certification review the nursing process

Certification ReviewThe Nursing Process

Jan Brooks RN, BSN, CGRNHRSGNA

Nursing Process

• Objectives: Assessment

• 1. Identify steps of a nursing assessment as it applies to the GI Patient

• 2. Discuss the assessment of the patient receiving sedation and analgesia in the GI Setting

Nursing Process

• Nursing Process is a systematic, interactive approach to Nursing care.

• Steps:– Assessment– Nursing Diagnosis– Planning– Implementation– Evaluation

Nursing ProcessAssessment

Medical Assessment is used to define the existence of medical problems and underlying pathology

Nursing assessment is to identify the response to medical conditions, treatments and changes in activities of life


– Performed initially to gather data about a patient– Focus assessment used to look further at a

specific issue – Requires updating and reassessment at regular

intervals– May also include an emergency assessment with a

life threatening situation– May require a collaborative effort with

multidisciplinary team


• Steps of a Nursing Assessment:• We do these automatically and don’t think about steps

1. Collecting Data• Interview --subjective and objective • Observation –involves all senses• Physical Exam—Inspection, Palpation, Percussion and

Auscultation• Review of Records and Diagnostic reports• Collaboration with Colleagues


2.Identifying cues and making inferencesInferences are made after collecting

subjective and objective data as related to the patient and his or her illness or situation

3. Validating DataConfirmation of data received or may

require further explanationExample is pt who states NKA, yet is documented with an allergy


4. Clustering Data

The organization of the data to assist with the Nursing Diagnosis

Needs to also be organized to focus on priority of care

5.Identifying patterns and Testing First ImpressionsValidation of information from initial assessment,

What is relevant or irrelevant?

Communication with other Team members


6. Reporting and Recording DataAll data must be communicated and/or recorded in a timely mannerCritical information must be recognized and communicated immediatelyData must be recorded legibly, in a timely mannerData should include descriptive, subjective and objective information supported by documented facts


• Assessment for the GI Patient– Many patients are frequently sedated for

procedures• Assessment includes:

– NPO status– Medications currently prescribed– Underlying medial problems– Any diagnostic testing completed– Respiratory status– Other underlying or contributing factors– Ride home

Nursing Process

• Objectives: Nursing Diagnosis

– 1. Define Nursing Diagnosis

– 2. Identify actual and potential nursing diagnoses applicable to GI patients

Nursing ProcessNursing Diagnosis

• Term began being used in 1950’s• 1996 Dr. Lester King wrote an article that

refuted the idea that Physicians were the only ones to diagnose.

• Defined as: A statement of an actual or potential health problem that can be alleviated or prevented by independent Nursing intervention.


• Provides a basis for selecting nursing interventions

• Provides useful and practical method for organizing nursing knowledge

• Based upon data obtained from nursing assessment

• Is a concise statement of interpretation of data collected


• Types of Nursing Diagnoses:

– Actual—Made when condition is validated by presence of clinical characteristics

– Risk—Patient/family or community are vulnerable to a potential problem

– Possible—problem that is suspected, but requires further supportive data


• Types of Nursing Diagnoses

Wellness—taking an individual, group or family from one level of wellness to a higher level

Syndrome—Fairly new conceptDescribes a cluster of signs and symptoms

Example—Disuse syndrome would incorporate risk for infection, constipation, thrombosis, activity tolerance


• Medical Diagnosis: Focuses on identification of diseased based pathology and etiology

• Nursing Diagnosis: Focuses on present health problems, strengths and limitations and methods of adapting to health problems

• Collaborative Diagnosis: Utilizes other members of the health care team


• Nursing diagnosis as related to the GI PatientActual--Elimination process—alteration of normal bowel patterns due to ulcerative colitis

Actual or potential—Knowledge deficit related to procedure and sedation

Potential—Impaired physical mobility due to sedation

Nursing Process

• Objectives: Planning

– 1. List three types of planning utilized in care planning

– 2. Compare nursing and medical plans of patient care

Nursing ProcessPlanning

• Planning --Development of Nursing activities based on nursing diagnosis for the purpose of preventing, reducing or resolving health problems through Nursing intervention.

• Involves setting priorities for care

• Determining patient goals and expected outcomes


• Reasons for Developing a Plan of Care– Assists to assign priorities of care– Provides a means of communication– Uses universal language– Gives professional quality to the act of nursing– Has an economic impact especially related to

Medicare and diagnosis related groups


• Medical and Nursing Plans of Care

– Similar –both derived from assessment– Both describe monitoring signs and symptoms– Both prescribe measures based on scientific

knowledge– Nursing diagnosis focus on patient responses to

medical treatment.– Nursing interventions can include actions that nurses

can legally perform


• Clinical Pathways

– Set along specific time lines– Multiple disciplinary– Provide teaching tools to patients and families– Demonstrate quality care


• Planning involves – Initial Planning– Ongoing Planning– Discharge Planning– Identifying NURSING actions• IE: Access breath sound immediately post procedure• Explain signs and symptoms of bleeding and

interventions to be taken if bleeding were to occur post procedure

Document Plan of care

Nursing ProcessImplementation

• Objectives:

