Nursing Process NUR101 Fall 2008 Lecture #6 and #7 K. Burger, MSEd, MSN, RN, CNE PPT By: Sharon Niggemeier RN MSN Revised KBurger 8/06 Revised JBorrero 09/08

Nursing Process §Specific to the nursing profession §A framework for critical thinking §It’s purpose is to: “Diagnose and treat human responses to actual or potential health problems”

Nursing Process §Organized framework to guide practice §Problem solving method - client focused §Systematic- sequential steps §Goal oriented- outcome criteria §Dynamic-always changing, flexible §Utilizes critical thinking processes

Scientific Method of problem solving §ID problem §Collect data §Form hypothesis §Plan of action §Hypothesis testing §Interpret results §Evaluate findings

Advantages of Nursing Process §Provides individualized care §Client is an active participant §Promotes continuity of care §Provides more effective communication among nurses and healthcare professionals §Develops a clear and efficient plan of care §Provides personal satisfaction as you see client achieve goals §Professional growth as you evaluate effectiveness of your interventions

5 Steps in the Nursing Process §Assessment §Nursing Diagnosis §Planning §Implementing §Evaluating

Assessment §First step of the Nursing Process §Gather Information/Collect Data l Primary Source - Client / Family l Secondary Source - physical exam, nursing history, team members, lab reports, diagnostic tests….. l Subjective -from the client (symptom) “I have a headache” l Objective - observable data (sign) Blood Pressure 130/80

Assessment-collecting data §Nursing Interview (history) §Health Assessment -Review of Systems §Physical Exam l Inspection l Palpation l Percussion l Auscultation

Assessment-collecting data §Make sure information is complete & accurate §Validate prn §Interpret and analyze data Compare to “standard norms” §Organize and cluster data

Example of Assessment §Obtain info from nursing assessment, history and physical (H&P) etc…... §Client diagnosed with hypertension §B/P 160/90 §2 Gm Na diet and antihypertensive medications were prescribed §Client statement “ I really don’t watch my salt” “ It’s hard to do and I just don’t get it”

Nursing Diagnosis §Second step of the Nursing Process §Interpret & analyze clustered data §Identify client’s problems and strengths §Formulate Nursing Diagnosis (NANDA : North American Nursing Diagnosis Association)-Statement of how the client is RESPONDING to an actual or potential problem that requires nursing intervention

Nsg Dx vs MD Dx §Within the scope of nursing practice §Identify responses to health and illness §Can change from day to day §Within the scope of medical practice §Focuses on curing pathology §Stays the same as long as the disease is present

Formulating a Nursing Diagnosis §Composed of 3 parts: §Problem statement- the client’s response to a problem §Etiology- what’s causing/contributing to the client’s problem §Defining Characteristics- what’s the evidence of the problem

Nursing Diagnosis §Problem( Diagnostic Label)-based on your assessment of client…(gathered information), pick a problem from the NANDA list... §Etiology- determine what the problem is caused by or related to (R/T)... §Defining characteristics- then state as evidenced by (AEB) the specific facts the problem is based on...

Example of Nursing Dx §Ineffective therapeutic regimen management R/T difficulty maintaining lifestyle changes and lack of knowledge AEB B/P= 160/90, dietary sodium restrictions not being observed, and client statements of “ I don’t watch my salt” “It’s hard to do and I just don’t get it”.

Types of Nursing Diagnoses §Actual Imbalanced nutrition; less than body requirements RT chronic diarrhea, nausea, and pain AEB height 5’5” weight 105 lbs. §Risk Risk for falls RT altered gait and generalized weakness §Wellness Family coping: potential for growth RT unexpected birth of twins.

Collaborative Problems §Require both nursing interventions and medical interventions EXAMPLE: Client admitted with medical dx of pneumonia Collaborative problem = respiratory insufficiency Nsg interventions: Raise HOB, Encourage C&DB MD interventions: Antibiotics IV, O2 therapy

Planning Third step of the Nursing Process §This is when the nurse organizes a nursing care plan based on the nursing diagnoses. §Nurse and client formulate goals to help the client with their problems §Expected outcomes are identified §Interventions (nursing orders) are selected to aid the client reach these goals.

