1. 3-1 Transition to Registered Nursing West Coast University Week 3 Nursing Process: Overview, Assessment and Nursing Diagnosis

2. 3-2 Objectives History of the Nursing Process and Nursing Diagnosis Discuss characteristics of Nursing Process and Nursing Diagnosis Describe Assessment Formulate a Nursing Diagnosis

3. 3-3 This is Nursing

4. 3-4 This is Brian on Nursing

5. 3-5 History of Nursing Diagnosis 1950’s –Introduction only – mainly used in relationship to the care plan –only sporadically in the literature 1970’s –1 st National Conference for classification of Nursing Diagnosis and formed the North American Nursing Diagnosis Association (NANDA) –ANA published standards of practice & a social policy statements

6. 3-6 History of Nursing Diagnosis 1970’s – continued –ANA published standards of practice & a social policy statements Defined nursing as diagnosis and treatment of human response to actual or potential health problems 1990’s –9 th Conference of NANDA was held and Taxonomy II was published

7. 3-7 Globalization of Nursing Nursing Diagnosis is recognized globally –Provides common language for nursing to talk to each other, identifies problems, gives nursing greater accountability, and professional autonomy –Captures nursing’s contributions to health, enables cross- country comparisons of nursing and promotes the development of nursing

8. 3-8 Pre-1955: No clearly identifiable boundaries defined for nursing practice 1955: Term nursing process coined by Lydia Hall 1973: ANA published Standards of Clinical Nursing Practice continues Timeline

9. 3-9 Timeline 1973: Classification of nursing diagnoses began: North American Nursing Diagnosis Association (NANDA) 1980: ANA published A Social Policy Statement 1982: NCLEX exams were revised to include concepts 1994: JCAHO initiated requirements for accredited hospitals to use the nursing process Current: Ongoing use of the five-step process In 2006 NANDA had their 13 Conference

10. 3-10 Basic Characteristics of the Nursing Process Method of providing care Purposeful, systematic, and orderly Method of problem solving and decision making Scientifically based—understanding of the human body Philosophically based—understanding of philosophical views

11. 3-11 Nursing Process Characteristics Method for organization Promotes wellness Restores wellness Maintains present state of health continues

12. 3-12 Nursing Process Characteristics Promotes quality care Promotes coordinated, ongoing care Serves as a guide to avoid omissions or inaccuracies Provides a framework for nursing continues

13. 3-13 Nursing Process Characteristics Client centered Assists to plan according to client needs Client participates Promotes collaboration with other disciplines Universally applicable

14. 3-14 Nursing Skills Interpersonal Technical Intellectual

15. 3-15 Critical Thinking Purposeful thought process Strategy used in search for meaning Deliberate questions are asked

16. 3-16 Problem Solving Gather data Identify problem Interpret data Plan to resolve Implement plan Evaluate results

17. 3-17 Decision Making Based on scientific theories Results from nurse’s ability to think critically Perceptual and intellectual skills used

18. 3-18 Maslow’s Hierarchy of Needs

19. 3-19 Benefits of the Nursing Process Improved quality of care Continuity of care Promotes client participation in care Delivery of care is organized, continuous, and systematic Efficient use of time and resources Expectations of client and standards of care are met Holds nurses accountable and responsible

20. 3-20 Five Steps of the Nursing Process Assessment Diagnosis Planning and outcome identification Implementation Evaluation

21. 3-21 Scope and Standards of Practice I.Assessment: Nurse collects data II.Diagnosis: Nurse analyzes data in determining diagnoses III.Outcome identification: Nurse identifies expected outcomes IV.Planning: Nurse develops a plan of care V.Implementation: Nurse implements interventions identified in plan VI.Evaluation: Nurse evaluates client’s progress From American Nurses Association. (1991). Standards of clinical nursing practice. Washington DC: Author.

22. 3-22 continues Questions Critical Thinkers Ask... What actual problems were identified during assessment? What are possible causes? Is client at risk for developing other problems? What are the factors involved? Did the client indicate a desire to function at a higher level of wellness?

23. 3-23 Questions Critical Thinkers Ask... What are the client’s strengths? What additional data might be needed to answer these questions? What are possible sources of data collection? Is collaboration needed at this time? What data are pertinent to collect before contacting the physician?

24. 3-24 Assessment Gathering data Organizing Verifying accuracy Documenting data

25. 3-25 Characteristics of Assessment Systematic, ongoing, and continuous Process of collecting data Identification of problems Data yield information regarding health status

26. 3-26 Types of Data Subjective Objective Complements, clarifies, supports

27. 3-27 Baseline Data Initial data becomes foundation Accurate data collection is critical Used for comparison of future data

28. 3-28 Data Collection Interview, physical exam, diagnostic exams Communicated and documented Begins when client enters health care system Continues as long as there is a need

29. 3-29 Validating & Clarifying Data Subjective Data: “I feel like my heart is racing” Objective Data: Pulse 150 beats per minute, regular, strong

30. 3-30 Sources of Data Client Family or significant other Nursing records Medical records Consultations Health care team members Diagnostic results Relevant literature

31. 3-31 Data Collection Tools Organization Documentation Nursing models Holistic

32. 3-32 Methods of Data Collection Observation Interview Physical assessment

33. 3-33 Promoting Data Collection Use communication techniques –paraphrasing –clarifying –focusing –summarizing –open-ended questions

