Unit 3-Nursing Process

8/3/2019 Unit 3-Nursing Process

1/58

UNIT 3: NURSING PROCESS

Definition and purpose of nursing process

Steps of nursing process

Nursing assessmentCollection and organization of data

A critical thinking approach to assessment

Types of data

Sources of data

Methods of data collection-history taking, physical

examination, measurement, diagnostic, laboratory data

etc.

Data documentation


2/58

NURSING PROCESS

The nursing process is a professional nurses

approach for selecting, organizing, and

delivering appropriate nursing care to a patient.

Characteristics: Within legal scope of practice

Planned

Based on knowledge research based

Patient centered Goal directed

Prioritized

Dynamic


3/58

Purpose of nursing process

(1) Assess the patientto determinetheneed for

nursing care;

(2) determinenursing diagnoses foractualand potential health problems;

(3) identify expected outcomes and plan

care;

(4) implement the care; and

(5) evaluate theresults.


4/58


5/58

Steps of nursing process

Assessment Data collection & verification

Data analysis

Diagnosis Analysis of data

Planning Goals prioritized

Set expected outcomes

Prescribe nursing interventions Implementation

Interventions

Evaluation Goals met?

Reassessment


6/58

NURSING ASSESSMENT


7/58

It is the deliberate and systematic collection of

data to determine a patients current and pasthealth status, functional status, and present and

past coping patterns

Key Activities

Collecting data

Validating data

Organizing (clustering) data

Identifying patterns Testing first impressions

Reporting & recording data


8/58


9/58

PURPOSE:

To establish a data base (all the information about the

client): nursing health history

physical assessment

the physicians history & physical examination

results of laboratory & diagnostic tests material from other health

personnel

- Toestablishbaselineinformationonthe client

- To determinethe clientsnormal function

- To determinethe clientsriskfordysfunction- To determinethe clientsstrengths

- To provide data forthe diagnosis phase


10/58

FOUR Types of Assessment

Initial assessment assessment performed within a

specified time on admission

Ex: nursing admission assessment

Problem-focused assessment use to determine status of

a specific problem identified in an earlier assessment

Ex: problem on urination-assess on fluid intake & urine

output hourly Emergency assessment rapid assessment done during

any physiologic/physiologic crisis of the client to identify life

threatening problems.

Ex: assessment of a clients airway, breathing status &circulation after a cardiac arrest.

Time-lapsed assessment reassessment of clients

functional health pattern done several months after initial

assessment to compare the clients current status to

baseline data previously obtained.


11/58

DATA COLLECTION

Types of Data

Subjective data

also referred to as Symptom/Covert data

Information from the clients point of view or are described by theperson experiencing it.

Information supplied by family members, significant others; other

health professionals are considered subjective data.

Example: pain, dizziness, ringing of ears/Tinnitus

Objective data also referred to as Sign/Overt data

Those that can be detected observed or measured/tested using

accepted standard or norm.

Example: pallor, diaphoresis, BP=150/100, yellow discoloration

of skin


12/58

Sources of data:

Primary source data directly gathered from the client

using interview and physical examination.

Secondary source data gathered from clients family

members, significant others, clients medical

records/chart, other members of health team, and

related care literature/journals.

Patient

Family and significant others

Health care team Medical records

Other records and the literature


13/58

Methods of data collection

1. interview and health history:

A planned, purposeful conversation/communication with the

client to get information, identify problems, evaluate change, to

teach, or to provide support or counseling.

it is used while taking the nursing history of a client

2. Physical examination:

An investigation of the body to determine its state of health.

Techniques used are: inspection, palpation, percussion,

auscultation and smell

should be conducted systematically:

Cephalocaudal approach head-to-toe assessment

Body System approach examine all the body system

Review of System approach examine only particular area

affected


14/58

Observation of patients behavior:

Use to gather data by using the 5 senses and instruments.

Throughout an interview and physical examination Helps to obtain objective data

Diagnostic and laboratory data:

To identify or verify alterations questioned or identified during thenursing helath history and physical examination


15/58

DATA VALIDATION

Comparing data with another source to avoid making

incorrect inferences.

Purposes of data validation ensure that data collection is complete

ensure that objective and subjective data agree

obtain additional data that may have been overlooked

avoid jumping to conclusion

differentiate cues and inferences


16/58

Examples of cues and inferences

Ex

ample 1Group of cues client has

- Blurry visionorvisual defect

- Headache

- Tingling and numbnessinextremities- Dizziness

Possible inferences

- Clienthas a braintumor

- Clientishaving warningsignalsof a stroke- Clientmay be diabetic

- Clientis anxious


17/58

ORGANIZING/CLUSTERING

DATAUses a written or computerized format that organizesassessment data systematically.

