1. Application of Nursing Process and Nursing Diagnosis: An Interactive Text for Diagnostic Reasoning Sixth Edition Copyright 2013 F.A. Davis Company

2. Chapter 1 The Nursing Process: Delivering Quality Care

3.  "Do everything as quietly as possible. Step lightly and gently and avoid creaking shoes."  "Use no snuff, or any article of food, the smell of which may be offensive to weak nerves."  "Ask no unnecessary questions."

4. The Nursing Profession Definition of Nursing The diagnosis and treatment of human responses to health and illness (ANA, 1995)

5. The Nursing Profession:  Has defined what makes nursing unique  Has identified a body of professional knowledge

6. The Nursing Profession  The American Nurses Association, in its Nursing Social Policy Statement, identified four essential features of today’s contemporary nursing practice...

7. The Nursing Profession 1.Attention to the full range of human experiences…. 2.Integration of objective data… 3.Application of scientific knowledge… 4.Provision of a caring relationship…

8. The Nursing Process  Offers an orderly, logical, problem-solving approach to patient care  Incorporates an interactive/ interpersonal approach for problem-solving and decision- making.

9. The Nursing Process FIVE STEPS  Assessment  Diagnosis/Analysis  Planning  Implementation  Evaluation

10. Diagram of the Nursing Process The steps of the nursing process are interrelated, forming a continuous circle of thought and action.

11. The Nursing Process STEP 1 Assessment— the systematic collection of data relating to clients

12. The Nursing Process STEP 2 Diagnosis— the analysis of collected data to identify the client’s needs or problems

13. The Nursing Process STEP 3 Planning— a two-part process of:  identifying goals and desired outcomes  selecting appropriate nursing interventions

14. The Nursing Process STEP 4 Implementation— putting the plan of care into action

15. The Nursing Process STEP 5 Evaluation—  determining the client’s progress  monitoring the client’s response

16. How the Nursing Process Works  A process you routinely use to solve problems  Applies readily to client-care situations

17. Basic skills the nurse must posses:  A thorough knowledge of science and theory  Creativity  Adaptability  Intelligence  Well-developed interpersonal skills  Competent technical skills  Commitment to practice according to the standards of care

18. Nursing Process Resources  ANA Code of Ethics for Nurses provides guidance  Refer to Appendix A

19. Standards of Care WHAT A REASONABLE PRUDENT PROFESSIONAL WITH SIMILAR EXPERTISE AND RESPONSIBILITIES WOULD HAVE DONE UNDER SIMILAR CIRCUMSTANCES

20. Standards of Care  Describes a competent level of nursing care  Demonstrated by use of the nursing process  Describes roles expected of all professional nurses appropriate to their:  education  position  practice setting

21. Practice Advantages of the Nursing Process  Organizing framework  Human response focus  Structured decision making  Patient involvement  Control over practice  Common language  Means to assess economic contribution of nursing to patient care

22. CRITICAL THINKING  WHAT IS IT?  PURPOSEFUL, FOCUSED THINKING  GUIDED BY STANDARDS, POLICIES, ETHICS, AND THE LAW.  BASED ON PRINCIPLES OF NURSING PROCESS  DRIVEN BY PATIENT NEEDS.  IMPROVES WITH PRACTICE!

23. CRITICAL THINKING “THE ART OF THINKING WHILE YOU ARE THINKING IN ORDER TO MAKE YOUR THINKING BETTER: MORE CLEAR, MORE ACCURATE, OR MORE DEFENSIBLE.” (Paul, Binker, Adamson, and Martin)

24. CRITICAL THINKING  ASSUMPTIONS  INFERENCES  BIASES

25. Chapter 2 The Assessment Step: Developing the Client Database

26. The Assessment Step Assessment involves three basic activities: 1.Systematically gathering data 2.Sorting and organizing data 3.Documenting data in a retrievable format

27. The Client Database  The compilation of data collected about a client  Consists of:  nursing history (*interview)  physical examination  results of diagnostic studies

28. The Client Database  Subjective data – what the client reports, believes, or feels  Objective data – what can be observed; for example, vital signs, behaviors, diagnostic studies

31. Framework for Data Collection  Two commonly used nursing models:  Doenges & Moorhouse’s Diagnostic Divisions  Gordon’s Functional Health Patterns  Others: body systems, head-to-toe

32. Framework for Data Collection  Nursing assessment model focuses data collection on the nurse’s concern—the human responses to health, illness, life processes  See Appendix B for a sample assessment tool

33. The Interview Process: 10 Key Elements  Clear sense of the underlying purpose  Preliminary research  Request to conduct the interview  Sound interviewing strategy  Effective use of icebreakers

34. The Interview Process: 10 Key Elements (cont.)  Addressing the business of the interview  Rapport  Sensitivity to client’s needs  Adequate time for recovery  Closure

35. Effective Data Collection Techniques  Open-ended questions  Hypothetical questions  Reflecting or mirroring responses  Focusing  Giving broad openings  Offering general leads  Exploring  Verbalizing the implied  Encouraging evaluation

