Fundementals of Nursing 2nd Lecture (1)

Application of Nursing Process

Prepared by

Mr. Ibrahim Ayasreh Mr.Ahmad AlRadi

RN, MSN RN, MSN Critical Care Nursing Medical –Surgical Nursing

Scientific Workshop in

Nursing Process

• The nursing process is a systematic ,rational method of planning and providing nursing care.

• A process is a series of steps or acts that lead to accomplishment of some goal or purpose.

• The purposes of the nursing process are to identify a client's healthcare status, and to actual or potential health problems, to establish plans to meet the identified needs, and to deliver specific nursing interventions to address those needs.

Steps of Nursing Process

• Assessment.

• Diagnosis.

• Planning.

• Implementation.

• Evaluation.

Characteristics of Nursing Process

• Nursing Process is clients-centered.

• Nursing Process is cyclic and dynamic (The steps of the nursing process build upon each other, but they are not linear. There is overlap of each step with the previous and subsequent steps) .

• Nursing Process is Universally applicable (is designed to be used with clients throughout the life span and in any setting in which a nurse provides care for clients).

Assessment

• Assessment is the systematic and continuous collection, organization, validation, and documentation of data (information).

• Assessment is continuous process carried out during all phases of nursing process.

• All phases of nursing process depend on accurate and complete collection of data.

Types of assessment

• Initial Assessment.

• Problem-focused assessment.

• Emergency assessment.

• Time –lapsed assessment.

Initial Assessment

• Performed within specified time after admission to a health care agency.

• To establish a complete database for problem identification, reference and future comparison.

• Example: Nursing admission assessment.

Problem – Focused Assessment

• Ongoing process integrated with nursing care.

• To determine the status of a specific problem identified in a earlier assessment , and to identify new or overlooked problems.

• Example: Hourly assessment of client’s fluid intake and output.

Emergency Assessment

• Performed during any physiologic or psychological crisis of the client.

• Its purpose is to identify life-threatening problems.

• Example: Rapid assessment of airway, breathing, circulation during a cardiac arrest.

Time- lapsed reassessment

• Performed several months after initial assessment.

• Its purpose is to compare the client’s current status to baseline data previously obtained.

• Example: Reassessment of the patients in outpatient setting after being discharged.

Components of Nursing Health History

• Biographic data: Name, Age, Gender, Marital status, Occupation, religion, Education, Income.

• Chief Complaint: - Is the answer of the patient to question of : “ What brought you to the hospital or clinic. - Should be recorded in patient’s own words. - Example : Patient said: “ I had sever pain in my chest , I was unable to

breathe since last night”

Components of Nursing Health History

• History of present illness:

- Onset : When the symptoms started? - Pattern of onset : Gradual or sudden. - Setting: Place where the patient was when the symptom started? - Severity: Mild, Moderate , Severe. - Location. - Quality: characteristics of problem. - Radiation. - Duration. - Palliative and aggravating factors. - Associated symptoms.

Components of Nursing Health History

• Example of “ History of present illness”:

1) Onset: pain started suddenly last night at 3.30 AM.

2) Setting: patient stated that he was in bed at home when pain started.

3) Location: pain is originated in the chest.

4) Quality: pain is like tightness on the chest.

5) Severity: patient said that pain was severe.

6) Radiation: patient stated that the pain is radiated to left arm and back.

7) Duration: patient stated that the pain was continuous.

8) Palliative factors: patient stated that the pain was slightly decreased with rest.

9) Aggravating factors: patient stated that pain was increasing with movement, and exposure to cold.

10) Associated symptoms: this pain was associated with Dyspnea, and nausea.

Components of Nursing Health History

• Past History:

- Childhood illnesses : Chickenpox, Rubella, measles, rheumatic

fever, …..etc.

- Childhood immunizations.

- Allergies to drugs, animals, food, insects.

- Accidents and injuries.

- Previous hospitalizations.

Components of Nursing Health History

• Family History:

Components of Nursing Health History

• Lifestyle:

- Personal habits: include amount, frequency, and duration of

substance use (Coffee, Tea, cola, Tobacco).

- Diet.

- Sleep.

- Hobbies.

- Daily activities.

Types of data

• Subjective data ( Symptoms) : data which is only can be described and verified by client himself/herself.

• Objective data ( Signs): data which can be detected by the observer or the nurse. They can be seen, heard, smelled, felt, and they obtained through observation or physical examination.

Examples of Subjective & Objective Data

Subjective dataObjective Data

•“ I feel pain in my chest”.

•“I drink 2 cups of tea daily”

•“I feel weak when I walk tow steps

forward”

•Blood Pressure: 140/90 mmHg.

•Skin is pale.

•Client cried during interview.

•Vomited 100 mL green fluid.