Maslows basic needs

Body System Model


18/58

DATA ANALYSIS &

INTERPRETATION Recognizing patterns and trends, compare data againststandard and identify significant cues to reach

conclusion. Standard/norm are generally accepted

measurements, model, pattern:

Ex: Normal vital signs, standard Weight and Height, normal

laboratory/diagnostic values, normal growth and development

pattern


19/58

DATA DOCUMENTATION

nurse records all data collected about the clients health

status

Should be timely thorough and accurate

data are recorded in a factual manner not as interpretedby the nurse

Record subjective data in clients word; restating in other

words what client says might change its original

meaning.


20/58

HISTORY TAKING Collection of information about the effect of the clients

illness on daily functioning and ability to cope with the

stressor (the human response)

Subjective data

May be called covert data Not measurable or observable

Obtained from client (primary source), significant others, or

health professionals (secondary sources).

For example, the client states, I have a headache

Objective data May be called overt data

Can be detected by someone other than the client

Includes measurable and observable client behavior

For example, a blood pressure reading of 190/110 mmHg.


21/58

PURPOSE:

To find out the patients condition

To support for nursing care

To support for diagnosis, treatment and management

TECHNIQUES:

Be dressed neatly and culturally acceptable

Establish rapport, greet warmly, be friendly and

congenial, make patient feel secure and free to talk

Maintain privacy

Quiet, calm and separate room

Seating arrangement

Show respect

Explain the purpose of interview

Indicate approximate among of time required

Conversation at patients level of understanding


22/58

Maintain eye contact

Be attentive listener

Do not interrupt

Observe non verbal clues

Use history taking format

Keep data obtained in interview confidential

COMPONENTS OF HEALTH HISTORY

History.doc


23/58

INTERVIEW

The purpose of an interview is to gather and provideinformation, identify problems of concerns, and provide

teaching and support.

The goals of an interview are to develop a rapport with

the client and to collect data An interview has 3 major stages:

Opening: purpose is to establish rapport by creating goodwill and

trust; this is often achieved through a self introduction, nonverbal

gestures (a handshake), and small talk about the weather, local

sports team, or recent current event; the purpose of the interview is

also explained to the client at this time.

Body: during this phase, the client responds to open and closed-

ended questions asked by the nurse.

Closing: either the client or the nurse may terminate the interview, it

is important fro the nurse to try to maintain the rapport and trust that

was developed thus far during the interview process.


24/58

Types of questions

Closed questions used in directive interview

Re____ short factual answers; e.g. Do you have pain?

Answers usually reveal limited amounts of information

Useful with clients who are highly stressed and/or have difficulty

communicating

Open-ended questions used in nondirective interview

Encourage clients to express and clarify their thoughts and feelings;e.g. How have you been sleeping lately?

Specify the broad area to be discussed and invite longer answers

Useful at the start of an interview or to change the subject

Leading questions

Direct the clients answer; e.g. You dont have any questions aboutyour medications, do you?

Suggests what answer is expected

Can result in client giving inaccurate data to please the nurse

Can limit client choice of topic for discussion


25/58

CRITICAL THINKING

Ability to thoughtful observations, judgments, and

choices.

Both a process and a set of skills.

It is active, organized, cognitive process used to carefullyexamine ones thinking and the thinking of others. It

involves recognizing that an issue exists, analyzing

information related to the issue, evaluating information

and drawing conclusions.

Skills: interpretation, analysis, inference, evaluation,

explanation, self-regulation.


26/58

Aspects of critical thinking:

Reflection, language, intuition

Levels of critical thinking:

Basic critical thinking

Complex critical thinking

Commitment

Critical thinking competencies:

General: scientific method, problem solving,decision making

Specific: diagnostic reasoning, clinical

inferences and clinical decision making

In nursing: nursing process.