Planning – Begin by prioritizing client problems §Prioritize list of client’s nursing diagnoses using Maslow §Rank as high, intermediate or low §Client specific §Priorities can change

Planning Developing a goal and outcome statement §Goal and outcome statements are client focused. §Worded positively §Measurable, specific observable, time-limited, and realistic §Goal = broad statement §Expected outcome = objective criterion for measurement of goal §Utilize NOC as standard EXAMPLE §Goal: Client will achieve therapeutic management of disease process…. §Outcome Statement: AEB B/P readings of / and client statement of understanding importance of dietary sodium restrictions by day of discharge.

Planning- Types of goals §Short term goals §Long term goals §Cognitive goals §Psychomotor goals §Affective goals

Goals are patient-centered and SMART Specific Measurable Attainable Relevant Time Bound Pt will walk 50 ft. Pt will eat 75% of meal Pt will be OOB 2-4hrs Pt will maintain HR<100 Pt will state pain level is acceptable 6 (0-10)

Planning-select interventions §Interventions are selected and written. §The nurse uses clinical judgment and professional knowledge to select appropriate interventions that will aid the client in reaching their goal. §Interventions should be examined for feasibility and acceptability to the client §Interventions should be written clearly and specifically.

Interventions – 3 types §Independent ( Nurse initiated )- any action the nurse can initiate without direct supervision §Dependent ( Physician initiated )-nursing actions requiring MD orders §Collaborative- nursing actions performed jointly with other health care team members

Implemention §The fourth step in the Nursing Process §This is the “Doing” step §Carrying out nursing interventions (orders) selected during the planning step §This includes monitoring, teaching, further assessing, reviewing NCP, incorporating physicians orders and monitoring cost effectiveness of interventions §Utilize NIC as standard

Implementing- “Doing” §Monitor VS q4h §Maintain prescribed diet (2 Gm Na) §Teach client amount of sodium restriction, foods high in sodium, use of nutrition labels, food preparation and sodium substitutes §Teach potential complications of hypertension to instill importance of maintaining Na restrictions §Assess for cultural factors affecting dietary regime

Implementing – “Doing” §Teach the client- hypertension can’t be cured but it can be controlled. §Remind the client to continue medication even though no S/S are present. §Teach client importance of life style changes: (weight reduction, smoking cessation, increasing activity) §Stress the importance of ongoing follow-up care even though the patient feels well.

Evaluation- To determine effectiveness of NCP §Final step of the Nursing Process but also done concurrently throughout client care §A comparison of client behavior and/or response to the established outcome criteria §Continuous review of the nursing care plan §Examines if nursing interventions are working §Determines changes needed to help client reach stated goals.

Evaluation §Outcome criteria met? Problem resolved! §Outcome criteria not fully met? Continue plan of care- ongoing. §Outcome criteria unobtainable- review each previous step of NCP and determine if modification of the NCP is needed. §Were the nsg interventions appropriate/effective?

Evaluation Factors that impede goal attainment: §Incomplete database §Unrealistic client outcomes §Nonspecific nsg interventions §Inadequate time for clients to achieve outcomes.

Checkpoint Identify which stage of the nursing process is being described below: §The nurse writes nursing interventions §A goal is agreed upon §The nurse performs a physical assessment §A revision is made to the NCP §The nurse administers antibiotic medication §A statement is written that outlines the clients response to a potential health problem

S and O Data Quiz §RR 22/min, even unlabored §“I can only walk 3 blocks before my legs start to hurt” §Pain rated 3 on a scale of 0-10 §Skin pink, warm and dry §Urine output 300mL/8 hr §“My wife doesn’t come to visit very often” §Dressing clean, dry and intact.

NCLEX Time §The nurse records the following subjective data in the client’s medical record: §A.Breath sounds clear to auscultation §B.Amber urine in sufficient quantities §C.Pain intensity 8 out of 10 §D.Skin warm and dry

NCLEX Time §When interviewing a client, the nurse uses the following open-ended style sentence: §A.Do you have any concerns right now? §B.Is your family worried about you being in the hospital? §C.How many times do you get up to go to the bathroom at night? §D.What do you mean when you say, “I don’t feel quite right?”

NCLEX Time In order for an actual nursing diagnosis to be valid it must have one or more supporting: §A.Laboratory results §B.Diagnostic data §C.Defining characteristics §D.Medical diagnoses

NCLEX Time Nursing diagnoses are aimed at identifying client problems that are treatable by _______. §A.The physician §B.The nurse §C.Invasive techniques §D.Complementary strategies