The Nursing Process Chapters 11-14

Assessing Chapter 11

The Nursing Process Components of the nursing process Assessment Nursing diagnosis Planning Implementation Evaluation Fig. 11-4 pg. 161

Assessment Collecting, organizing,, validating and documenting a patient’s health data Data gathered from: .

Assessment (Data Collection) Collection of data Database Subjective Objective Sources of data

Methods of Data Collection Observing Interviewing

Directive Approach to Interviewing Nurse establishes purpose Nurse controls the interview Used to gather and give information when time is limited, e.g., in an emergency

Nondirective Approach to Interviewing Rapport-building Client controls the purpose, subject matter, and pacing Combination of directive and nondirective approaches usually appropriate during the information-gathering interview

Types of Questions Closed Open Advantages/disadvantages Why …?

Planning the Interview Time Place Seating Distance Language

Stages of an Interview The opening The body of the interview The closing Copyright © 2014 by Elsevier Inc. All rights reserved.

The Physical Examination Use techniques of inspection, auscultation, palpation, and percussion Systematic manner Ongoing nursing data collection and examination focuses on the body systems in which there is a problem or potential problem

Organizing Data Systematically Nursing health history, nursing assessment, or nursing data base Differentiate normal from abnormal Copyright © 2014 by Elsevier Inc. All rights reserved.

Validating Data (Tab 11-7 pg. 172) Assessment complete Objective and related subjective data agree Additional data overlooked Differentiate between cues and inferences Data that is extremely abnormal Avoiding jumping to conclusions

Let’s Practice: Classify the following data as subjective or objective: “I’m hurting.” Pain level = 8 BP 121/84 Weight 172 lbs. Complete blood count normal (CBC) Dressing clean, dry, intact Denies nausea, vomiting, diarrhea (N/V/D)

Diagnosing Chapter 12

A Nursing Diagnosis is “…a clinical judgment about individual, family, or community responses to a actual or potential health problem/life processes. A nursing diagnosis provides the basis for selection of nursing interventions to achieve outcomes for which the nurse is accountable” (NANDA-I, 2009) Copyright © 2014 by Elsevier Inc. All rights reserved.

Types of Nursing Diagnoses Actual Diagnosis Risk Diagnosis Health Promotion Diagnosis Readiness for enhanced family coping Wellness Diagnosis NANDA-I nursing diagnoses Prioritization

Components of a Nursing Diagnosis Problem statement (diagnostic label) Describes the client’s health problem or response Use of qualifiers Etiology (related factors and risk factors) Identifies one or more probable causes of the health problem Do not use medical diagnosis

Components of a Nursing Diagnosis Defining characteristics for actual problems Cluster of signs and symptoms indicate the presence of a particular diagnostic label Have signs and symptoms Constipation R/T medication use AEB infrequent passage of stool and hard, dry stool.

Components of a Nursing Diagnosis (cont'd) Defining characteristics for risk problems For risk for nursing diagnoses have no signs/symptoms Factors that cause the client to be more vulnerable to the problem form the etiology or a risk for nursing diagnoses Risk for Infection R/T break in skin integrity.

Differentiating Nursing Diagnosis from Medical Diagnosis Nursing judgment Describes human response Changes as client responds Medical Diagnosis Made by physician Disease process Stays the same

Steps in Diagnostic Process Analyzing Data Compare data against standards Cluster cues Identify gaps and inconsistencies Identifying health problems, risks, and strengths Formulating diagnostic statements

Writing Nursing Diagnoses Basic Two-Part Statement (at risk) Problem (P) Etiology (E) Basic Three-Part Statement (actual) Signs and symptoms (S)

AEB observed choking (observed evidence of difficulty in swallowing). Practice A client who experienced a stroke last week is unable to swallow. You witness him choke during a feeding session. Impaired swallowing R/T facial paralysis AEB observed choking (observed evidence of difficulty in swallowing).

Hypothermia R/T immature body system Practice A older patient has a temp of 96.1 Ax. Hypothermia R/T immature body system AEB Ax temp of 97.1.

AEB verbalization of the inability to cope. Practice A client comes to the clinic and states he can’t handle the stress anymore. Ineffective coping R/T inadequate coping AEB verbalization of the inability to cope.

Ineffective airway clearance Practice An assessment on a post-operative client reveals rhonchi. The client refuses to cough due to pain. Ineffective airway clearance R/T ineffective cough AEB abnormal breath sounds.

Risk for infection R/T surgical incision Practice The nurse is caring for a post-operative surgical client. The nurse identifies the client is at risk for developing infection. The client does not have symptoms of an infection at this time. Risk for infection R/T surgical incision

Risk for injury r/t altered mental status. Identify the problem, etiology, defining characteristics for each nursing diagnostic statement. Activity intolerance r/t generalized weakness AEB verbal reports of weakness and fatigue. Deficient fluid volume r/t excessive blood loss AEB decreased BP, poor skin turgor, decreased urinary output and dry skin and mucous membranes. Risk for injury r/t altered mental status.

Planning Chapter 13

Planning Nurse and the client in collaboration Set priorities Determine goals to eliminate, diminish, or control identified problems Choose specific interventions to enable the client to meet the specific outcomes listed in the plan of care Copyright © 2014 by Elsevier Inc. All rights reserved.