Sources of data

• Primary source: includes only the client.

• Secondary Source: All sources other than client such as family members, records and reports, laboratory and diagnostic findings, and health care providers.

Data collection methods

• Observing.

• Interviewing.

• Examining.

Observing

• To observe is to gather data by using the senses.

SenseExample of client data

VisionBody size, posture, grooming, skin color.

SmellBody or breath odors

HearingLung and heart sounds, bowel sounds, orientation.

TouchSkin temperature, pulse rate, muscle strength.

Interviewing

• Interview: is a planned communication or conversation with purpose to get or give information.

• Types of interview: - Directive interview: the nurse establishes the purpose of the interview and control the interview. - Nondirective interview: the nurse allow the client to control purposes of the interview.

• It is better to use a combination of both directive and nondirective in interviewing clients.

Types of Interview Questions

• Close questions: used in directive interview, and generally

requires only “yes” or “No” or short factual

answers.

- Example: “ What medication did you take?”

“ Are you having pain now?”

“ How old are you?”

“ When did you fall?”

Types of Interview Questions

• Open questions: used in nondirective interview, ad invites the

client to elaborate, discover, discuss, explore

feelings and thoughts.

- Example: “ What brought you to the hospital?”

“ Describe the pain you feel in more details?”

“ What would you like to talk about today?”

Factors affecting interview planning

• Time: nurse need to plan interviews with hospitalized clients when

the clients is physically comfortable, free of pain, minimal

interruptions by friends and family members.

• Place: a well-lightened, well-ventilated, moderate sized room, free of

noises.

• Distance: must be neither too small nor too great. It is about 8 -12

inches in Arab countries.

• Language: The nurse must convert complicated medical terminology

to simple language.

Stages of Interview

• The Opening.

• The Body.

• The Closing.

The opening

• In this stage, the nurse introduces her/himself to the client, and explain the purpose of the interview.

• Through thus stage , the rapport between nurse and client is established.

• It can be begin with greeting ( “Good morning, Mr. Salem”) or a self introduction ( “ I am Ibrahim, I am a nursing student”), accompanied by nonverbal gestures such as smile, handshake.

The body

• In this stage the client communicates what he/she thinks, feels, knows, and perceives in responses to questions of the nurse.

The closing

• The nurse terminates the interview when the needed information is obtained.

• The closing is important for maintaining rapport and trust and for facilitating future interactions.

• Techniques for closing interview:

- offer to answer questions : “ do you have any questions?”

- conclude by saying: “ well, that’s all I need to know for now?”

- Thank the client : “ thank you for your time and help”

- Express concern for person's welfare: “ take care of yourself”

- Plan for next meeting.

- Provide a summary to verify accuracy and agreement.

Organizing data

• We use nursing and non-nursing models.

• Non-nursing models such as Maslow hierarchy of needs, and body system models.

body systems model

• Integumentary system.• Respiratory system.• Cardiovascular system.• Nervous system.• Musculoskeletal system.• Gastrointestinal system• Genitourinary system.• Reproductive system• Immune system.

Do not forget to document every thing you assess

Diagnosing

• Is the pivotal second phase of the nursing process, in which the nurse interprets assessment data, identifies clients strengths and health problems, and formulates diagnostic statements.

• According to NANDA : “ Diagnosis is a clinical judgment about individual, family, and community response to actual or potential health problem\ life processes”.

Types of Nursing Diagnoses

• Actual diagnosis: is a client problem that is present t the time

of assessment.

- Example: Anxiety, Ineffective breathing pattern.

• Risk Diagnosis: is a clinical judgment that a problem doesn’t

exist, but the presence of risk factors indicates

that the problem is likely to develop.

- Example: Risk for infection.

Types of Nursing Diagnoses

• Wellness diagnosis: it describes the human responses to level

of wellness in an individual, family, and

community that have a readiness for

enhancement. - Example: Readiness for enhanced family coping.

• Possible diagnosis: is one in which evidence about a health

problem is incomplete or unclear.

Components of NANDA Nursing Diagnosis

1. Problem: describe the client health problem or response for which nursing therapy is given.

- Examples: * Anxiety. * Fluid Volume Deficit. * Ineffective breathing pattern. * Knowledge deficit. * Risk for infection.

Components of NANDA Nursing Diagnosis

2. Etiology: identifies one or more probable causes of the health

problem.

- Example:

Constipation related to inactivity and insufficient fluid intake.

Problem Etiology

Components of NANDA Nursing Diagnosis

3. Defining characteristics: are the cluster of signs and symptoms

that indicate the presence of a

particular problem

- Example:

Anxiety related to breathlessness and medication’s side effects As manifested by

patient verbalization and facial expressions

Problem Etiology

Defining characteristics

Examples of nursing diagnosis

• Chest pain Related to Increased oxygen demand and decreased oxygen supply As Manifested By patient verbalizations, facial expression (furrow eyebrows).

