Nursing Process n116

The Nursing Process  Assessment  Diagnosis  Planning  Implementing  Evaluating

assess  Gather information about client’s condition

diagnose  Identify the client’s problem

plan  Set goals of care and desired outcomes and identify appropriate nursing actions

implement  Perform the nursing actions identified in planning

evaluate  Determine if goals are met and outcomes achieved

Assessment

 Deliberate and systematic collection of data  Primary source (client) and secondary source (family, chart, other clinicians)  Analysis of data to identify problems and plan care

Assessment  Critical thinking:  lets you see the big picture  lets you prioritize assessment  Includes:  physical, emotional, mental, spiritual status of client

Assessment  Functional health patterns table 16-1  Subjective data: interview and nurse history  Objective data: physical assessment, lab and radiology data, observation of behavior  Analyze and interpret data

assessment  Validate findings with client, medical record, family  Validating clarifies vague or unclear data  Determine if further assessment is necessary…is more information needed to reach a logical conclusion?

Assessment  Steps of data analysis:  1. recognize a pattern or trends  2. compare with normal standards  3. make a reasonable conclusion

Diagnosis

 Problems treated primarily by nurses (nursing diagnoses)  Problems requiring treatment by several disciplines (collaborative problems)  Represent a range of human conditions that require nursing care

Diagnosis  Medical diagnosis identification of a disease condition based on specific evaluation of a physical sign, symptom, history, results of tests and procedures.  Nursing diagnosis clinical judgment about the client responses to actual or potential health problems or life processes. The human response that the nurse is licensed and competent to treat.

diagnosis  Nursing diagnoses are the basis for selecting interventions  Emphasize nursing’s independent practice  Defines role of nursing as separate from but collaborative with medicine  North American Nursing Diagnosis Association (NANDA) approves and revises

diagnosis  Precise definitions  Enhances communication  Helps nurses focus on scope of practice  Fosters development of nursing knowledge

diagnosis  Critical thinking…  Clusters and patterns of data contain defining characteristics  table 17-2  Use accepted norms for comparison and judgment

diagnosis  Actual  Risk  Health promotion  Wellness

Diagnosis components  Diagnostic label: NANDA approved name  Related factors: condition or etiology identified from assessment data. The condition responds to nursing interventions  pathophysiological, treatment related,  situational, maturational  Support of Diagnostic statement

diagnosis  Do not use the medical diagnosis as the etiology of the nursing diagnosis  Diagnoses are client centered, not nurse centered.  Identify the problem, not the goal  Don’t use circular language  Identity only one client problem in each diagnostic statement

diagnosis  Acute pain, related to swelling and pressure on nerves, as evidenced by verbal report of pain 8/10, grimacing, self- limiting movement.  Acute pain, related to fractured arm, as evidenced by cast on arm.

Diagnosis  Nutrition, more than body requirements, related to insufficient knowledge about caloric value of foods, as evidenced by BMI of 30 and food diary indicating large consumption of soda  Nutrition, more than body requirements, related to obesity, as evidenced by obesity

diagnosis  Risk for infection related to exposure to pathogens via break in skin integrity  Risk for infection related to fevers

diagnosis  Ineffective coping, related to lack of family support and learned coping mechanisms, as evidenced by self-report of sleeplessness, disheveled appearance, job absentseeism  Ineffective coping, related to nurse not having time to talk to patient, as evidenced by high patient load

Diagnosis  Errors in data collecting  Errors in data interpretation  Errors in data clustering  Errors in Diagnostic Statement