The Nursing Process Craven Unit 2 – Ch

The Nursing Process Craven Unit 2 – Ch
The Nursing Process Craven Unit 2 – Ch Cathi Collings MSN & Peggy Korman CNM 4/16/2017 4/16/2017 NRS320 Collings2012 1

Chapter 11: Nursing Assessment
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Nursing Process 4/16/2017 NRS320 Collings2012

Nursing Assessment Activities
Collection of data Validation of data Organization of data 4/16/2017 NRS320 Collings2012

Preparing for Assessment
Types of assessment Admission assessment Focused assessment Time-lapse assessment Emergency assessment 4/16/2017 NRS320 Collings2012

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NCLEX Question ????? Which of the following is done to evaluate any changes in the patient’s functional health from baseline? a. Focus assessment b. Time-lapse assessment c. Emergency assessment d. Initial assessment 4/16/2017 NRS320 Collings2012

Preparing for Assessment
Setting and environment Quiet, private setting Restricted or secluded Minimal distractions 4/16/2017 NRS320 Collings2012

Assessment Skills Interviewing Preparatory phase Introductory phase
Maintenance phase Concluding phase Observation Vision Smell Hearing Touch 4/16/2017 NRS320 Collings2012

Assessment During an Interview
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Assessment Skills Physical examination techniques Inspection Palpation
Percussion Auscultation 4/16/2017 NRS320 Collings2012

Data Collection Types of data Subjective Objective Sources of data
Primary Secondary 4/16/2017 NRS320 Collings2012

Question Tell whether the following statement is true or false:
Bowel sound is an example of objective data. 4/16/2017 NRS320 Collings2012

Validate Data Comparing cues to normal function
Referring to textbooks, journals, and research reports Checking consistency for cues Clarifying the patient’s statements Seeking consensus with colleagues about inferences 4/16/2017 NRS320 Collings2012

Organize Data Functional health approach Head-to-toe model
Body systems model 4/16/2017 NRS320 Collings2012

Case Study P.J. is an 81 year old widowed male.
c/o sore right foot, trouble walking for “few years”, worse in the last month. Hx: Type 2 DM, HTN, diabetic neuropathy, former smoker 3 children, all live out of state. c/o recent poor appetite. 2 dime sized ulcers on right foot, yellow, black toes. + sensation to bilateral feet. 4/16/2017 NRS320 Collings2012

Assessment Denies severe pain, 2/10 at toes.
BP 180/92, HR 88 and regular, RR 20 and unlabored, T 36.7 S1, S2. DP/PT pulse 1+ left, not able to doppler or palpate on right. 4/16/2017 NRS320 Collings2012

Assessment Bilateral feet cool, R>L
Cap refill R > 3 sec., L = 3 sec. Scattered expiratory wheezes RUL, RA, SpO2 = 95%. AAOX3, pleasant, conversant. c/o hunger, “haven’t eaten yet today” (time is now 6:10pm) Denies bowel/bladder problems. 4/16/2017 NRS320 Collings2012

NURSING PROCESS DEFINITION
THE ACT OF REVIEWING THE PATIENT’S SITUATION IN ORDER TO OBTAIN INFORMATION OF PAST HISTORY, PRESENT STATUS AND TO IDENTIFY PATIENT CURRENT PROBLEMS AND NEEDS 4/16/2017 4/16/2017 NRS320 Collings2012 19

NURSING PROCESS (ADPIE)
ASSESSMENT NURSING DIAGNOSIS PLANNING IMPLEMENTATION OF NURSING ACTIONS EVALUATION 4/16/2017 4/16/2017 NRS320 Collings2012 20

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ASSESSMENT (Carpenito-Moyet, 2005)
ASSESSMENT IS THE DELIBERATE AND SYSTEMATIC COLLECTION OF DATA TO DETERMINE A CLIENT’S CURRENT AND PAST HEALTH STATUS AND FUNCTIONAL STATUS AND TO DETERMINE THE CLIENTS PRESENT AND PAST COPING PATTERNS (Carpenito-Moyet, 2005) 4/16/2017 4/16/2017 4/16/2017 NRS320 Collings2012 22 22

