Slide 1 1 Nursing Process: Foundation for Practice NPN 105 Joyce Smith RN, BSN

Slide 2 2 What is the “Nursing Process”? It is a systematic method that directs the nurse and patient in planning patient care, and enables you to organize and deliver nursing care It is patient centered and outcome oriented The steps are interrelated and dependent on the accuracy of each of the preceding steps It is used to identify, diagnose, and treat human responses to health and illness

Slide 3 3 Together the nurse and the patient accomplish the following: Assess the patient to determine need for nursing care Determine nursing diagnoses for actual and potential health problems Identify expected out comes and plan care Implement care Evaluate the results

Slide 4 4 Five Steps of the Nursing Process Assessment – collection of patient data Diagnosis – identifies patients strengths and potential problems Planning – develop the specific holistic desired goals and nursing interventions to assist the patient Implementation – carry out the plan of care Evaluation – determine the effectiveness of the plan of care

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Slide 6 6 Assessment: Phase One of the Nursing Process Purpose: Establish a baseline of information on the client and develop a data base Determine client’s normal function Determine client’s risk for dysfunction Determine presence or absence of dysfunction Determine client’s strengths Provide data for diagnostic phase

Slide 7 7 Unique Focus of Nursing Assessment Nursing assessments do not duplicate medical assessments Medical assessments target data pointing to pathologic conditions Nursing assessments focus oh the patient’s responses to health problems or potential health problems

Slide 8 8 Assessment The purpose is to establish a database by: Collecting data Subjective versus objective Interviewing and taking a health history Subjective and organized Performing a physical examination Vital signs, patient’s behavior, diagnostic and laboratory data, medical records

Slide 9 9 Approaches for Data Collection Gordon’s 11 Functional Health Patterns Uses a series of questions which assist in formulating a nursing diagnosis Problem focused assessment Focuses on the patient’s problem and develop you plan of care around the problem

Slide Gordon’s Health Patterns Health perception- management Nutritional-metabolic Elimination Activity-exercise Sleep-rest Cognitive -perceptual Self-perception-self- concept Role-relationship Sexuality-reproductive Coping-stress- tolerance Value-belief

Slide Types of Nursing Assessments Initial assessment Focused assessment Emergency assessment Time-lapsed assessment

Slide Types of Data Subjective Data Information perceived only the affected person Cannot be perceived or verified by another person Examples: feeling nervous, nauseated, chilly

Slide Types of Data Objective Data Observable and measurable data Data that can be see, heard or felt by someone other than the person experiencing it Examples: elevated temperature (>101 F), moist skin, refusal to eat, vital signs

Slide Characteristics of Data Complete Factual and accurate Relevant

Slide Components of Data Collection Interview Orientation phase Working phase Termination

Slide Sources of Data Primary patient Secondary Family members Significant other Other healthcare professionals Health records

Slide Components of Data Collection Nursing History Biographical information Reasons for seeking healthcare Present illness or health concern Health history Environmental history Psychosocial and cultural history Review of systems or functional health patterns

Slide Interpreting Assessment Data Data interpretation and validation Data clustering Data documentation

Slide Diagnosis: Phase 2 of the Nursing Process Data is useless if not used An important part of nursing practice is determining what the client needs Developing a nursing diagnosis is the next step in planning for the care of the patient Looking at the data, we can see both problems treated by nursing (nursing diagnosis) and treated by other disciplines (collaborative problems). Nursing diagnosis are not medical diagnosis

Slide Purpose of a Nursing Diagnosis 1. Identify how and individual, group or community responds to an actual or potential health and life processes 2. Identify factors that contribute to or cause health problems (etiology). 3. Identify resources or strengths the individual, group or community can utilize to prevent or resolve problems

Slide Health Problem A condition that necessitates intervention to prevent or resolve the disease or illness or to promote coping and wellness

Slide Health Problems for Nursing Focus Monitoring for changes in health status Promoting safety and preventing harm Identifying and meeting learning needs Tailoring treatment and medication regimens for each individual

Slide Health Problems for Nursing Focus Promoting comfort and managing pain Promoting health and a sense of well being Recognizing and addressing barriers to an independent, healthy lifestyles Determining human responses

