Nursing Process

Nursing Process Specific to the nursing profession A framework for critical thinking It’s purpose is to: “Diagnose and treat human responses to actual or potential health problems”

Nursing Process Organized framework to guide practice Problem solving method - client focused Systematic- sequential steps Goal oriented- outcome criteria Dynamic-always changing, flexible Utilizes critical thinking processes 1. Lets the nurse dev. A plan of care for the client and gives the nurse direction 2. Helps determine the client’s problems and ways to help the client overcome these problems 3.Based on 5 specific steps which need to be completed in order 4. Based on goals to determine if client’s needs have been met. Designed on monitoring the outcomes of the process 5. Continually looked at, reviewed, and changed based on the client’s condition 6. Guides the nurse to assist the client with reaching their greatest level of health

Advantages of Nursing Process Provides individualized care Client is an active participant Promotes continuity of care Provides more effective communication among nurses and healthcare professionals Develops a clear and efficient plan of care Provides personal satisfaction as you see client achieve goals Professional growth as you evaluate effectiveness of your interventions

5 Steps in the Nursing Process Assessment Nursing Diagnosis Planning Implementing Evaluating Each step needs to be completed before we can progress further in the process

Assessment First step of the Nursing Process Gather Information/Collect Data Primary Source - Client / Family Secondary Source - physical exam, nursing history, team members, lab reports, diagnostic tests….. Subjective -from the client (symptom) “I have a headache” Objective - observable data (sign) Blood Pressure 130/80 Form a data base on information collected about the client

Assessment To elicit as many symptoms as possible, the nurse should use open-ended rather than yes/no questions. Examples: “Describe what you are feeling” “How long have you been feeling this way?” “When did the symptoms start?” “Describe the symptoms” This type of questions will encourage the client to give more information about his or her situation. Listen carefully for cues and record relevant information.

Assessment-collecting data Nursing Interview (history) Health Assessment -Review of Systems Physical Exam Inspection Palpation Percussion Auscultation Methods of data collection Nurse client interview-health history Physical exam inspection Palpation Percussion ausculation

Assessment-collecting data Make sure information is complete & accurate Validate prn Interpret and analyze data Compare to “standard norms” Organize and cluster data

Example ofAssessment Obtain info from nursing assessment, history and physical (H&P) etc…... Client diagnosed with hypertension B/P 160/90 2 Gm Na diet and antihypertensive medications were prescribed Client statement “ I really don’t watch my salt” “ It’s hard to do and I just don’t get it” Based on this assessment we can see one factor effecting the client’s uncontrolled hypertension is lack of maintaining sodium intake restrictions. Which one of these is subjective and objective

Nursing Diagnosis Second step of the Nursing Process Interpret & analyze clustered data Identify client’s problems and strengths Formulate Nursing Diagnosis (NANDA : North American Nursing Diagnosis Association)-Statement of how the client is RESPONDING to an actual or potential problem that requires nursing intervention Nursing Dx is a problem statement of how the client is RESPONDING to a problem…it may be an actual or potential problem Interpreted data is clustered inaccording to body systems, risk factors, family factors,emotional fectors etc.

Diagnosis Statement A working of nursing diagnosis may have two or three parts. The three-part system consists of the nursing diagnosis, the “related to” statement, and the defining characteristics. PES system: P (problem) - The nursing diagnosis, the label; a concise term or phrase that represent a pattern of related cues E (etiology) – “Related to” phrase or etiology; related cause or contributor to the problem S (symptoms) –Defining characteristics phrase; symptoms that the nurse identified in the assessment

Nsg Dx vs MD Dx Within the scope of medical practice Within the scope of nursing practice Identify responses to health and illness Can change from day to day Within the scope of medical practice Focuses on curing pathology Stays the same as long as the disease is present

Example of Nursing Dx Ineffective therapeutic regimen management R/T difficulty maintaining lifestyle changes and lack of knowledge AEB B/P= 160/90, dietary sodium restrictions not being observed, and client statements of “ I don’t watch my salt” “It’s hard to do and I just don’t get it”. Based on our assessment of the client with hypertension who wasn’t following the prescribed low salt diet this is an example of a nsg dx. First part is the clients problem taken from the NANDA list Second part is a reason why the client has the problem Third part is the evidence of the problem

Types of Nursing Diagnoses Actual Imbalanced nutrition; less than body requirements RT chronic diarrhea, nausea, and pain AEB height 5’5” weight 105 lbs. Risk Risk for falls RT altered gait and generalized weakness Wellness Family coping: potential for growth RT unexpected birth of twins.