DATA COLLECTION SUBJECTIVE DATA OBJECTIVE DATA “THE PATIENT STATES”
“I feel …” OBJECTIVE DATA MEASURABLE DATA TEMPERATURE PULSE RESPIRATIONS What you see 4/16/2017 4/16/2017 4/16/2017 NRS320 Collings2012 23 23

ASSESSMENT DATA WHERE DOES THE NURSE OBTAIN ALL OF THE INFORMATION NEEDED TO DEVELOP A CARE PLAN FOR THE PATIENT? PATIENT FAMILY INFORMATION SYSTEMS (PT. CHART) REPORT (NURSE TO NURSE) Physical Assessment 4/16/2017 4/16/2017 NRS320 Collings2012 24

What next? Organize data - by system, problem, etc.
Identify Subjective & Objective data Identify abnormal findings, links between information E.g. c/o pain, hx of injury, current condition of wound, treatments used, pain scale rating Nursing student, mother of 2 toddlers, PT work all fit in “roles” or ‘stressors’ w/ coping strategies, statements [“I am too busy to be sick”] 4/16/2017 NRS320 Collings2012

ASSESSMENT DATA SUBJECTIVE OBJECTIVE
Nurses report (second hand assessment information) Patient statements “In quotes” Family statements OBJECTIVE X-Ray shows ……. Lab results are …… What you see History from chart 4/16/2017 4/16/2017 NRS320 Collings2012 26

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NURSING DIAGNOSIS NURSING DIAGNOSIS CLASSIFIES HEALTH PROBLEMS WITHIN THE DOMAIN OF NURSING DOMAIN A REALM OR RANGE OF PERSONAL KNOWLEDGE AND RESPONSIBILITY 4/16/2017 4/16/2017 4/16/2017 NRS320 Collings2012 28 28

NURSING DIAGNOSIS A NURSING DIAGNOSIS IS A CLINICAL JUDGMENT ABOUT INDIVIDUALS, FAMILIES, OR COMMUNITIES AND THEIR RESPONSE TO ACTUAL AND/OR POTENTIAL HEALTH PROBLEMS OR LIFE PROCESSES (NANDA International, 2007) 4/16/2017 NRS320 Collings2012

Nursing Diagnosis Provides the basis for selecting nursing interventions to achieve outcomes for which the nurse is accountable Both a label for the description and the action of describing the patient’s problems 4/16/2017 NRS320 Collings2012

Purpose of the Nursing Diagnosis
Purpose: ID problems, synthesize info from assessment by: Analyzing data ID patient strengths ID normal [baseline] functional level and Indicators of actual or potential dysfunction Formulate a diagnostic statement 4/16/2017 NRS320 Collings2012

Your judgment The Nursing Diagnosis is where you share your decisions about what the patient’s PRIORITY Problems are; what are the causes [Etiology- R/T]; and what are the Symptoms [AEB] When you begin, use plain English Then find the NANDA diagnosis and language 4/16/2017 NRS320 Collings2012

How to Choose a Nsg. Dx Identify patterns [in data]
Validate the diagnosis Formulate the statement using nursing language, within domain of nursing 4/16/2017 NRS320 Collings2012

Nursing Diagnosis Language provides means of communication between nurses Taxonomy: classification system [NANDA] Problem, etiology Leads naturally to planning, goal setting and evaluation 4/16/2017 NRS320 Collings2012

The Rules N.D. is different than medical diagnosis
Medical DX describes disease/pathology Nursing DX describes patient response Actual, risk, or wellness Areas that nurses treat independently Collaborative Problems: M.D. and RN involved – not in independent nursing RN can ID problem, communicate, Treat w/ M.D 4/16/2017 NRS320 Collings2012

Sample data collection
HR 80 B/P 140/78, sPO2 95% on RA, temp 103F [oral] Pt c/o dizziness Skin is intact, flushed, warm/hot, dry to touch Pt reports he was working outside, mowing lawn for 3 hours; “had a couple of beers” Outside temp 97, humidity 17% Pt is 22 year old male Caucasian, appears stated age, Ht/Wt//BMI WNL 4/16/2017 NRS320 Collings2012