Slide Nursing Diagnosis A clinical judgment about individual, family, or community responses to actual and potential health problems or life processes The goal of a nursing diagnosis is to identify actual and potential responses

Slide Medical Diagnosis Identification of a disease condition based on a specific evaluation of physical signs, symptoms, history, diagnostic tests, and procedures The goals of a medical diagnosis is to identify the cause of a illness or injury and design a treatment plan

Slide Nursing Diagnosis Actual or potential health problems that can be prevented or resolved by independent nursing interventions

Slide Nursing Diagnosis Nursing diagnoses provide the basis for selecting nursing interventions that will achieve valued patient outcomes for which the nurse is responsible

Slide NANDA NANDA: North American Nursing Diagnosis Association Established in 1973 to identify standards and classify health problems treated by nurses

Slide NANDA NANDA conferences are held every two years to continue progress in defining, classifying and describing diagnoses

Slide NANDAS’ Definition of Nursing Diagnosis Nursing diagnosis is a clinical judgment about individual, family, or potential health problems/life processes. Nursing diagnosis provides the basis for selection of nursing interventions to achieve outcomes for which the nurse is accountable

Slide Nursing Diagnosis Clinical judgment about individual, family or community Response to actual or potential health or life process Provides basis for nursing interventions Label and action of describing functional problems Identify and synthesize information gathered during assessment

Slide Nursing Diagnosis vs. Medical Diagnosis Medical diagnosis Identify disease Nursing diagnosis Focus on unhealthy response to health or illness Medical diagnosis Physician directs treatment Nursing diagnosis Nurse treats problem within scope of independent nursing practice

Slide Nursing Diagnosis vs. Medical Diagnosis Medical Diagnosis Remains the same as long as the disease is present Nursing Diagnosis May change from day to day as the patient’s responses change

Slide Nursing Diagnosis Medical Diagnosis Myocardial infarction Nursing Diagnosis Fear Altered health maintenance Knowledge deficit Pain Altered tissue perfusion

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Slide 36 Differentiating Nursing Diagnosis versus Medical Diagnosis Nursing DiagnosisMedical Diagnosis - focus on unhealthy responses to health and illness. - identify diseases - describe problems treated by nurses within the scope of independent nursing practice. - describe problems for which the physician directs the primary treatment. - may change from day to day as the patient’s responses change - remains the same for as long as the disease is present

Slide 37 Myocardial infarction (heart attack) is a medical diagnosis. Examples of nursing diagnoses for a person with myocardial infarction include Fear, Altered Health Maintenance, Knowledge Deficit, Pain, and Altered Tissue Perfusion.

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Slide Development of Nursing Diagnosis Assess the patient Review data and find actual and potential problems Use diagnostic reasoning to identify patient needs Arrange data in clusters or defining characteristics Use all data available Reach conclusions for patient needs Determine Nursing Diagnosis according to NANDA approved diagnoses

Slide Components of a Nursing Diagnosis Diagnostic label – name of the nursing diagnosis with descriptors Related factors – includes factors which contribute to the problem and are not the cause,but are associated with it. THESE ARE NOT MEDICAL DIAGNOSIS. Defining characteristics - Assessment data which supports the nursing diagnosis Subjective data – what the patients tells you Objective data – what you observe or data obtained Risk factors – clues which point to potential problems

Slide Nursing Diagnosis Types of diagnoses Actual Risk Wellness

Slide 43 Types of Nursing Diagnoses 1- Actual Nursing Diagnoses Describe a human response to a health problem that is being manifested. They are written as three- part statements: diagnostic label, related factors, defining characteristics. Example – Acute pain related to surgical trauma and inflammation, as evidenced by grimacing and verbal reports of pain.

Slide Risk nursing diagnosis As defined by NANDA, ’’describes human responses to health conditions that may develop in a vulnerable individual, family, or community. It is supported by risk factors that contribute to increased vulnerability’’.

Slide 45 Risk nursing diagnoses are two – part statements because they do not include defining characteristics (diagnostic label, risk factors). Example - Risk for infection related to surgery and immunosuppression. Risk for aspiration related to reduced level of consciousness Risk for Impaired Skin Integrity related to inability to turn self from side to side in bed.