36. Data Collection Techniques to Avoid  Closed-end questions  Leading questions  Probing  Agreeing/disagreeing

37. The Client History Client history involves:  Reviewing data  Organizing and determining the relevance of each item  Documenting the facts

38. Guidelines for History Taking  Listen carefully  Use active listening skills  Be objective  Keep detail manageable  Sequence information  Document clearly  Record data in a timely manner

39. PRACTICE HEALTH HISTORY NAME_____J.F______________________AGE__42____DOB_______SEX___F________ MARITAL STATUS____Divorced_______OCCUPATION_Radiology Technician__________ PHYSICIAN (OR USUAL SOURCE OF HEALTHCARE): Dr. Scot, Family physician CHIEF COMPLAINT: Ear hurting for past 4 days. HISTORY OF PRESENT ILLNESS (HPI): Worsening dull pain in right ear for past 3 days. Ear feels "blocked". Pain worse when lying down, relieved slightly with Tylenol. No pain in left ear. Denies sore throat or headache. Has not noticed any drainage from ear. PAST MEDICAL HISTORY (PMH): HTN x 5 years, seasonal allergies, Migraine headaches. PAST SURGICAL HISTORY (PSH): Appendectomy as child, carpal tunnel surgery left hand 2 years ago. MEDICATIONS: Toprol XL 50 mg daily, hydrochlorothiazide 25 mg daily, Frova 2.5 mg as needed for migraine (uses approx 1/month). Baby ASA once daily. Motrin 1-2 times/week for muscle "aches and pains." ALLERGIES/REACTIONS: Benedryl - rash. SOCIAL HISTORY: Smoked 1 pack/day x 20 years, quit 2 months ago. 1-2 glasses wine q eve. Denies street drugs. Lives with boyfriend. FAMILY HISTORY: Father has HTN, mother has osteoporosis, diabetes. 1 sister in good health. 2 sons, ages 17, 21, in good health.

40. REVIEW OF SYSTEMS: (ALL-INCLUSIVE): NEUROLOGICAL_____Denies tremors, difficulty walking. Has aura with migraines, otherwise no vision problems. CARDIOVASCULAR Occasional "skipped" heartbeats, denies chest pain, denies swelling in legs. RESPIRATORYNo SOB, no cough. ______________________________________________________________________________________________________

41. Physical Examination Four methods used:  Inspection  Palpation  Percussion  Auscultation

42. COLLECTING DATA  PHYSICAL ASSESSMENT  ORGANIZATION – GUIDED EITHER BY PT COMPLAINT OR DONE IN A ROUTINE FLOW PATTERN (HEAD-TO-TOE OR SYSTEMS)  DEVELOP AN APPROACH AND USE IT CONSISTENTLY.

43. COLLECTING DATA  Physical exam  GENERAL APPEARANCE  MAY INCLUDE HEIGHT AND WEIGHT  VITAL SIGNS  TPR, BP  INCLUDES PAIN  MAY INCLUDE COUGH, SpO2

44. COLLECTING DATA  PHYSICAL EXAM (CONT.) –  SYSTEMS  NEURO - LOC, ORIENTATION, PUPIL REACTION  (Example of documentation.: Alert, oriented x 3, PERRL, speech clear ). **  May include ext. movement. (Glasgow coma scale)

47. COLLECTING DATA  CARDIOVASC - HT RHYTHM/SOUNDS, PULSES, CAPILLARY REFILL  (Doc. ex: HR 78 & regular, pedal pulses palpable bilaterally, cap. refill <3 sec.)  RESP - RESP, LUNG SOUNDS, PULSE OX  (Doc. ex: Resp. easy, lungs clear bilaterally, non- productive cough. SpO2 98 on room air.)

48. COLLECTING DATA GI - ABD SHAPE, BS, TENDERNESS, BM  (Doc. ex: Abd soft and non-distended, BS auscultated x 4 quads. No tenderness on palpation. Soft brown, formed BM.  GU - URINE, FOLEY?,  (Documentation: Voided clear yellow urine.

49. COLLECTING DATA  SKIN - TEMP, MOISTURE, COLOR, LESIONS?  (Doc. ex: Skin warm, dry, and fleshtone.)  MS - range of motion, active/passive?  (Doc. ex: Active, full ROM in all 4 ext..)

50. Laboratory Tests and Diagnostic Procedures  Part of information-gathering stage  Used to:  Diagnose disease  Follow the course of a disease  Adjust therapy  When analyzing laboratory tests, consider drugs being administered

51. Organizing Information Elements  Cluster the collected data  Review data  Validate findings

52. Chapter 3 The Diagnosis Step: Analyzing the Data (Need/Problem Identification)

53. The Diagnosis Step Purpose: To draw conclusions regarding a client’s specific needs or human responses so that effective care can be planned and delivered

54. The Diagnosis Step These terms may be used interchangeably:  Analysis  Need (or problem) identification  Nursing diagnosis

55. The Diagnosis Step  What is Diagnosis? Forming a clinical judgment identifying a disease/condition or human response through scientific evaluation of signs/symptoms, history, and diagnostic studies.

