1 the nursing process nur 403 foundations of nursing practice sp 10

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1 The Nursing Process NUR 403 Foundations of Nursing Practice SP 10

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Page 1: 1 The Nursing Process NUR 403 Foundations of Nursing Practice SP 10

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The Nursing Process

NUR 403 Foundations of Nursing PracticeSP 10

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The Nursing Process is ...

“A systematic, rationale method of planning and providing individualized nursing care.

Its purpose is to identify client’s health status, actual or potential healthcare

problems or needs, to establish plans to meet those needs and to deliver specific

nursing interventions to meet those needs”.(Kozier, 2004)

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The Nursing Process is ...

The set of activities that professional nurses perform to determine the needs of the patient and make a judgment to provide the care that is needed.

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Your legal and professional accountability and the nursing of process

CA BRN Standards of Competent Performance: RN shall be considered to be competent when he/ she consistently demonstrates the ability to transfer scientific knowledge…in applying the nursing process:

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Standards of Competent Performance (Board of Registered Nursing)

Formulates nursing diagnosis, through observation and interpretation of information.Formulates a care plan in collaboration with the client.Performs skills essential to the nursing actions to be taken.Delegates tasks to subordinatesEvaluates the effectiveness of the care planActs as the client’s advocate.

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American Nurses Association Standards of Practice

The collection of data is systematicDerive nursing diagnosis from dataPlan nursing care including goalsPlan includes priorities and nursing approachesNursing actions provide for client participation in health promotion, maintenance, and restorationEvaluation of progress or lack of progress

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Problem-Solving & Priority Setting

Priority Setting:Determine client health values & beliefsEstablish priorities from highest to lowest

Determine urgency or the problemProblem-Solving:

Once problem is identified, collect dataAnalyze the data & identify an action-planImplement the plan, observing initial responsesEvaluate the results

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Steps of the Nursing Process

AssessmentDiagnosisPlanningImplementationEvaluation

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The Nursing Process

Otten/403 9

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The Nursing Process

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Assessment Phase

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Assessment Data

Subjective Data- The client states “ . . .”

Objective Data- Vital signs- Physical assessments- Previous documentation

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Examples of DataTemp of 102 degree“I feel tired”WBC 24,000/mm3“I need help to walk”B/P 180/96“My leg hurts”Redness and swelling in R ankle

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Diagnosis Phase

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A Nursing Diagnosis is ...

A description of the client’s response to a disease state, process, condition or situation. It is “a

clinical judgment about an individual, family or community responses to actual/potential health

problems/life processes. Nursing diagnoses provide the basis for selection of nursing

interventions to achieve desired client outcomes”.

(NANDA, 1990)

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Comparing Nursing & Medical Diagnoses

Nursing Diagnosis Describes a response to a

disease process, condition or situation

Oriented to individual

changes as client changes

Compliments medical diagnoses

Teaches client re self-care

Medical Diagnosis Describes a specific disease

process

Oriented to pathology & remains constant

Well defined classification system

Teaches clients about treatments

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Advantages & Disadvantages of Nursing DiagnosesAdvantages:

Provides a common language for nursesOutcome-orientedEfficient, Organized , Systematic, and Goal Directed

Disadvantages:Inconsistently usedNot always formally recognized (by MDs.)Some problems don’t fit diagnostic statements as outlined by NANDA

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Two Types of Nursing Diagnoses

Actual Problems:Altered Nutrition, less than body requirements

related to poor oral intake as evidenced by weight loss of 12 lbs. in two weeks.

Potential Problems:High risk for infection (Potential for) related to

decreased primary defenses.

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Components of a Nursing DiagnosisActual Problem (3 Part Statement)

Diagnostic Label/Statement (Problem Statement):“ Activity Intolerance” “Impaired Physical Mobility”(identifies unhealthy responses, what needs change)Etiology (Contributing Factors)“… related to _______________”(identifies factors causing undesirable response)Defining Characteristics (Manifestations)“ … as evidenced by __________” (what you see)

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Components of a Nursing Diagnosis

Potential Problems (2 Part Statement) Diagnostic Label/Statement Etiology (Contributing Factors)

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Planning Phase

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Planning Phase: Goals & Outcomes

Goals are broad statements about the effects of nursing interventions on the client (overall, non-measurable statements) Outcomes are specific, measurable criteria used to evaluate whether goals have been met based on specific nursing interventions

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Outcome Statements (Criteria)

Outcomes are derived from the diagnosisOutcomes are measurable/behavioralOutcomes are realistic compared to the client’s self-care abilitiesOutcomes have a time-frame for completionOutcomes provide direction for care

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Planning Phase: Interventions

Interventions should be developed which are consistent with the established plan of care

Interventions should be implemented in a safe, appropriate manner based on sound nursing theory and judgment

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Planning Phase: Interventions

Interventions should always be documented in the medical recordInterventions should be realistic for client, based on abilities and resources

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Types of Nursing InterventionsIndependent:

Able to be implemented without a physician’s order

Dependent: Must have or obtain physician’s order to implement this intervention

Collaborative: Combination of dependent/independent nursing intervention

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Types of Nursing FunctionsIndependent: functions that are within scope of nursing practice.

