Presentation on theme: "Application of Nursing Process and Nursing Diagnosis: An Interactive Text for Diagnostic Reasoning Sixth Edition Copyright 2013 F.A. Davis Company."— Presentation transcript:
Application of Nursing Process and Nursing Diagnosis: An Interactive Text for Diagnostic Reasoning Sixth Edition Copyright 2013 F.A. Davis Company
Chapter 1 The Nursing Process: Delivering Quality Care
"Do everything as quietly as possible. Step lightly and gently and avoid creaking shoes." "Use no snuff, or any article of food, the smell of which may be offensive to weak nerves." "Ask no unnecessary questions."
The Nursing Profession Definition of Nursing The diagnosis and treatment of human responses to health and illness (ANA, 1995)
The Nursing Profession: Has defined what makes nursing unique Has identified a body of professional knowledge
The Nursing Profession The American Nurses Association, in its Nursing Social Policy Statement, identified four essential features of today’s contemporary nursing practice...
The Nursing Profession 1.Attention to the full range of human experiences…. 2.Integration of objective data… 3.Application of scientific knowledge… 4.Provision of a caring relationship…
The Nursing Process Offers an orderly, logical, problem-solving approach to patient care Incorporates an interactive/ interpersonal approach for problem-solving and decision- making.
The Nursing Process FIVE STEPS Assessment Diagnosis/Analysis Planning Implementation Evaluation
Diagram of the Nursing Process The steps of the nursing process are interrelated, forming a continuous circle of thought and action.
The Nursing Process STEP 1 Assessment— the systematic collection of data relating to clients
The Nursing Process STEP 2 Diagnosis— the analysis of collected data to identify the client’s needs or problems
The Nursing Process STEP 3 Planning— a two-part process of: identifying goals and desired outcomes selecting appropriate nursing interventions
The Nursing Process STEP 4 Implementation— putting the plan of care into action
The Nursing Process STEP 5 Evaluation— determining the client’s progress monitoring the client’s response
How the Nursing Process Works A process you routinely use to solve problems Applies readily to client-care situations
Basic skills the nurse must posses: A thorough knowledge of science and theory Creativity Adaptability Intelligence Well-developed interpersonal skills Competent technical skills Commitment to practice according to the standards of care
Nursing Process Resources ANA Code of Ethics for Nurses provides guidance Refer to Appendix A
Standards of Care WHAT A REASONABLE PRUDENT PROFESSIONAL WITH SIMILAR EXPERTISE AND RESPONSIBILITIES WOULD HAVE DONE UNDER SIMILAR CIRCUMSTANCES
Standards of Care Describes a competent level of nursing care Demonstrated by use of the nursing process Describes roles expected of all professional nurses appropriate to their: education position practice setting
Practice Advantages of the Nursing Process Organizing framework Human response focus Structured decision making Patient involvement Control over practice Common language Means to assess economic contribution of nursing to patient care
CRITICAL THINKING WHAT IS IT? PURPOSEFUL, FOCUSED THINKING GUIDED BY STANDARDS, POLICIES, ETHICS, AND THE LAW. BASED ON PRINCIPLES OF NURSING PROCESS DRIVEN BY PATIENT NEEDS. IMPROVES WITH PRACTICE!