Types of Planning Initial Ongoing Discharge

Developing Nursing Care Plans Informal nursing care plan Formal nursing care plan Standardized care plan Individualized care plan

Standardized Approaches Standards of care Standardized care plans Protocols Policies/procedures Standing order

Formats for Nursing Care Plans Student care plans Concept maps Computerized care plans Multidisciplinary (collaborative) care plans Also called critical pathway

Student Nursing Care Plan

Concept Map 38

The Planning Process Consists of following activities: Setting priorities Establishing client goals/desired outcomes Selecting nursing interventions Writing individualized nursing interventions on care plans

Setting Priorities Establishing a preferential sequence for addressing nursing diagnoses and interventions High priority (life-threatening) Medium priority (health-threatening) Low priority (developmental needs)

Goals/Desired Outcomes Broad statements about the client’s status Desired outcomes Specific, observable criteria used to evaluate whether the goals have been met Purpose

Table 13-2 Deriving Desired Outcomes from Nursing Diagnoses 42

Components of Goal/Desired Outcome Statements Subject Verb Condition or modifier Criterion of desired performance Guidelines for writing

Goal Statements Will ambulate to the nurses’ station, using cane, unassisted by 5/13/12. Will describe system for taking medication by 5/21/12. Will verbalize pain level of less than 3 (on a 0-10 pain scale 30-60 minutes after each pain management intervention. Will maintain airway that is free of secretions AEB clear lung sounds, ability to cough up secretions, no SOA, no cyanosis or pallor every shift.

Practice Write a short term goal for a post-op surgical client who has a nursing diagnosis of Risk for Infection? What do you want the client to achieve? How can you measure free of infection? What time frame?

Remain free of infection/ no signs of infection AEB: VS WNL, incision without drainage, edema, redness, and well approximated By discharge

Nursing Interventions Actions performed to achieve client goals Independent interventions Dependent interventions Collaborative interventions Delegation

Implementing and Evaluating Chapter 14

Implementation

Five Activities of the Implementing Phase Reassessing the client Determining the nurse’s need for assistance Implementing nursing interventions Supervising delegated care Documenting nursing activities

Evaluating

Evaluation Assessing the patient to evaluate his or her response to the nursing interventions Evaluate whether outcomes have been met Based on results from the evaluation process, the nursing plan of care may need to be changed Continuous process Copyright © 2014 by Elsevier Inc. All rights reserved.

Components of the Evaluation Process Collecting data Comparing the data with outcomes Relating nursing activities to outcomes Drawing conclusions about problem status Continuing, modifying, or terminating the nursing care plan

Revising the Nursing Care Plan If goals/outcomes are not met If goals are reached Continue current care plan Terminate care plan Copyright © 2014 by Elsevier Inc. All rights reserved.

Quality of Nursing Care Quality assurance Quality improvement Great emphasis on sentinel event Unexpected occurrence involving death or serious physical or psychological injury or at the risk thereof Audits at predetermined intervals Copyright © 2014 by Elsevier Inc. All rights reserved.

PUTTING IT ALL TOGETHER

Denies other pertinent medical history “My stomach hurts.” Let’s Practice The nurse is admitting a client to the healthcare facility. The data below is obtained from a brief conversation with the client. RR-24 BPM T 98.1 PO Denies other pertinent medical history “My stomach hurts.” Pain level = 8 50 year old female BP 152/91 P-96 BPM What other information is necessary to obtain? Any other GI symptoms Location, duration, quality of pain Onset of pain Diet history Stool history Any other observations regarding pain level of 8 Bowel sounds History of HTN Any observable signs of pain

Additional assessment data: Hyperactive bowel sounds heard in all 4 quadrants c/o nausea and diarrhea x 6 during last 8 hrs. c/o intermittent sharp pain in rt. lower abd. X 8 hrs Denies V/D Abdomen soft, non-distended, and tender Organize your assessment data Does any data need validating? ID abnormal findings What other data would you like to gather? Diet history- turkey sandwich and chips about 10 hrs ago Exposure to GI virus?

Risk for deficient fluid volume ?? GI Infection (virus) Anxiety Fear Possible Nursing Diagnoses Acute pain Risk for deficient fluid volume ?? GI Infection (virus) Anxiety Fear Observable indicators of pain include: Moaning, crying, irritability, inability to sleep, grimacing or frowning, restlessness, rigid posture in bed. Other detectable signs include elevation in BP, HR, RR, nausea, diaphoresis.

Nursing Diagnosis Pain R/T AEB

Will report pain is relieved or controlled AEB every shift AEB: Goal Will report pain is relieved or controlled AEB every shift AEB: Rate pain less than or equal to 4 on a 0-10 pain scale 30-60 minutes after each pain intervention No grimacing or guarding VS wnl How do we know someone is not in pain anymore???

Interventions (nursing actions) Administer pain medication as prescribed Encourage relaxation techniques Provide diversionary activities Observe for pain relief and side effects of medication Assess pain level, intensity, duration q 8 hrs and prn Provide teaching on diet status Include: Assessments Dependent interventions (MD orders) Nursing independent interventions (I&O) Teaching

Evaluation Did the client meets expected outcomes? How do we know? Once interventions are carried out, you must determine whether they are effective in helping the client meets expected outcomes.