56. Defining Nursing Diagnosis Nursing Diagnoses are:  Derived from the assessment data  Validated with the patient/others  Documented within a nursing plan of care

57. Medical vs. Nursing Diagnoses  Medical diagnoses illnesses/conditions; reflect alteration of the structure or function of organs/systems; verified by medical diagnostic studies  Nursing diagnoses address human responses to actual and potential health problems/life processes

58. TERMINOLOGY  NANDA - North American Nursing Diagnosis Association International  Ex:  Actual: Impaired Skin Integrity  Potential: Risk for Injury

59. Defining Nursing Diagnosis NANDA’s Definition  Nursing diagnosis is a clinical judgment about responses to actual and potential health problems.  Nursing diagnoses provide the basis for selecting nursing interventions to achieve results for which the nurse is accountable.

60. The Use of Nursing Diagnoses Benefits of the nursing diagnosis 1.Gives nurses a common language 2.Promotes identification of appropriate goals 3.Provides acuity information 4.Can create a standard for nursing practice 5.Provides a quality improvement base

61. Identifying Client Needs  During the Assessment step, the collection, clustering, and validation of client data flow directly into the Diagnosis step of the nursing process

62. Analyzing the Client Database Six Steps in Problem Identification 1. Problem-Sensing 2. Rule-Out Process 3. Synthesizing the Data 4. Evaluating or Confirming the Hypothesis 5. Listing the Client’s Needs 6. Reevaluating the Problem List

63. Analyzing the Client Database Step 1: Problem-Sensing  Data are reviewed and analyzed to identify cues (signs and symptoms) suggesting patient needs.

64. Analyzing the Client Database Step 2: Rule-Out Process  Alternative explanations considered  Compare and contrast relationships among data

65. Analyzing the Client Database Step 3: Synthesizing the Data  Looking at all the data as a whole  Creating a hypothesis

66. Analyzing the Client Database Step 4: Evaluating or Confirming the Hypothesis  Test hypothesis for fit by:  reviewing the nursing diagnosis definition  comparing the assessed data with NANDA’s related or risk factors  comparing the signs/symptoms with NANDA’s defining characteristics

67. Analyzing the Client Database Step 5: Listing the Client’s Needs  Combine the accurate nursing diagnosis label with the assessed etiology and signs/symptoms “PES” STATEMENT

68. Analyzing the Client Database Step 6: Reevaluating the Problem List  List all nursing diagnoses according to priority and classify according to status:  an actual need  a risk need

69. Identifying Client Problems: Other Considerations  The medical/psychiatric diagnosis can provide a starting point for identifying associated client needs.  Even if the need seems to exist only in the mind of the patient, it needs to be addressed and resolved.  Reduce the problem to its basic component to identify more clearly the appropriate interventions to be taken.

70. Writing a Client Diagnostic Statement  Nursing diagnoses identify client needs that can be positively affected, or possibly prevented, by nursing actions.  Some diagnoses permit greater independent function; others are more collaborative.

71. Writing a Client Diagnostic Statement  The extent of independent function is influenced by the nurse’s—  experience  expertise  work setting  established protocols

72. Writing a Nursing Diagnosis  P-E-S Statement – 3 part statement  Problem - Diagnosis according to NANDA  Etiology - the cause or risk factors, stated as “related to”-  Signs and symptoms – called defining characteristics, the evidence that showed your diagnosis or problem. Stated as “as evidenced by”   PROBLEM R/T ETIOLOGY AEB SIGNS AND SYMPTOMS.  (No “S” if potential problem)

73. Writing a Nursing Diagnosis  (P) Constipation R/T (E)use of opioid analgesics AEB (S) abdominal discomfort and hard, small stools.  Impaired verbal communication R/T aphasia AEB inability to communicate basic needs.  Imbalanced nutrition: Less than body requirements R/T vomiting AEB weight loss of 3 lbs over 2 days.

74. Writing a Nursing Diagnosis  Knowledge deficit of med administration R/T lack of recall AEB patient statement “I can never remember to take those pills”  Risk for fluid volume deficit R/T fluid loss secondary to NGT to continuous suction.

75. Writing a Client Diagnostic Statement  Collaborative problem: A need identified by another discipline that contains a nursing component requiring nursing intervention

76. Writing a Client Diagnostic Statement Common Errors :  Using the medical diagnosis: Self Care deficit r/t stroke  Confusing the etiology or signs/symptoms for the need: Postoperative lung congestion r/t bedrest  Use of a procedure instead of the “human response”: Catheterization r/t urinary retention

77. Writing a Client Diagnostic Statement Common Errors:  Lack of specificity: Constipation r/t nutritional intake  Combining two nursing diagnoses: Anxiety and Fear r/t separation from parents

78. Writing a Client Diagnostic Statement Common Errors:  Relating one nursing diagnosis to another: Ineffective coping r/t anxiety  Use of judgmental or value-laden language: Chronic pain r/t secondary/monetary gain

79. Writing a Client Diagnostic Statement Common Errors:  Making assumptions: Risk for impaired Parenting, risk factors of inexperience (new mother)  Writing a legally inadvisable statement: Impaired Skin Integrity r/t not being turned every 2 hours