CRITICAL THINKING “THE ART OF THINKING WHILE YOU ARE THINKING IN ORDER TO MAKE YOUR THINKING BETTER: MORE CLEAR, MORE ACCURATE, OR MORE DEFENSIBLE.” (Paul, Binker, Adamson, and Martin)
Chapter 2 The Assessment Step: Developing the Client Database
The Assessment Step Assessment involves three basic activities: 1.Systematically gathering data 2.Sorting and organizing data 3.Documenting data in a retrievable format
The Client Database The compilation of data collected about a client Consists of: nursing history (*interview) physical examination results of diagnostic studies
The Client Database Subjective data – what the client reports, believes, or feels Objective data – what can be observed; for example, vital signs, behaviors, diagnostic studies
Framework for Data Collection Two commonly used nursing models: Doenges & Moorhouse’s Diagnostic Divisions Gordon’s Functional Health Patterns Others: body systems, head-to-toe
Framework for Data Collection Nursing assessment model focuses data collection on the nurse’s concern—the human responses to health, illness, life processes See Appendix B for a sample assessment tool
The Interview Process: 10 Key Elements Clear sense of the underlying purpose Preliminary research Request to conduct the interview Sound interviewing strategy Effective use of icebreakers
The Interview Process: 10 Key Elements (cont.) Addressing the business of the interview Rapport Sensitivity to client’s needs Adequate time for recovery Closure
Effective Data Collection Techniques Open-ended questions Hypothetical questions Reflecting or mirroring responses Focusing Giving broad openings Offering general leads Exploring Verbalizing the implied Encouraging evaluation
Data Collection Techniques to Avoid Closed-end questions Leading questions Probing Agreeing/disagreeing
The Client History Client history involves: Reviewing data Organizing and determining the relevance of each item Documenting the facts
Guidelines for History Taking Listen carefully Use active listening skills Be objective Keep detail manageable Sequence information Document clearly Record data in a timely manner
PRACTICE HEALTH HISTORY NAME_____J.F______________________AGE__42____DOB_______SEX___F________ MARITAL STATUS____Divorced_______OCCUPATION_Radiology Technician__________ PHYSICIAN (OR USUAL SOURCE OF HEALTHCARE): Dr. Scot, Family physician CHIEF COMPLAINT: Ear hurting for past 4 days. HISTORY OF PRESENT ILLNESS (HPI): Worsening dull pain in right ear for past 3 days. Ear feels "blocked". Pain worse when lying down, relieved slightly with Tylenol. No pain in left ear. Denies sore throat or headache. Has not noticed any drainage from ear. PAST MEDICAL HISTORY (PMH): HTN x 5 years, seasonal allergies, Migraine headaches. PAST SURGICAL HISTORY (PSH): Appendectomy as child, carpal tunnel surgery left hand 2 years ago. MEDICATIONS: Toprol XL 50 mg daily, hydrochlorothiazide 25 mg daily, Frova 2.5 mg as needed for migraine (uses approx 1/month). Baby ASA once daily. Motrin 1-2 times/week for muscle "aches and pains." ALLERGIES/REACTIONS: Benedryl - rash. SOCIAL HISTORY: Smoked 1 pack/day x 20 years, quit 2 months ago. 1-2 glasses wine q eve. Denies street drugs. Lives with boyfriend. FAMILY HISTORY: Father has HTN, mother has osteoporosis, diabetes. 1 sister in good health. 2 sons, ages 17, 21, in good health.
REVIEW OF SYSTEMS: (ALL-INCLUSIVE): NEUROLOGICAL_____Denies tremors, difficulty walking. Has aura with migraines, otherwise no vision problems. CARDIOVASCULAR Occasional "skipped" heartbeats, denies chest pain, denies swelling in legs. RESPIRATORYNo SOB, no cough. ______________________________________________________________________________________________________
COLLECTING DATA GI - ABD SHAPE, BS, TENDERNESS, BM (Doc. ex: Abd soft and non-distended, BS auscultated x 4 quads. No tenderness on palpation. Soft brown, formed BM. GU - URINE, FOLEY?, (Documentation: Voided clear yellow urine.
COLLECTING DATA SKIN - TEMP, MOISTURE, COLOR, LESIONS? (Doc. ex: Skin warm, dry, and fleshtone.) MS - range of motion, active/passive? (Doc. ex: Active, full ROM in all 4 ext..)
Laboratory Tests and Diagnostic Procedures Part of information-gathering stage Used to: Diagnose disease Follow the course of a disease Adjust therapy When analyzing laboratory tests, consider drugs being administered
Organizing Information Elements Cluster the collected data Review data Validate findings
Chapter 3 The Diagnosis Step: Analyzing the Data (Need/Problem Identification)
The Diagnosis Step Purpose: To draw conclusions regarding a client’s specific needs or human responses so that effective care can be planned and delivered
The Diagnosis Step These terms may be used interchangeably: Analysis Need (or problem) identification Nursing diagnosis
The Diagnosis Step What is Diagnosis? Forming a clinical judgment identifying a disease/condition or human response through scientific evaluation of signs/symptoms, history, and diagnostic studies.
Defining Nursing Diagnosis Nursing Diagnoses are: Derived from the assessment data Validated with the patient/others Documented within a nursing plan of care
Medical vs. Nursing Diagnoses Medical diagnoses illnesses/conditions; reflect alteration of the structure or function of organs/systems; verified by medical diagnostic studies Nursing diagnoses address human responses to actual and potential health problems/life processes
TERMINOLOGY NANDA - North American Nursing Diagnosis Association International Ex: Actual: Impaired Skin Integrity Potential: Risk for Injury
Defining Nursing Diagnosis NANDA’s Definition Nursing diagnosis is a clinical judgment about responses to actual and potential health problems. Nursing diagnoses provide the basis for selecting nursing interventions to achieve results for which the nurse is accountable.