27/58

Attitudes for critical

thinking

Confidence

Independence

Fairness

Responsibility

Risk taking

Discipline

Perseverance

Creativity

Curiosity

Integrity

humiliy

Standards for critical

thinking

Intellectual standard

Clear, precise, specific,accurate, relevant,

plausible, consistent,

logical, deep, broad,

complete, significant,adequate, fair

Professional standards

Ethical criteria for nursingjudgment

Criteria for evaluation

Professional

responsibility


28/58

NURSING DIAGNOSIS

Definition

Critical thinking and the nursing diagnostic process- analysis and

interpretation of data, identification of the clients needs, formulation

of the nursing diagnosis

Nursing diagnosis statement- eg. Nanda.Diagnosis error

Difference between nursing diagnosis and medical diagnosis

Advantages and limitations of nursing diagnosis


29/58

A nursing diagnosis is a clinical judgement about

individual, family, or community responses to actual and

potential health problems or life processes. (NANDAInternational 2005)

a clients actual or potential health problems that a nurse

can identify and for which she can order nursing

interventions to maintain the health status, to reduce,

eliminate or prevent alterations/changes.

A medical diagnosis is the identification of a disease

condition based on a specific evaluation of physical

signs, symptoms, history, diagnostic tests, and

procedures. A collaborative problem is a physiological complication

that nurses monitor to detect the onset or changes in

patients status.

Eg: bledding, infection, cardiac arrest.


30/58

Medical diagnosis

Defines the patients

health problem in relation

to the pathologicalcondition

It usually remains the

same through out his

illness It is treatable by the

physician within the

scope of medical practice

Nursing diagnosis

Focuses on the patients

response to the

pathological condition It varies with the same

patient with his changing

condition

Treatable within thescope of nursing practice.


31/58

Critical thinking and nursing diagnosis:

It uses the critical-thinking skills analysis and synthesis

in order to identify client strengths & health problems thatcan be resolves/prevented by collaborative and

independent nursing interventions.

Analysis separation into components or the breaking down of

the whole into its parts.

Synthesis the putting together of parts into whole

Purpose:

Provides basis for selection of nursing interventions to

achieve outcomes for which nurse is accountable

Leads to the development of an individualized plan of

care so that patient and family adapt well to changes

resulting from health problem.


32/58

Activities during diagnosis:

Compare data against standards

Cluster or group data

Data analysis after comparing with standards

Identify gaps and inconsistencies in data

Determine the clients health problems, health risks,

strengths

Formulate Nursing Diagnosis prioritize nursing

diagnosis based on what problem endangers the clients

life


33/58

Types of nursing diagnosis1. Actual Nursing Diagnosis a client problem that is present at the

time of the nursing assessment. It is based on the presence ofsigns and symptoms.

Examples:

Imbalanced Nutrition: Less than body requirements r/t decreased

appetite nausea.

Disturbed Sleep Pattern r/t cough, fever and pain.

2. Potential Nursing diagnosis one in which evidence about a

health problem is incomplete or unclear therefore requires more

data to support or reject it; or the causative factors are unknown but

a problem is only considered possible to occur.Examples:

Possible nutritional deficit

Possible low self-esteem r/t loss job

Possible altered thought processes r/t unfamiliar surroundings


34/58

3. Risk Nursing diagnosis is a clinical judgment that a

problem does not exist, therefore no S/S are present, but

the presence of RISK FACTORS is indicates that a problem

is only is likely to develop unless nurse intervene or dosomething about it. No subjective or objective cues are

present therefore the factors that cause the client to be

more vulnerable to the problem are the etiology of a risk

nursing diagnosis.

Examples: Risk for Impaired skin integrity (left ankle) r/t decrease

peripheral circulation in diabetes.

Risk for interrupted family processes r/t mothers illness &

unavailability to provide child care.4.Syndrome diagnosis: diagnosis associated with a cluster

of other diagnoses. Eg. Disuse syndrome

5. Wellness diagnosis: indicates a healthy response of client.

Eg: potential for enhanced spiritual wellbeing.


35/58

Characteristics of Nursing Diagnosis

It states a clear and concise health problem.

It is derived from existing evidences about the client.

It is potentially amenable to nursing therapy.

It is the basis for planning and carrying out nursing care.

Components of A nursing diagnosis (PES or PE)

Problem statement/diagnostic label/definition = P

Etiology/related factors/causes = E

Defining characteristics/signs and symptoms = S

*Therefore may be written as 2-Part or a 3-Part

statement.