Example Data Set Cont. Slept well last nt; ate usual food in a.m.; none since 8 a.m. Hx of Rt rotator cuff repair last year, immunizations up to date; describes self as ‘healthy’. No previous similar problems 4/16/2017 NRS320 Collings2012

Example – Nsg. Dx Pt with temp 103 F, dry, flushed skin, c/o dizziness, tachycardia Open to interpretation [judgment] Fever? Infection? Something else…. “Fever” doesn’t tell us much Interventions? Antipyretic? Antibiotics? “Hyperthermia r/t environmental stressors and overexertion AEB dry, flushed skin, temp 103F and “dizziness” tells us what is going on and what we think caused the problem… 4/16/2017 NRS320 Collings2012

N.D. …. And leads us to goals and interventions
Hyperthermia r/t environmental stressors and overexertion AEB dry, flushed skin, temp 103F and “dizziness” Environment and overexertion are things to educate pt about, control if possible 4/16/2017 NRS320 Collings2012

N.D. and goals R/T …overexertion AEB dry, flushed skin, temp 103F and “dizziness” Clues toward goals and interventions Pt will.. have temp WNL, …report absence of dizzy feeling, ..demonstrate understanding of risks of overexertion in heat.. increase fluid intake at work [by …] 4/16/2017 NRS320 Collings2012

N.D. and Interventions Etiology [R/T] leads us to appropriate interventions NO antipyretics, antibiotics – wrong etiology for this ‘fever’ Hydrate, change environment, cool pt, educate re: risks and need for H2O 4/16/2017 NRS320 Collings2012

Nsg. Dx resources Care plan Book NANDA List [Craven p 209-210]
Start with plain English THEN find NANDA DX With use, language will come more easily PRACTICE! 4/16/2017 NRS320 Collings2012

Sample ASSESSMENT DATA 2
OBJECTIVE VITAL SIGNS Bp 182/90, P-110 irreg. R-22, T-99.0, Pulse Ox. 93% Pain 8/10 Blood Sugar 113 HEAD TO TOE ASSESSMENT Neuro A & O X1 [person] VS as noted Heart sounds clear -rhythm irregular BS clear + Bowel sounds x4 0 edema Rt. Extremities flaccid Rt. Leg externally rotated SUBJECTIVE Family states that pt. developed increasing confusion prior to falling Family states that pt. complained of severe headache Family states that patient continues to be in pain. Pt c/o pain; points to face = >6/10 or ‘severe’ pain Pt is 88 y.o male 4/16/2017 4/16/2017 NRS320 Collings2012 43

Significant ASSESSMENT DATA
SUBJECTIVE Family states that pt. developed increasing confusion prior to falling Family states that pt. complained of severe headache Family states that patient continues to be in pain. Pt c/o pain; points to face = >6/10 or ‘severe’ pain Pt is 88 yo male OBJECTIVE VITAL SIGNS Bp 182/90, P-110 irreg. R-22, T-99.0, Pulse Ox. 93% Pain 8/10 Blood Sugar 113 HEAD TO TOE ASSESSMENT Neuro A & O X1 [person] VS as noted Heart sounds clear -rhythm irregular BS clear + Bowel sounds x4 0 edema Rt. Extremities flaccid Rt. Leg externally rotated 4/16/2017 4/16/2017 NRS320 Collings2012 44

Additional Findings from chart
FRACTURED Rt. HIP [x-ray] CONFUSION HYPERTENSION X 15 years INSULIN DEPENDENT DIABETES [25 yrs] HISTORY OF FALLS [ 3 last year] IRREGULAR HEART BEAT [a fib] 4/16/2017 4/16/2017 NRS320 Collings2012 45

Priorities ABC’s Safety Pain
Pretty universal priorities – apply to most all situations Actual Diagnoses before Risk Dx 4/16/2017 NRS320 Collings2012