– 1. Define general guidelines for implementing care of the GI Patient

– 2. Discuss the nurse’s role when implementing care of the GI Patient


• Is the Blue Print that guides Nursing Care

• Based on Scientific Principles

• Reflects the rights and desires of the patient and significant others

• Actions are carried out safely, skillfully and efficiently


• Implementation is impacted by the Care Team’s:– Cognitive Ability

– Interpersonal Skills

– Technical Skills


• Functions:

– Independent Interventions

– Interdependent Interventions

– Dependent Interventions

– Based on Nurse Practice Acts


• Variables that Affect Care Implementation

– Patient Variables– Nurse Variables– Standards of Care– Research Findings– Resources– Ethical and Legal Guides to Practice


• Importance of Documentation– Formal method of communication– Used in multiple ways—• Planning• Process improvement audits• Research• Education• Legal Evidence• Historical Document


• Patient Teaching

– Integral part of the Implementation Process

• Still has same activities– Assessing and diagnosing knowledge deficit– Planning learning Activity– Providing learning Activities– Evaluating learning


• Counseling– The Act of rendering guidance to a patient and /or

significant other– May be short term, long term, or motivational

Advocacy--Informing patients and families

--Supporting that decision


Advocacy in Ethical DilemmasSeen especially with feeding tubes

Guidelines in ethical decision making

1.Teach, clarify, reinforce medical information2.Remain as objective as possible3. Provide willing ear, cautious mouth4.Approach respectfully5.Accept and support patient and family decisions6.Observe and communicate7.Work through appropriate channels

Nursing ProcessEvaluation

• Objectives:

– 1. Explain the tasks involved in the evaluation process

– 2. Explain the role Standards of Care have in the Nursing Process


• The Final phase in the Nursing Process• Is the analytical portion• Were the things implemented effective?• Time of reassessment, modifications made• Is the goal realistic?


• Nursing Practice is based on a Scientific Framework including:

Critical Thinking Communication Adherence to a STANDARD of CARE

Criteria are measurable qualities that apply to Standard of Care or Practice

Nursing Practice

• Guidelines vs Standards

– Guidelines • Suggested performance

• Current recommendations

• May deal with technical performance

Nursing Process

Standards• Measurable criteria to evaluate practice• Incorporate a stronger statement of expected

performance

RegulationLegal statement that defines

Required Performance


• Standards of Care or Practice

– 1. Quality of Care

– 2. Performance Appraisal

– 3. Education

– 4. Collegiality


Standards of Care (or Practice)

5. Ethics

6. Collaboration

7. Research

8. Resource Utilization

9. Leadership found in Practice

Nursing ProcessReview Questions

1. A nursing assessment:A. Is a systematic approach to nursing careB. Is always comprehensiveC. Is a process of identifying a patient problemD. Should precede a nursing history

2.Validation is the act of:A. ClarificationB. VerificationC. Repeating a patient’s responses twiceD. Checking to be sure a nursing history was taken


3. The correct order of physical assessment is:• A. Inspection, palpation, percussion, auscultation• B. Palpation, percussion, inspection, auscultation• C. Auscultation, percussion, inspection, palpation• D. Inspection, percussion, palpation, auscultation

• 4. Formulating a nursing diagnosis provides:– A. Important assessment data– B. An interpretation of data collected– C. Interdependent nursing interventions– D. Outcome criteria for evaluation


5. “Cholecystitis with cholelithioasis” is an example of a:

A. Collaborative diagnosisB. Nursing DiagnosisC. Medical DiagnosisD. Medical History


6. The Nursing Care Plan:A. Is based on scientific principles and incorporates

findings of nursing researchB. Advances nursing’s four aims and is tailored to the individual patient.C. Is designed to meet developmental, psychological,

sociological and physiological needs of patients.D. All of the above.


7. A GI nurse might vary the way he or she comforts an anxious 10 year old boy based on:

A. The developmental task of children aged 7-11B. His willingness to participate in counselingC. Recent findings concerning the impact of certain words in calming or provoking anxietyD. All of the above


• 8. Administering Medication is:

A. An independent nursing activity B. An interdependent task C. A dependent nursing obligation D. A non-nursing chore


9. Nurses accomplish patient teaching in four phases, including: planning the learning activity, providing learning opportunities, evaluating learning, and:

A. Correcting mistakesB. Diagnosing a patient’s knowledge deficitC. Explaining the patient’s privacy needs to s/oD. Helping patients make informed decisions


• 10. Criteria are:

A. Nationally recognized standards B. Facts C. Interventions D. Measurable


11. The reason the nursing professionals evaluate the quality of care include all of the following except:

A. Nursing professionals aim to promote excellence in nursing care.

B. Nurses must be accountable to society for the qualityof the care they provide.

C. Nurses want to improve professional performance. D. Nurses recognize that quality in health care is elusive

and complex.

Nursing Process

• Thank you

• Thank you to all SGNA Board: – Lisa, Mary, Lynn, Brenda and Debra– As well as Rita, Candice, Laura, Randy and others

behind the sceens.

certification review the nursing process

Documents

nursing care

nursing diagnosis1

nursing diagnosisneeds

nursing diagnosis2

emergency assessment

initial assessment

patientfocus assessment

objective data