36/58

Formula in writing nursing diagnosis (PES or PE)

Actual nursing diagnosis = Patient problem + Etiology

(related factor can be pathophysiolgical, situational,treatment related, and maturational) + S/S

Risk Nursing diagnosis = Problem + Risk Factors

Possible nursing diagnosis = Problem + Etiology

Qualifiers words added to the diagnostic label/problem

statement to gain additional meaning.

deficient - inadequate in amount, quality, degree,

insufficient, incomplete impaired made worse, weakened, damaged,

reduced, deteriorated

decreased lesser in size, amount, degree

ineffective not producing the desired effect


37/58

Guidelines to write nursing diagnosis

Write in terms of persons response rather than nursing need

Use related to rather than due to or caused by toconnect the two parts of statement

Write the diagnosis in legally advisable terms

Write the diagnosis without value judgments-the behavior of

the client should not be judged by nurses personal values

and attendants.

Avoid reversing the part

Do not include medical diagnosis in the nursing diagnosis

statement

State clearly and concisely

Avoid including signs and symptoms of illness in the first part

of the statement.

Be sure that the two parts of diagnosis do not mean the same

thing.


38/58

DIAGNOSTIC ERRORS

SOURCES OF ERROR:

Errors in data collection

Errors in interpretation and analysis

Errors in data clustering Errors in the diagnostic statement


39/58

To avoid data collection errors:

Review your competence with interview and physical

assessment Approach assessment in steps. Complete interview

before examination

Review clinical assessment

Be organized, have appropriate forms and examinationequipments.

To avoid data interpretation errors

Review your database to decide if it is accurate andcomplete

Validate the data

Consider patients cultural background also


40/58

To avoid data clustering errors:

Avoid premature and incorrect clustering

Formulate nursing diagnosis only after grouping data Dont try to fit nursing diagnosis into signs and symtoms..

It should come from data not other way

To avoid errors in diagnostic statement Word sentence in appropriate, concise and precise

language

Use correct terminology

Use standard nursing language. NANDADIAGNOSIS.docx


41/58

PLANNING

Establishing priorities

Establishing goals and expected outcomes- goals of care,expected outcomes, guidelines for writing goals and expected

outcomes

Planning nursing care- purpose of care plans, care plans in various

set up in health care systems

Writing the nursing care plan involving the clientConsulting other health care professionals as per need.


42/58

It is the decision making step of the nursing process

During this a set of diagnoses are identified, priorities are

set, patient centered goals and expected outcomes areset and nursing interventions are prescribed

PURPOSE:

To achieve an improved level of health and functioning

To maintain the patients present level of health and

function

To make adjustments to a reduced level of health and

functioning when cure is not possible To prepare as much as possible for terminal illnesses,

when the patients survival is threatened.


43/58

TYPESOF PLANNING:

Initial planning: initial comprehensive plan of care at the

time of admission

Ongoing planning: obtain new information and evaluate

clients response to care and individualize the initial care

plan.

Discharge planning: process of anticipating and planning

for needs.

ESTABLISHING PRIORITIES

Involves ranking nursing diagnoses in order of

importance. Allows to attend most important needs and to organize

your ongoing care activities.

Help to anticipate and sequence nursing interventions

Mutual agreed on priorities based on urgency.


44/58

Classification of priorities:

High: diagnoses if not treated will harm to patient

Intermediate: non emergent, no life threatening needs ofpatient

Low priority: needs not directly related to specific illness

but may affect the patients future well being.

Guidelines:

Remember Maslow's hierarchy of needs

Consider patients potential effect of the future problems

Consider availability of time and resources. Involve the patient in priority setting

Keep conditions of patient in mind as priorities change

with condition of the patient.


45/58

GOALS AND EXPECTED OUTCOME:

Specific statements of patient behavior or physiological

responses that you set to achieve as a result of your

patient care.

GOAL OF CARE

Specific and measurable behavior or response that

reflects the patients highest possible level of wellness

and independence in function.

Characteristics: realistic, based on patient needs and

resources, represents predicted resolution of a problem,

includes evidence of improved health status ormaintenance of health, contains only one patient

behavior, is time-limited (short term goals and long term

goals).


46/58

Significance:

Gives direction to nursing intervention

Serves a guide for nursing action Motivates patient as well as nurse to continue their effort

Serves as a criterion to evaluate the effectiveness of

nursing interventions

Guidelines:

Should be related to response

Client centered

Should address what the client will do, when and whatextent it will accomplish

Goals should be observable and measurable

Time limited, realistic and mutual agreement


47/58

EXPECTED OUTCOMES:

Specific measurable change in a patients status that you

expect to occur in response to nursing care.

Purpose: provides focus or direction to nursing care plan

Many expected outcomes can be set for each nursing

diagnosis and goal

Always write expected outcomes sequentially with time

frames

Critical thinking in planning nursing care

Clinical decisions by choosing the interventions most

appropriate to patients need.