34. 3-34 Data Clustering Determines relation Finds patterns

35. 3-35 Diagnosis Analysis Problem identification Nursing diagnosis

36. 3-36 Nursing vs. Medical Diagnoses Nursing Diagnosis Determined by the nurse Clinical judgment about the client Human responses to disease or treatment May change Medical Diagnosis Determined by physician Indicates disease, illness Doesn’t change

37. 3-37 Definition: Nursing Diagnosis A clinical judgment about individual, family, or community responses to actual or potential health problems/life processes. Nursing diagnosis provides the basis for selecting interventions to achieve outcomes for which the nursing is accountable

38. 3-38 Types Nursing Diagnosis Actual Risk Possible Syndrome Wellness Collaborative

39. 3-39 Making a Nursing Diagnosis Know diagnoses –Collect valid & pertinent data, cluster data, differentiate nursing diagnosis from collaborative problems, prioritize Defining the characteristics –Major & Minor Related factors –Pathophysiological –Treatment –Situational –Maturational

40. 3-40 Actual ND Represents a problem that has been validated by the presence of major defining characteristics. Has four parts –Label –Definition –Defining characteristics –Related factors

41. 3-41 Risk ND Clinical judgment that an individual, family or community is vulnerable to develop the problem than others in the same or similar situation

42. 3-42 Possible ND Describes a suspected problem requiring additional data. This is where data is not complete or an evaluation has not been completed Not a NANDA ND because it is not classified, yet viable for the clinical nurse for further clarification of a problem

43. 3-43 Syndrome ND Clustering of predictable actual or high-risk NDs related to events or situations Complex clinical situation, use with care and stated as a one-part statement There should be a clustering of other NDs

44. 3-44 Wellness ND Clinical judgment about an individual, family or community transition from a specific level of wellness to a higher level Stated as a one-part

45. 3-45 Collaborative Problems Physiologic complications that nurses monitor to detect onset or changes in status. Nurses manage collaborative problems with PCP-prescribed (dependent nursing functions) and Nursing-prescribed (independent nursing functions) to minimize complications

46. 3-46 Cultural, Ethical & Spiritual ND Cultural Needs –Where is the cultural component? –Belief system, knowledge, food, environment, powerlessness Ethical Issues –What do you do with issues that are illegal, or different from your belief system? Spiritual Concerns –Does, or how does the patient utilize spirituality in there health care?

47. 3-47 Components of a Nursing Diagnosis Stated as one, two or three parts Type of DiagnosisParts needed Actual3 – Label, Factors, S/S Risk2 – Label, Factors Possible2 – Label, Factors Syndrome1 – Label Wellness1 – Label CollaborativeNeed the stem: Potential Complications (PC)

48. 3-48 Formulating Nursing Diagnosis Diagnostic Label (Stem) Contributing Factors (Etiology – RT) Signs & Symptoms (AEB) Related to As evidenced by/secondary to

49. 3-49 Example of Actual Nursing Diagnoses Hyperthermia –Client’s temperature is 104.6°F. Impaired Gas Exchange –Client’s oxygen saturation in arterial blood is 92%. continues

50. 3-50 Example of Actual Nursing Diagnoses Pain –Client states pain level “8” on scale of one to ten. Anxiety –Client states he is experiencing anxiety. Self-care deficit –Client is unable to perform ADLs.

51. 3-51 Components of Actual Nursing Diagnoses Problem Etiology Defining characteristics

52. 3-52 Problem Label Nursing diagnosis

53. 3-53 Etiology Related to (R/T) or related factor Involved in development of problem Becomes focus for interventions Cause component Gives direction to problem statement

54. 3-54 Defining Characteristics As evidenced by (AEB) Clinical evidence How response is manifested

55. 3-55 Examples

56. 3-56 Scenario One: The nurse is caring for a client who was involved in a motor vehicle accident and sustained superficial skin trauma. The client’s epidermal layer of skin on the right knee, forearm, and hand is excoriated, reddened, and bleeding as the result of sliding across a cement pavement.

57. 3-57 Answer: Impaired Skin Integrity R/T: mechanical factors, shearing forces AEB: disruption of skin surface, destruction of skin, layers, traumatized skin excoriated, reddened, bleeding

58. 3-58 Scenario Two The client you are caring for has been medically diagnosed with a right cerebral vascular accident (stroke). He experiences partial paralysis on the left side of his body. He is unable to turn over while in bed without assistance and has demonstrated decreased muscle strength and control in the left extremities.

59. 3-59 Answer: Impaired Physical Mobility R/T: neuromuscular impairment AEB: inability to purposefully move within the environment, decreased muscle strength, control, left-sided partial paralysis

60. 3-60 Components of Risk Nursing Diagnoses Potential problem Risk factor No evidence Problem does not exist

61. 3-61 Risk Nursing Diagnoses Examples Cancer patient, Risk for Infection –Risk Factors (R/T): inadequate secondary defenses, immunosuppression Client with surgical incision, Risk for Infection –Risk Factors (R/T): inadequate primary defenses, invasive procedure continues

62. 3-62 Risk Nursing Diagnoses Examples Client who is semi-conscious, vomiting, Risk for Aspiration –Risk Factors (R/T): reduced level of consciousness, vomiting Neonate unable to maintain his body temperature, parent does not keep the child covered, Risk for Hypothermia –Risk Factors (R/T): extremes of age, inadequate clothing