Case study: A 73-year-old man has been admitted to the unit with a diagnosis of chronic obstructive pulmonary disease (COPD). He states that he has “difficulty breathing when walking short distances”. He also states that his “heart feels like it is racing” at the same time. He states that he is “tired all the time”, and while talking to you he is continually wringing his hands and looking out the window.

Step II: Nursing Diagnosis Part 1 (Problem) Interpretation of information: “difficulty breathing when walking short distances”= dyspnea “heart feels like it is racing”= dysrythmia “tired all the time”= fatigue In Section II we can find the nursing diagnosis Activity intolerance listed with these symptoms.

Step II: Nursing Diagnosis To validate that the diagnosis Activity intolerance is appropriate for the client, we have to read NANDA definition of the nursing diagnosis. When reading, ask Does this definition describe the symptoms demonstrated by the client? If the appropriate nursing diagnosis has been selected, the definition should describe the condition that has been observed.

Activity intolerance NANDA Definition Insufficient physiological or psychological energy to endure or complete required or desired daily activities. Defining Characteristics Verbal report of fatique or weakness; abnormal heart rate or blood pressure response to activity; exertional discomfort or dyspnea; electrocardiografic changes reflecting dysrhytmias or ischemia Related factors (r/t) Bed rest or immobility; generalized weakness,; sedentary lifestyle; imbalance between oxygen supply and demand

Part 2 (Etiology) “Reated to” Phrase This phrase states what may be causing or contributing to the nursing diagnosis, commonly referred to as the etiology. Ideally the etiologe, or cause, of the nursing diagnosis is something that can be treated by a nurse. When this is the case, the diagnosis is identified as an independent nursing diagnosis. If medical Intervention is also necessary, it might be identified as a collabarative diagnosis. For each suggested nursing diagnosis, the nurse should refer to the statements listed under the heading “Related Factors”

Part 3 (Symptoms) Defining Characteristic phrase It consist of the signs and symptoms that have been gathered during the assessment phase. Signs and symptoms are labeled as defining characteristics in Section III. The use of identifying defining characteristics is similar to the process the physician uses when making a medical diagnosis

Writing a Nursing Diagnosis Statement P - Activity intolerance E – “Related to” imbalance between oxygen supply and demand S – Verbal reports of fatique, exertional dyspnea (“difficulty breathing when walking”), and dysrythmia (“racing heart ”)

Collaborative Problems Require both nursing interventions and medical interventions EXAMPLE: Client admitted with medical dx of pneumonia Collaborative problem = respiratory insufficiency Nsg interventions: Raise HOB, Encourage C&DB MD interventions: Antibiotics IV, O2 therapy

Planning Third step of the Nursing Process This is when the nurse organizes a nursing care plan based on the nursing diagnoses. Nurse and client formulate goals to help the client with their problems Expected outcomes are identified Interventions (nursing orders) are selected to aid the client reach these goals. Now that we have a nsg dx we need a plan to help this client Goals allow us to determine the specific outcome desired by the client Short term- goal in which a specific time frame with date ie Able to identify 20 foods which are low in sodium within 2 days Long term goal in which desired outcome is expected in a broader time frame ie Client be able to develop a daily meal plan based on 2 Gm Na restrictions by the end of the monthl Cognitive goal - goal in which client gains new knowledge ie able to correctly identify foods high and low in sodium Pyschomotor goal- goal in which client’s acquire a new skill ie client able to correctly monitor B/P using stethoscope and sphygmomanometer Affective goal - goal in which the client’s values or attitudes change ie client able to accept the need for maintaining life time dietary changes to control B/P Interventions are nursing orders that you are empowered to select based on your judgement of the client’s needs Prioritize most important goals first

Planning – Begin by prioritizing client problems Prioritize list of client’s nursing diagnoses using Maslow Rank as high, intermediate or low Client specific Priorities can change Pt. Have many dx…..need to prioritize

Planning Developing a goal and outcome statement Goal and outcome statements are client focused. Worded positively Measurable, specific observable, time- limited, and realistic Goal = broad statement Expected outcome = objective criterion for measurement of goal Utilize NOC as standard EXAMPLE Goal: Client will achieve therapeutic management of disease process…. Outcome Statement: AEB B/P readings of 110-120 / 70-80 and client statement of understanding importance of dietary sodium restrictions by day of discharge. NOC = nursing outcome classification