Slide Wellness nursing diagnosis Is a diagnostic statement that describe the human response to levels of wellness in an individual, family, or community that have a potential for enhancement to a higher state (NANDA, 2005).

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Slide 48 Wellness nursing diagnosis are one part statement includes diagnostic label. Example – Readiness for enhanced spiritual well being - Readiness for Enhanced Self-Esteem. Q- Which One is accurate nursing diagnosis? 1- Readiness for Enhanced Family Coping 2- Family coping potential due to desire for better health

Slide What a Nursing Diagnosis is Not A nursing diagnosis is NOT a medical diagnosis A nursing diagnosis is NOT a statement of patient need

Slide Legal Ramifications of Nursing Diagnosis A nurse Can only identify problems within the scope of practice Cannot diagnose or treat medical disease Must identify problems within his/her scope o practice, abilities and education

Slide 51 Nursing Planning The third step of the nursing process includes the formulation of guidelines that establish the proposed course of nursing action in the resolution of nursing diagnoses and the development of the client’s plan of care. The planning of nursing care occurs in three phases: initial, ongoing, and discharge. Each type of planning contributes to the coordination of the client’s comprehensive plan of care.

Slide 52 - Initial planning involves development of beginning of care by the nurse who performs the admission assessment and gathers the comprehensive admission assessment data. Initial planning is important in addressing each prioritized problem, identifying appropriate client goals, and correlating nursing care to hasten resolution of the client’s problems.

Slide 53 - Ongoing planning entails continuous updating of the client’s plan of care. Every nurse who cares for the client is involved in ongoing planning. - Discharge planning involves critical anticipation and planning for the client’s needs after discharge.

Slide 54 The four critical elements of planning include: Establishing priorities Setting goals and developing expected outcomes (outcome identification) Planning nursing interventions (with collaboration and consultation as needed) Documenting

Slide 55 The four critical elements of planning include: Establishing priorities Setting goals and developing expected outcomes (outcome identification) Planning nursing interventions (with collaboration and consultation as needed) Documenting

Slide 56 The client’s basic needs, safety, and desires, as well as anticipation of future diagnoses must be considered. One of the most common methods of selecting priorities is the consideration of Maslow’s hierarchy of needs, which requires that a life-threatening diagnosis be given more urgency than a non life threatening diagnosis. The client must participate in the identification of priorities so that the nature of the problem, as well as the client’s values, are reflected in the selected course of action.

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Slide 58 3rd Component of the Nursing Process- Implementing: The provider carries out the plan of care

Slide 59 During Implementing, the care provider: Carries Out The Plan Of Nursing Care or Setting your plans in motion and delegating responsibilities for each step. Continues Data Collection And Modifies The Plan Of Care As Needed Documents Care

Slide 60 Implementing Consists of doing and documenting the activities that are the specific nursing actions needed to carry out the interventions or nursing orders. The first three nursing process phases- assessing, diagnosing, and planning-provide the basis for the nursing actions performed during the implementing step. In turn, the implementing phase, provide the actual nursing activities and client responses that are examined in the final phase, the evaluating phase.

Slide 61 Process of Implementing Reassessing the client Determining the nurse’s need for assistance Implementing the nursing interventions Supervising the delegated care Documenting nursing activities

Slide 62 Documenting Nursing Activities, the nurse complete the implementing phase by recording the interventions and client responses in the nursing process notes. The nurse may record routine or recurring activities such as mouth care in the client record at the end of shift, while some actions recorded in special worksheets according to agency policy. Immediate recording helps safeguard the client to prevent double actions.

Slide 63 During Evaluating, the care provider: Measures The Clients Achievement Of Desired Goals/Outcomes Identifies Factors That Contribute To The Client’s Success Or Failure Modifies The Plan Of Care, If Indicated

Slide 64 Process of Evaluating Client Responses Collecting data related to the desired outcomes Comparing the data with outcomes Relating nursing activities to outcomes Drawing conclusions about problem status Continuing, modifying, or terminating the nursing care plan.

Slide 65 When determining whether a goal has been achieved, the nurse can draw one of the three possible conclusions: The goal was met, that is the client response is the same as the desired outcomes. The goal was partially met, that is either a short term goal was achieved but the long term was not, or the desired outcome was only partially attained. The goal was not met.

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Slide 67 Thank you…. 67