effects.  Nursing interventions must be safe, within the legal scope of nursing practice, and compatible with medical orders. 


Communicating The Plan  The

nurse shares the plan of care with nursing team members, the client, and client’s family.  The plan is a permanent part of the record.


Evaluation  The

way nurses determine whether a client has reached a goal.  It is the analysis of the client’s response, evaluation helps to determine the effectiveness of nursing care.


The Nursing Process Evaluation Ongoing

part of the nursing process Determining the status of the goals and outcomes of care Monitoring the patient’s response to drug therapy


Documentation Clear and concise  Appropriate terminology 

 

Usually on a designated form

Physical assessment 

Usually by Review of Systems • Overview of symptoms • Diet • Each body system


The Nursing Process