Planning- Types of goals Short term goals Long term goals Cognitive goals Psychomotor goals Affective goals

Goals are patient-centered and SMART Specific Measurable Attainable Relevant Time Bound

Goals PT. will walk 50 ft. Pt. will eat 75% of meals Pt. will be OOB 2-4 Hrs. Pt. will maintain HR <100 To will state pain level is acceptable 6 (0-10)

Planning-select interventions Interventions are selected and written. The nurse uses clinical judgment and professional knowledge to select appropriate interventions that will aid the client in reaching their goal. Interventions should be examined for feasibility and acceptability to the client Interventions should be written clearly and specifically. Be specific clearly state what teaching is needed, materials to be used etc Utilize research and evidence based practice protocols

Interventions – 3 types Independent ( Nurse initiated )- any action the nurse can initiate without direct supervision Dependent ( Physician initiated )-nursing actions requiring MD orders Collaborative- nursing actions performed jointly with other health care team members

Implemention The fourth step in the Nursing Process This is the “Doing” step Carrying out nursing interventions (orders) selected during the planning step This includes monitoring, teaching, further assessing, reviewing NCP, incorporating physicians orders and monitoring cost effectiveness of interventions Utilize NIC as standard NIC = nursing intervention classification

Implementing- “Doing” Teach potential complications of hypertension to instill importance of maintaining Na restrictions Assess for cultural factors affecting dietary regime Monitor VS q4h Maintain prescribed diet (2 Gm Na) Teach client amount of sodium restriction, foods high in sodium, use of nutrition labels, food preparation and sodium substitutes Teaching may be given to client as well as family members…state this in the nursing interventions Specific handouts, dietary consults etc all would be included

Implementing – “Doing” Teach the client- hypertension can’t be cured but it can be controlled. Remind the client to continue medication even though no S/S are present. Teach client importance of life style changes: (weight reduction, smoking cessation, increasing activity) Stress the importance of ongoing follow-up care even though the patient feels well.

Evaluation- To determine effectiveness of NCP Final step of the Nursing Process but also done concurrently throughout client care A comparison of client behavior and/or response to the established outcome criteria Continuous review of the nursing care plan Examines if nursing interventions are working Determines changes needed to help client reach stated goals. Is the goal met and problem resolved? Is goal not yet reached but progress being made and care ongoing? Is goal not met and revisions needed to the care plan?

Evaluation Outcome criteria met? Problem resolved! Outcome criteria not fully met? Continue plan of care- ongoing. Outcome criteria unobtainable- review each previous step of NCP and determine if modification of the NCP is needed. Were the nsg interventions appropriate/effective?

Evaluation Factors that impede goal attainment: Incomplete database Unrealistic client outcomes Nonspecific nsg interventions Inadequate time for clients to achieve outcomes.

Checkpoint Identify which stage of the nursing process is being described below: The nurse writes nursing interventions A goal is agreed upon The nurse performs a physical assessment A revision is made to the NCP The nurse administers antibiotic medication A statement is written that outlines the clients response to a potential health problem Planning Assessment Implementation Diagnosis

S and O Data Quiz RR 22/min, even unlabored “I can only walk 3 blocks before my legs start to hurt” Pain rated 3 on a scale of 0-10 Skin pink, warm and dry Urine output 300mL/8 hr “My wife doesn’t come to visit very often” Dressing clean, dry and intact.

NCLEX Time The nurse records the following subjective data in the client’s medical record: A.Breath sounds clear to auscultation B.Amber urine in sufficient quantities C.Pain intensity 8 out of 10 D.Skin warm and dry

NCLEX Time When interviewing a client, the nurse uses the following open-ended style sentence: A.Do you have any concerns right now? B.Is your family worried about you being in the hospital? C.How many times do you get up to go to the bathroom at night? D.What do you mean when you say, “I don’t feel quite right?”

NCLEX Time In order for an actual nursing diagnosis to be valid it must have one or more supporting: A.Laboratory results B.Diagnostic data C.Defining characteristics D.Medical diagnoses

NCLEX Time Nursing diagnoses are aimed at identifying client problems that are treatable by _______. A.The physician B.The nurse C.Invasive techniques D.Complementary strategies