PLANNING INTERVENTION


48/58

PLANNING INTERVENTION

Treatment or actions based upon clinical judgment and

knowledge that nurses perform to meet patients outcome.

Types: Nurse initiated

Physician initiated

Collaborative

Selection of intervention:

Characteristics of the nursing diagnosis

Expected outcome and goals

Evidence base or proven practice guidelines for the

intervention

Feasibility of the intervention

Acceptability of the patient

Own competency


49/58

NURSING CARE PLAN

Is a written guideline for coordinating nursing care,

promoting continuity of care, and listing outcome criteriato be used in the evaluation of nursing care.

Directs nursing care and decreases the risk of

incomplete, incorrect or inaccurate care.

Communicates nursing care priorities to other healthcare professionals.

Organize information exchanged by nurses in change of

shift reports.

Enhances the continuity of nursing care

Includes patients long term needs


50/58

Types of nursing care plans:

Student care plan: useful for learning the problem

solving technique, the nursing process, skills of written

communication and organizational skills needed for

nursing care.

It is more elaborate than a care plan in a hospital or

community health care agency.

Concept maps: a visual representation of patientsproblems and interventions that show their relationships

to one another.step3.jpg

Critical pathways: integrated care plans for a projected

length of stay or number of visits for the patients with aspecific case type.Ann Intern Med 1997 Dec 127(11)

996-1005, Figure 1.ppt


51/58

CONSULTING OTHER HEALTH PROFESSIONALS

Process in which you seek another health care

providers help to identify ways to handle problems in

patient care management or problems related to the

planning and implementation of programs.

Done when you identify a problem that you cannot solve

using personal knowledge, skills, and resources.

Steps: begins with understanding of a patients clinicalproblem

Making a consult

Direct to appropriate professional

Provide relevant information and resources about the problem Do not influence the consultant

Discuss consultants finding and recommendations

Incorporate recommendations into care plan


52/58

NURSING IMPLEMENTATION

Types of nursing care- independent nursing care, protocols and

standing orders (eg. Governmental and organizational policies)

Critical thinking in implementing nursing care plan

Implementation process- reassessing the client, reviewing and

revising the existing nursing care plan, organizing availableresources and care deliver, implementing nursing care plan.

Implementation methods-assisting with activities of daily living (self

care), counseling, teaching, providing direct nursing care, infection

preventive measures, correct techniques in administering nursing

care and preparing a client for procedures, lifesaving measures,

achieving goals of care

Communicating nursing care plan


53/58

Giving care according to the plan is implementation.

Implementation process: Reassessing the patient

Reviewing and revising the care plan

Organizing resources:

Equipment Personnel

Environment

Patient

Anticipating and preventing complication

Implementation skills:

Cognitive skills, interpersonal skills, psychomotor skills


54/58

Direct care:

Activities of daily living

Instrumental activities of daily living

Physical care

Counseling

Teaching

Controlling for adverse reaction Preventive measures

Indirect care

Delegating, supervising and evaluating the work of otherstaff members


55/58

EVALUATION

Evaluation of goal achievement, evaluative measures and sources

Care plan revision, discontinuing a care plan, modifying a care plan


56/58

Crucial step to determine whether after application of the

nursing process, a patients condition or well being

improves

Evaluation process:

Identifying evaluative criteria and standards

Collecting data to determine if you met the criteria or

standards

Interpreting and summarizing findings

Documenting findings

Terminating, continuing or revising care plan


57/58

CARE PLAN REVISION

DISCONTINUING A CARE PLAN: done when expected

outcome and goals have been met. Should be

documented.

MODIFYING A CARE PLAN: when goals are not

achieved, factors are identified that interfere with goal

achievement.

Usually a change in patients condition, needs or abilities

makes alteration of the care plan

Complete reassessment of all patient factors relating to

nursing diagnosis and etiology is necessary when

modifying a plan. Compare new data with previously assessed

information.


58/58

PHYSICAL EXAMINATION

Systematic collection of information about the bodysystems through the use of observation, inspection,

auscultation, palpation and percussion

Purpose: Gather baseline data about the patients health status

Supplement, confirm, or refute data obtained in the history

Confirm and identify nursing diagnoses

Make clinical judgments about a patients

Evaluate the physiological outcomes of care.

To identify clients eligibility for health insurance, military service

or a new job.

Documents

Unit 3-Nursing Process