- Problem: Chest pain.

- Etiology: Increased oxygen demand and decreased oxygen supply.

- Defining characteristics: patient verbalizations, facial expression

Components of NANDA Nursing Diagnosis

• Risk for Infection related to presence of open surgical wound in chest and left leg.

- Problem : Risk for infection.

- Etiology: Presence of open surgical wound in chest and

leg.

Example

• Patient said:" I feel chest pain radiated to my back and left arm lasted for

about 20minutes".

• Patient stated that pain severity is about 8 on scale.

• Patient stated that pain was slightly decreased but not relieved by rest.

• Facial expressions: furrow eyebrows, no smile.

• Patient’s heart rate was 123 b/m.

• Severe chest pain Related to Increased oxygen demand and decreased oxygen supply As Manifested By patient verbalizations, facial expression (furrow eyebrows, absence of smile), tachycardia, patient is anxious.

Planning

• Planning is the third phase in which the nurse and the client develop goal\desired outcomes, and nursing interventions to prevent, reduce, or alleviate a client health problem.

• Nursing Intervention: is any treatment, based upon clinical judgment and knowledge, that the nurse perform to enhance patient or client outcomes.

Types of planning

• Initial Planning: is planning which performed by the nurse

after admission assessment.

• Ongoing Planning: is performed by all nurses who work with

the client. Also ongoing planning may

performed before each shift as the nurse

plans the care given at that day.

• Discharge Planning: is the process of anticipatin and planning

for needs after discharge.

Care Plans

• Informal nursing care plan : is a strategy of action that exists in the nurse’s mind.

• Formal nursing care plan : is a written or computerized guide that organizes information about the client’s care.

• Standardized care plan: a formal plan that specifies the nursing care for groups of clients with common needs.

• Individualized care plan: a formal plan that specifies the nursing care for individual with unique needs.

The Planning Process

• Setting priorities.

• Establishing client goal / desired outcomes.

• Selecting nursing interventions.

• Writing nursing orders.

Setting priorities

• Setting priority : is the process of establishing a preferential sequence for addressing nursing diagnoses and nursing interventions.

• Nurses frequently use Maslow hierarchy of needs when setting priorities.

• For example : “Ineffective airway clearance” take higher priority over “Anxiety”.

Establishing Client Goals/Desired Outcomes

• On care plan, “Goal/Desired Outcomes” describes what the nurse hopes to achieve by implementing the nursing interventions.

• Goal : is a broad statement about the client’s status.

• Desired outcomes: specific statements used to evaluate

whether goal have been met or not.

Example of Goal and Desired Outcomes

• Nursing diagnosis : Altered nutrition: less than body requirements.

• Goal: To improve nutritional status of the client.

• Desired outcome: Patient will gain 10 kg within 1 month.

Types of Goals

• Short – term goal : is the goal that needs shorter time to be

achieved ( usually lesser than 6 weeks).

- Example : Client will reports decrease in anxiety

level within 6 hours.

• Long- term goal: is the goal that needs longer time to be

achieved ( usually more than 6 weeks).

- Example : Client will regain full use of right arm

within 6 weeks .

Components of Goal/Desired Outcomes

• Subject: is the noun, or any part of client’s name, or some attribute of the client.

• Verb: specifies the action that the client is to perform.

• Condition: added to verb to explain circumstances under which the behavior is t be performed. They explain what, where, when , and how.

• Criterion of desired performance: specifies the time or speed, accuracy, distance, and quality.

How to Write Desired Outcome

• Client will drink 100 mL of water per hour

Subject CriterionConditionVerb

Examples of Desired Outcome

• Client will perform leg range of motion exercises as taught every 8 hours.

• Client will list three signs and symptoms of diabetes before discharge.

Subject Verb Condition Criterion

CriterionConditionVerbSubject

Examples of Action Verbs

• Apply. • Breathe.• Choose.• Compare.• Define.• Demonstrate.• Describe.• Discuss.

• Drink.• Explain.• Identify.• Inject.• List.• Move.• Name.• Report.

• Select.• Share.• Sit.• Sleep.• State.• Talk.• Transfer.• Verbalize.

Selecting Nursing Interventions

• Nursing interventions: are the activities that the nurse perform to

achieve client goals.

• Types of nursing interventions:

- Independent nursing intervention: are those activities that nurses

are licensed to initiate on the basis of their knowledge and

skills.

- Dependent nursing intervention: are those activities that carried

out by the nurses under the physician's order or supervision.

Writing Nursing orders

4/4/2011 : Administer prescribed analgesics every 12 hours / I.R.A

Time element SignatureContent AreaAction VerbDate