Assessment - history and physicalNursing diagnosis, which require nursing interventionsNursing actionsReferrals to other health membersEvaluation of patient’s responses

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Types of Nursing FunctionsInterdependent: activities that are carried out in conjunction with other health team members.

RN works with a dietician to help a diabetic patient control blood sugar.RN works with PT to help improve patient’s ambulation.

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Nursing Functions

Dependent: activities performed based on the physician’s orders

Administration of medicationCarrying out specific treatments

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Independent? Interdependent? Dependent?Patient has a B/P of 160/100, the RN

Retakes the B/P; ask the pt what he was doing.Asks the pt. how he is feeling, notes changesChecks B/P with the previous B/P readings.Checks the MD’s order for any related orders.Gives treatments ordered by the MD.Monitors effects of medication.Teaches the pt. relaxation techniques.

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Focus of Patient CareMedicine and Nursing

Patient reports, “It feels like my chest is being crushed”Observations show facial grimace, SOB (shortness of breath), and diaphoresis (perspiring)

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Focus of Patient Care

Goal of Medicine: cure, treat disease, heal physiologic being

Goal of Nursing: works with the whole person

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Focus of Patient CareMedical interpretation of pain: diminished blood flow from coronary arteries to myocardiumProbable Diagnosis: Myocardial Infarction

Nursing interpretation: Pain in the chestProbable Nursing Diagnosis: chest pain related to cardiac disease

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Focus of Patient CareMedical Plan: dependent functions

BedrestVital Signs q 15 min.Morphine 2mg IV prnNTG 1/200 gr SL prnEKG, O2 at 2L/min

Nursing Plan: independent functions

Monitor EKG and dysrhythmiaAssess chest painEmploy comfort measures, allow restAlleviate anxiety

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Implementation Phase

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Implementation Skills (3)

Require cognitive skills (problem-solving, creative & critical thinking skills)Require interpersonal skills (verbal/non-verbal communication,teaching, caring etc.)Require technical skills (“hands-on” psychomotor skills, tasks, procedures)

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Evaluation Phase

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The Nursing Process

STEP 5

Evaluation—

determining the client’s progress

monitoring the client’s response

Otten/403 38

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Evaluation ProcessCompare the actual to expected outcomes- Did my client achieve their outcomes?- If not, determine why outcomes were unmet - Were the outcomes realistic? Correct problem? Enough time to achieve outcomes?If you determine the outcomes to be appropriate, assess the interventions

-Were the interventions appropriate? Were they completed? Does the client require other nursing interventions?If everything looks good, continue with plan of care, observing for improvement

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Purposes of a Written Care PlanProvides direction & individualizes client careProvides for continuity of careProvides direction for follow-up & documentationProvides assistance in assigning staffProvides information for reimbursement

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Mrs. Ida Hubert, 67 y.o.Admitted to the unit with diagnosis of lung cancer with bone metastases 3 days agoMeds: morphine 180 mg daily; Tylenol 650 mg +Oxycodone 10 mg q6h p.r.n.Morning report: Mrs. Huber had been restless all night

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What assessments would you want to make in your preparation for her care?

Chart review: Has been taking narcotics for 2 months; spends most of her days in bed

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Assessment of Mrs. HubertPatient interview:

Alert and responsive“Couldn’t sleep or rest; just couldn’t get into a comfortable position.” Had trouble describing her discomfort. Reported decreased appetite, ate 3 small meals/day, one 8 oz can of supplement. Said she is drinking very little fluids

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Assessment of Mrs. HubertMeasurements:

V.S. were stableHad active bowel sounds, abdomen non-tender to palpation, but noted a firm area in LLQ.Said she had not had a BM since admission (3 days ago).

What nursing diagnosis might be appropriate for Mrs. Hubert?

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Critical Thinking: What is it?

Critical thinking is “making decisions based on reason, reflection, knowledge and instinct

derived from experience. Critical thinking helps nurses make patient-care decisions by helping them to think creatively, and explore new ideas

and alternative ways of solving problems.(Catalano, 1996)

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The Critical Thinking ProcessIdentify the problemIdentifying the underlying beliefs (patient, personal and other healthcare providers)Find support for the beliefs (accurate, timely, consistent literature/research)Evaluate the situation for possible solutions and weigh the solutions against the beliefs and valuesPresent a course of action

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Comparison of SOAP & Nursing Process Steps

Subjective

Objective

Assessment

Plan

Assessment

Diagnosis

Plan

Implementation

Evaluation