2. 2/18/20161 NURSING PROCESS

3. 2/18/20162 Definition Nursing process is a systematic method of giving humanistic care that focuses on achieving desired outcomes (results) in a cost effective fashion

4. 2/18/20163 The Nursing Process is Systematic Using 5 Steps Assessment Diagnosis Planning Implementation Evaluation ADPIE

5. 2/18/20164 Why Should We Learn The Nursing Process? Requirement by ANA Basis for questions on state boards Promotes critical thinking Application Assists with goals of nursing

6. 2/18/20165 Assessment You collect and examine information about health status, looking for evidence of abnormal function or risk factors that may contribute to health problems

7. 2/18/20166 Assessment Primary source-data from client Secondary source-other than client Resources- your turn to given examples

8. 2/18/20167 How Do You Get Your Info? Interview Chart review Physical Assessment Inspection-look Auscultation-listen Palpation-feel

9. 2/18/20168 Types of Data Subjective Objective Cues Inferences Data Base

10. 2/18/20169 How Do You Organize Data? Clustering-A critical thinking principle that enhances your ability to get a clearer picture of health status Cluster data to body systems What are some of the subsystems? Maslow

11. 2/18/201610 Final Stage of Assessment Reporting- expedites diagnosis and treatment of urgent problems Ongoing process Recording-promotes continuity, accuracy, and critical thinking

12. 2/18/201611 Diagnosis-Problem Identification The process of analyzing data and putting related cues together to make judgments about health status You analyze data and identify actual/potential problems, which are the basis for the plan of care

13. 2/18/201612 NANDA INTERNATIONAL North American Nursing Diagnosis Association is the official classification of nursing diagnosis Use it well

14. 2/18/201613 Definitions Medical diagnosis Nursing diagnosis

15. 2/18/201614 Parts of a Nursing Diagnosis Problem-the purpose of the problem statement is to describe the health state or health problem of the client

16. 2/18/201615 Etiology of Problem/Related Factors The cause

17. 2/18/201616 Risk factors-something known to contribute to or be associated with a specific problem Defining characteristics-a cluster of cues (signs, symptoms, risk and related factors) often associated with a specific nursing diagnosis. They identify the subjective and objective data that signal the existence of the problem.

18. 2/18/201617 Types of Nursing Diagnosis Actual Risk for Wellness

19. 2/18/201618 Types of Diagnosis Actual-the client’s data base contains evidence of sign/symptoms or defining characteristics of the diagnosis- use a 3 part statement

20. 2/18/201619 Writing Risk for Diagnosis Risk for- data base contains evidence of the related (risk factors) of the diagnosis but no evidence of defining characteristics-use a 2 part statement There are no defining characteristics present, thus there are only 2 parts to a Risk for diagnosis

21. 2/18/201620 Wellness Diagnosis Judgment about a client in transition from a specific level of wellness to a higher level of wellness Effective Breast Feeding

22. 2/18/201621 How to Write a Nursing Diagnosis

23. 2/18/201622 Collaborative Problem, Potential Complication (PC) Intravenous therapy PC- Phlebitis related to IV

24. 2/18/201623 Errors Don’t make value judgments Don’t legally incriminate yourself Don’t use 2 problems at the same time Don’t use a medical diagnosis as the etiology of the diagnostic statement

25. 2/18/201624 Mapping

26. 2/18/201625 Planning Let’s review your outline

27. 2/18/201626 Maslow’s Hierarchy of Needs Physiologic Safety/Security Love and Belonging Self Esteem Self Actualization

28. 2/18/201627 Goals/Expected Outcomes Measurable

29. 2/18/201628 Common Errors in Writing Goals/Expected Outcomes Expressing the expected outcome as an intervention Not using measurable verbs Writing vague outcome criteria

30. 2/18/201629 Nursing Interventions

31. 2/18/201630 See, Do, Teach, Record What to look for (see) What to do? (do) What to teach (teach) What to record? (record)

32. 2/18/201631 EXPECTED OUTCOMES Client will achieve pain control within 48 hours (2/4/07, 1600) Client will achieve pain control by discharge

33. 2/18/201632 Nursing Orders/Interventions Always date and time per hospital policy at the beginning of the entry Your signature at the end of the entry

34. 2/18/201633 Another Example (Client has pneumonia following gallbladder surgery and has Ineffective Airway Clearance) Always date and time per hospital policy Auscultate lungs q 2 hr. (Even hours). Encourage coughing and breathing exercises with pillow over incision every 4 hr. (8,12, etc.) Up in chair once a shift Signature

35. 2/18/201634 Implementation Put the plan into motion Assist the client in the achievement of healthcare goals

36. 2/18/201635 Evaluation Is an ongoing process

37. 2/18/201636 Evaluation Determine whether the expected outcomes have been achieved! Determine if the goal has been met!

38. 2/18/201637 Rome Wasn’t Built in 1 day

39. 2/18/201638 Identify Variables What factors do you think may cause the client to not achieve the expected outcomes and thus the goal?

40. 2/18/201639 Implementation Put the plan into motion Get report Assess and reassess Performing interventions Charting Giving report

41. 2/18/201640 Impaired Skin Integrity 1/18/04 Inspect the client's skin for redness and breakdown q 4 hours. Lift and move client carefully using a turn sheet and adequate assistance q 2 hours. Turn client q 2 hours (even hours). Signature

42. 2/18/201641 Planning Determine immediate priorities Establish expected outcomes (goal) Determine interventions (nursing actions) Record and individualize the plan of care

43. 2/18/201642 Include in Nursing Orders Date Verb-action to be performed Subject-who is to do it Descriptive-How, when, where, how often, duration, how much Signature

44. 2/18/201643 Humanistic approach Based on the belief that as we deliver care, we must consider the interests, ideals and desires of the health care consumer Person, family, community

45. 2/18/201644 Clinical Setting Prevent illness, promote, maintain and restore health and in terminal illness-to achieve a peaceful death Enables people to manage own care Promote cost effective quality care Improvement

46. 2/18/201645 Definitions-Nursing A clinical judgment about an individual or family response to actual or potential health problems and life processes Interpret and analyze data gathered from the nursing assessment It describes the client’s response to a health problem that the nurse is licensed and competent to treat

47. 2/18/201646 Possible nursing diagnosis- using your intuition

48. 2/18/201647 How to write a diagnosis 3 part system-PRS Problem Related (Risk) Factors Signs/Symptoms (defining characteristics) ______________R/T________AEB__ __ ______________R/T________2_____ _

49. 2/18/201648 Examples Impaired Physical Mobility R/T pain and weakness in weight bearing extremity AEB pt. statement “I can’t move because of the pain” Impaired Physical Mobility R/T pain and weakness in wt. bearing extremity 2 L total knee surgery R/T links the problem and the etiology or related factors AEB/2-states evidence that supports the diagnosis is present

50. 2/18/201649 Ineffective Airway Clearance R/T fatigue AEB “I’m to weak to cough” Ineffective Airway Clearance R/T fatigue 2 to Pneumonia

51. 2/18/201650 Writing outcomes Subject Verb Criteria Target date