The Nursing Process

Resources

Andrea Ackermann, Mount St. Mary College, Critical-thinking-the-nursingprocess 2001. http://www.umanitoba.ca/nursing/courses/1 28,(2005) Sara-jo Wiscombe, Nursing Process ,Wallace Community College ,May 22,2001.
Tucker C, MODULE A INTRODUCTION TO NURSING Process, August 21, 2002 .

The Nursing Process organizational framework for the practice of nursing Orderly. systematic Central to all nursing care Encompasses all steps taken by the nurse in caring for a patient An .

Definition of the Nursing Process An organized sequence of problemsolving steps used to identify and to manage the health problems of clients It is accepted for clinical practice established by the American Nurses Association .

Benefits of Nursing Process Provides an orderly & systematic method for planning & providing care Enhances nursing efficiency by standardizing nursing practice Facilitates documentation of care Provides a unity of language for the nursing profession Is economical Stresses the independent function of nurses Increases care quality through the use of deliberate actions .

The Nursing Process Utilizes The Following Assessment Nursing Diagnosis Planning Implementation Evaluation .

Characteristics of the Nursing Process Within the legal scope of nursing Based on knowledge-requiring critical thinking Planned-organized and systematic Client-centered Goal-directed Prioritized Dynamic .

Benefits of using the nursing process Continuity of care Prevention of duplication Individualized care Standards of care Increased client participation Collaboration of care .

Being Accountable Using critical thinking before taking actions Being responsible for your actions Entering the professional role Working at the level of your peers Using the nursing process .

Something to think about: Nurses are responsible for a unique dimension of healthcare ± ³ the diagnosis and treatment of human responses to actual or potential health problems´ .

see apples in the seeds. others see seeds in the apple.´ . We.MARTHA ROGERS. NURSE THEORIST ³When an apple is cut. as nurses.

What Are Your Responsibilities? Recognize health problems. Initiate actions to ensure appropriate and timely treatment. Anticipate complications. Begin to think CRITICALLY !!!!!! .

Critical Thinking MENTAL OPERATIONS ±decision making & reasoning KNOWLEDGE-having the facts & understanding the reason behind the knowledge ATTITUDES. .curious/open-minded/nonjudgmental«.

and goal directed.Critical Thinking Critical thinking in nursing is an essential component of professional accountability and quality nursing care. . Critical thinking is careful. deliberate.

Assessment of Well-Being According to the World Health Organization is well-being in these domains:  Emotional  Physical  Social  Spiritual .

Lets Get Started :         Nurse collects background info from previous charts Ensure environment is conducive Arrange seating Allow adequate time Nurse introduces self Identifies purpose of interview Ensure confidentiality of information Provide for patient needs before starting .

TYPES OF INTERVIEWS DIRECTED NON-DIRECTED THINGS THAT IMPAIR COMMUNICATION: PRESENTING QUICK SOLUTIONS UNWARRANTED CHEERFULNESS FALSE REASSURANCE GIVING ADVICE CHANGING THE SUBJECT .

ASSESSMENT Observation Interview  Types of questions  Environment (physical and emotional) Spiritual conciderations Examination .

Types of Data To Collect: Objective data-observable and measurable facts (Signs) Subjective data-information that only the client feels and can describe (Symptoms) .

What is the significance of the problem or illness to the client? What does it mean in the family/community? .CULTURAL DIVERSITY MUST PROVIDE CARE CONGRUENT WITH A CLIENT¶S EXPECTATIONS ³This is not about you´ ? Respect INDIVIDUAL¶S DIFFERENCES.

COMMON Challenges: Defense Mechanisms
COMPENSATION DENIAL DISPLACEMENT RATIONALIZATION

PROJECTION REPRESSION SUPPRESSION REGRESSION

Continued

THE NURSING PROCESS HELPS NURSES UNDERSTAND THE STRATEGIES CLIENTS USE IN their attempt at coping: This knowledge will help you FURTHER INDIVIDUALIZE THEIR CARE

Resources

Client Other individuals Previous records Consultations Diagnostics studies Relevant literature

.Assessment Data base assessment ± comprehensive information you gather on initial contact with the person to assess all aspects of health status. Focus assessment ± the data you gather to determine the status of a specific condition.

test results. and discussions with other health care workers . reports. information in current and past medical records.Sources of Data Primary source: Client Secondary source: Client¶s family.

Secondary prevention ± early detection and treatment of disease. .Disease Prevention Primary prevention ± protection from a disease while still in a healthy state. Tertiary prevention ± prevent complications and to maintain health once the disease process has occurred.

Verifying Data Essential in critical thinking!!!!! Measurable data Double check personal observations Double check equipment Check with experts and team members Recheck out-liers Compare objective and subjective data Clarify statements .

Planning Establish the goals. interventions and outcomes .

Nurse-identified priorities based on the overall picture. 2. 3. Patient-identified issues. .General Guidelines for Setting Priorities 1. Safety issues. 4. Take care of immediate life-threatening issues. the patient as a whole person. and availability of time and resources.

Interdisciplinary planning. and setting. . Time. resources. Hierarchy of needs.Nurse Identified Priorities Composite of all patient¶s strengths and health concerns. Moral and ethical issues.

