Nursing Process Unit III NURS 2210 Nancy Pares, RN, MSN Metro Community College

RN Role in developing nursing dx First used in 1953, but not implemented until 1974 Currently five steps – Assessment, diagnosis, outcome identification, implementation, evaluation Emphasis on professionalism, accountability, multiculturalism and scientific method of problem solving

Comparison of nursing vs medical model medical Focuses on illness, injury or disease process Remains constant until cured Identifies conditions that can be treated by qualifying healthcare practitioner nursing Focus on responses to actual or potential diseases Changes as client condition changes Identifies situations in which the nurse is qualified to intervene

Assessment Step 1 Collection of data, organizing data, validating data, identifying patterns, recording data Primary source Secondary source Subjective vs objective

Types of nursing diagnosis Actual – Problem exists Risk – Factors are present to cause problem Possible – Problem could arise unless preventative action taken Wellness – ‘potential for enhanced…’; expressed desire

Developing Nursing dx- Step 2 What are the problems? What are causes? Risk factors? Could a problem occur if prevention not taken? What data is needed to answer these questions? If more than one problem…which is priority?

Planning- Step 3 List priority of nursing dx – Use critical thinking- what needs attention first? Long and short term goals are written – SMART Specific interventions are developed Plan of care is recorded

Implementation- Step 4 Communicate with team to solve complex problems Accurately report data and clues RN needs to know what can be delegated Is there a need to alter the intervention?

Evaluation- Step 5 Was the goal met? Why not? – Assessment incomplete – Goal not SMART – Goal not appropriate for individual client

Maslow’s Priority of Care Physiologic Safety and security Love and belonging Self esteem Self actualization

Delegation decision tree Are there rules and laws in place supporting the rules of delegation? Is the task within the scope of practice Has there been an assessment of the client needs Is the person being delegated tasks competent Does the ability of the caregiver match the needs of the client Can the task be completed without nursing judgment Is the result of the task predictable Can the task be safely performed according to directions Can the task be completed without repeat assessment Is the appropriate supervision available

NCLEX questions LPN –cannot: Do new admission assessments Give IV push meds Write nursing diagnosis Do complex skills Care for clinically unstable clients Care for clients with acute conditions

NCLEX– UAP/CNA Lowest level of skill Least complicated task Most stable Look for client with chronic illness

Client care needs RN Admission Assessment IV meds/blood products Care plan Client teaching Unstable clients/acute LPN Vital signs Uncomplicated skills Stable clients/chronic Oral and IM meds UAP Feeding Basic skills Stable clients/chronic ambulation

The nursing dx, ‘alteration in skin integrity R/T immobility as manifested by Stage 1 pressure ulcer on coccyx ‘ is what type of nursing dx? 1. Risk 2. Possible 3. Wellness 4. Actual

Which of the following is an accurate summary of the difference between medical and nursing dx.? 1. Nursing dx determined by med dx 2. Med dx can be treated by nurse 3. Nursing dx reflects a human response to actual problem 4. Only physicians can treat a pathophysiology.

Client will ambulate 20 ft with walker twice a day. Which phase of nursing process is this? 1. assessment 2. planning 3. implementing 4. evaluation

An example of an independent nursing intervention is: 1. admin IV fluids for client with nutritional impairment 2. turning and repositioning q 2 hr 3. ordering chest xray for client with breathing problem 4. reviewing lab values and reordering tests for abnormal values.

Using aseptic techniques, a nurse demonstrates insulin preparation to a client. This is an example of which phase of nursing process?

When a task is delegated, the role of the nurse is to 1. validate the skill level of the care provider 2. assume the task was completed as expected 3. allow the care provider independence 4. review care provider notes

You determine that the client has not met an expected outcome..What action do you take? 1. call a meeting of team 2. ask the client why the goal was not accomplished 3. call for a nursing consultation 4. review and revise the care plan

A nursing audit is used to evaluate 1. the nursing process 2. institutional standards 3. quality of nursing care 4. client outcomes and goal achievement

The purpose of evaluation is 1. determine whether problems are resolved 2. determine if the nurse developed outcome criteria for the client 3. select appropriate goals and objectives 4. develop a time frame for completing the nurse client relationship.