The Use of Nursing Diagnoses Benefits of the nursing diagnosis 1.Gives nurses a common language 2.Promotes identification of appropriate goals 3.Provides acuity information 4.Can create a standard for nursing practice 5.Provides a quality improvement base
Identifying Client Needs During the Assessment step, the collection, clustering, and validation of client data flow directly into the Diagnosis step of the nursing process
Analyzing the Client Database Six Steps in Problem Identification 1. Problem-Sensing 2. Rule-Out Process 3. Synthesizing the Data 4. Evaluating or Confirming the Hypothesis 5. Listing the Client’s Needs 6. Reevaluating the Problem List
Analyzing the Client Database Step 1: Problem-Sensing Data are reviewed and analyzed to identify cues (signs and symptoms) suggesting patient needs.
Analyzing the Client Database Step 2: Rule-Out Process Alternative explanations considered Compare and contrast relationships among data
Analyzing the Client Database Step 3: Synthesizing the Data Looking at all the data as a whole Creating a hypothesis
Analyzing the Client Database Step 4: Evaluating or Confirming the Hypothesis Test hypothesis for fit by: reviewing the nursing diagnosis definition comparing the assessed data with NANDA’s related or risk factors comparing the signs/symptoms with NANDA’s defining characteristics
Analyzing the Client Database Step 5: Listing the Client’s Needs Combine the accurate nursing diagnosis label with the assessed etiology and signs/symptoms “PES” STATEMENT
Analyzing the Client Database Step 6: Reevaluating the Problem List List all nursing diagnoses according to priority and classify according to status: an actual need a risk need
Identifying Client Problems: Other Considerations The medical/psychiatric diagnosis can provide a starting point for identifying associated client needs. Even if the need seems to exist only in the mind of the patient, it needs to be addressed and resolved. Reduce the problem to its basic component to identify more clearly the appropriate interventions to be taken.
Writing a Client Diagnostic Statement Nursing diagnoses identify client needs that can be positively affected, or possibly prevented, by nursing actions. Some diagnoses permit greater independent function; others are more collaborative.
Writing a Client Diagnostic Statement The extent of independent function is influenced by the nurse’s— experience expertise work setting established protocols
Writing a Nursing Diagnosis P-E-S Statement – 3 part statement Problem - Diagnosis according to NANDA Etiology - the cause or risk factors, stated as “related to”- Signs and symptoms – called defining characteristics, the evidence that showed your diagnosis or problem. Stated as “as evidenced by” PROBLEM R/T ETIOLOGY AEB SIGNS AND SYMPTOMS. (No “S” if potential problem)
Writing a Nursing Diagnosis (P) Constipation R/T (E)use of opioid analgesics AEB (S) abdominal discomfort and hard, small stools. Impaired verbal communication R/T aphasia AEB inability to communicate basic needs. Imbalanced nutrition: Less than body requirements R/T vomiting AEB weight loss of 3 lbs over 2 days.
Writing a Nursing Diagnosis Knowledge deficit of med administration R/T lack of recall AEB patient statement “I can never remember to take those pills” Risk for fluid volume deficit R/T fluid loss secondary to NGT to continuous suction.
Writing a Client Diagnostic Statement Collaborative problem: A need identified by another discipline that contains a nursing component requiring nursing intervention
Writing a Client Diagnostic Statement Common Errors : Using the medical diagnosis: Self Care deficit r/t stroke Confusing the etiology or signs/symptoms for the need: Postoperative lung congestion r/t bedrest Use of a procedure instead of the “human response”: Catheterization r/t urinary retention
Writing a Client Diagnostic Statement Common Errors: Lack of specificity: Constipation r/t nutritional intake Combining two nursing diagnoses: Anxiety and Fear r/t separation from parents
Writing a Client Diagnostic Statement Common Errors: Relating one nursing diagnosis to another: Ineffective coping r/t anxiety Use of judgmental or value-laden language: Chronic pain r/t secondary/monetary gain
Writing a Client Diagnostic Statement Common Errors: Making assumptions: Risk for impaired Parenting, risk factors of inexperience (new mother) Writing a legally inadvisable statement: Impaired Skin Integrity r/t not being turned every 2 hours