Patient behaviors not nurse behaviors!! ³The patient will«´  .Identifying Client-centered Outcomes State what the patient will do or experience at the completion of care. Give direction to the patient¶s overall care.

analyze information Identify potential problems and strengths Write statement of problem or strength Risk of infection related to compromised nutrition . cluster.DIAGNOSIS Sort.

) Potential for effective breastfeeding related to knowledge level and support system Prioritize the problems Not a medical diagnosis .Nursing Diagnosis (cont.

.Steps for deriving outcomes from Nursing Diagnosis   Look at the first clause of the nursing dx and restate in a statement that describes improvement. control or absence of the problem. The client will demonstrate no signs or symptoms of infection. Risk for infection r/t surgical procedure.

Components of Outcomes Subject: who is the person expected to achieve the outcome? Verb: what actions must the person take to achieve the outcome? Condition: under what circumstances is the person to perform the actions? Performance criteria: how well is the person to perform the actions? Target time: by when is the person expected to be able to perform the actions? .

. Assist with ADLs. Monitor health status. Promote optimum health and independence. 5. 3. Resolve or control a problem. Evidence based nursing. Road maps directing the best ways to provide nursing care. 2. Minimize risks.Nursing Interventions 1. 4.

Indirect interventions: actions performed away from the client.Interventions Direct interventions: actions performed through interaction with clients. on behalf of a client or group of clients. .

or enhanced through independent nursing measures . reduced.Nursing Diagnosis Health issue that can be prevented. resolved.

2. . 3. Consists of: Prioritized nursing diagnostic statements. Outcomes. the plan must be written and shared with all health care personnel caring for the client.Documenting the Plan of Care 1. To ensure continuity of care. Interventions.

Documentation Clear and concise Appropriate terminology  Usually on a designated form Usually by Review of Systems ‡ Overview of symptoms ‡ Diet ‡ Each body system Physical assessment  .

I don¶t care about that´ .e. patient is being ornery should be patient resists instruction or patient states ³Don¶t talk to me.Documentation Use patient¶s own words in subjective data ± enclose in ³ ___´ (quotation marks) Avoid generalizations ± be specific Don¶t make summative statements ± describe .g.

or terminate the plan . 3.Evaluation 1. modify. 2. Determining outcome achievement Identifying the variables affecting outcome achievement Deciding whether to continue.

. Is patient able to meet outcome criteria? Is it: Completely met? Partially met? Not met at all? Record in progress in notes.Determining Outcome Achievement Must be aware of outcomes set for the client. Must be sure patient is ready for evaluation. Update care plan.

Were changes made in the plan when needed? 4. Is the plan realistic for the client? 2.Identifying Variable Affecting Outcome Achievement Maintain individuality of care plan: 1. How does the client feel about the plan? . Is the plan appropriate at the time for this particular client? 3.

and Manage Focus on early intervention Based on research Predict and anticipate problems Look for risk factors .Predict. Prevent.

Diagnostic Statements Name of the health-related issue or problem as identified in the NANDA list Etiology (its cause) Signs and Symptoms The name of the nursing diagnosis is linked to the etiology with the phrase ³related to.´ and the signs and symptoms are identified with the phrase ³as manifested (or evidenced) by´ .

Collaborative ProblemsNurse¶s Responsibility Correlating medical diagnoses or medical treatment measures with the risk for unique complications Documenting the complications for which clients are at risk Making pertinent assessments to detect complications .

Continued Reporting trends that suggest development of complications Managing the emerging problem with nurse.and physician-prescribed measures Evaluating the outcomes .

The Nursing Process Nursing Diagnosis Judgment or conclusion about the risk for² or actual²need/problem of the patient NANDA format .

NANDA ± North American Nursing Diagnosis Association Identifies nursing functions Creates classification system Establishes diagnostic labels Risk of infection related to compromised nutritional state Potential complication of seizure disorder related to medication compliance .

. The nurse consults with the client while developing and revising the plan. identifying measurable goals or outcomes. and documenting the plan of care. selecting appropriate interventions.Planning The process of prioritizing nursing diagnoses and collaborative problems.

Setting Priorities Determine problems that require immediate action Maslow¶s Hierarchy of Human Needs .

Short-Term Goals Outcomes achievable in a few days or 1 week Developed form the problem portion of the diagnostic statement Client-centered Measurable Realistic Accompanied by a target date .

Long-Term Goals Desirable outcomes that take weeks or months to accomplish for client¶s with chronic health problems .

The Nursing Process Planning Identification Prioritization Time of goals and outcome criteria frame .

Nursing interventions are directed at eliminating the etiologies.Selecting Nursing Interventions Planning the measures that the client and nurse will use to accomplish identified goals involves critical thinking. .

Selecting an intervention The nurse selects strategies based on the knowledge that certain nursing actions produce desired effects. within the legal scope of nursing practice. Nursing interventions must be safe. . and compatible with medical orders.

Communicating The Plan The nurse shares the plan of care with nursing team members. The plan is a permanent part of the record. . the client. and client¶s family.

It is the analysis of the client¶s response. evaluation helps to determine the effectiveness of nursing care.Evaluation The way nurses determine whether a client has reached a goal. .

The Nursing Process Evaluation Ongoing part of the nursing process Determining the status of the goals and outcomes of care Monitoring the patient¶s response to drug therapy .

Documentation Clear and concise Appropriate terminology  Usually on a designated form Usually by Review of Systems ‡ Overview of symptoms ‡ Diet ‡ Each body system Physical assessment  .