POTENITIAL NURSING DIAGNOSES
SAFETY [Risk for injury] R/T confusion, history of falls, impaired mobility SKIN INTEGRITY [risk for or actual impaired] R/T Pressure/ischemia 2* to immobility, delicate skin /age, tissue trauma PAIN [acute] R/T Tissue damage, swelling 2* to FRACTURED HIP 4/16/2017 4/16/2017 NRS320 Collings2012 47

Other Possible N.DX Risk for impaired tissue/cerebral perfusion R/T irregular heartbeat [potential clots] Risk for powerlessness R/T dependent status after injury Risk for delayed surgical recovery R/T altered immune and healing response 2* to IDDM, age 4/16/2017 NRS320 Collings2012

BUILDING A NURSING DIAGNOSIS
1. PROBLEM 2. ETIOLOGY 3. SYMPTOMS 4/16/2017 4/16/2017 NRS320 Collings2012 49

PES Diagnosis [for actual problems]
Acute Pain R/T tissue trauma AEB c/o pain >6/10, fractured Rt hip Tells us [etiology] Tissue Trauma [which we see (symptom) as a fracture on X-ray] is causing PAIN (Problem) We also know because the pt says he is in pain (Symptom) 4/16/2017 NRS320 Collings2012

An ‘At Risk’ Diagnosis Problem Etiology No symptoms ….
Because the problem is not actual [yet] We want to prevent the problem! 4/16/2017 NRS320 Collings2012

P - AT RISK FOR IMPAIRED SKIN INTEGRITY
PE PROBLEM P - AT RISK FOR IMPAIRED SKIN INTEGRITY RELATED TO E – pressure/ ischemia 2* to immobilization, delicate skin, tissue damage 4/16/2017 4/16/2017 NRS320 Collings2012 52

Wellness Diagnosis P only Readiness for enhanced health maintenance
Diagnostic label Describes human responses to levels of wellness in individual/populations that have a readiness for enhancement to a higher state Readiness for enhanced health maintenance 4/16/2017 NRS320 Collings2012

Choosing Priority NURSING DIAGNOSES
Risk for injury R/t history of falls, impaired mobility, confusion Acute Pain r/t tissue injury 2* to Hip FX AEB c/o pain “severe” 6/10 Risk for impaired skin integrity R/T ischemia/pressure 2* to Immobility AEB bedrest and traction Which is the priority? Why? 4/16/2017 NRS320 Collings2012

Priorities Pain If pain is 8 on a scale from 1-10, will pt be able to comply with interventions until pain is relieved? Probably not This is a clinical judgment Standard priorities – ABC, Safety, Pain Actual before Risk 4/16/2017 NRS320 Collings2012

Resources in Craven Box 12-1 on page 208 Box 12-2 on page 209-210
Help you find N DX by area [cluster] of data, functional health patterns Practice! “Practicing for NCLEX” questions pg. 211 4/16/2017 NRS320 Collings2012

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Chapter 13: Outcome Identification and Planning
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Outcome Identification
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Purpose Providing individualized care Promoting patient participation Planning care that is realistic and measurable Allowing for involvement of support people 4/16/2017 NRS320 Collings2012

Activities Establish priorities Establish patient goals and outcome criteria 4/16/2017 NRS320 Collings2012

Nursing Sensitive Patient outcomes Nursing Outcomes Classification
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Outcome Identification Activities
Establish priorities High priority Medium priority Low priority 4/16/2017 NRS320 Collings2012

NCLEX Question Which of the following is a high-priority nursing diagnosis? a. Impaired Gas Exchange b. Fatigue c. Stress Incontinence d. Dysfunctional Grieving 4/16/2017 NRS320 Collings2012

Establish Patient Outcomes and Outcome Criteria
Short- versus long term Outcome criteria Specific, measurable, realistic 4/16/2017 NRS320 Collings2012

Planning 4/16/2017 NRS320 Collings2012

Planning Purposes Direct patient care activities
Promote continuity of care Focus charting requirements Allow for delegation of specific activities 4/16/2017 NRS320 Collings2012

Nursing Interventions Classification (NIC)
Physiologic: Basic Physiologic: Complex Behavioral Safety Family Health system Community 4/16/2017 NRS320 Collings2012

Planning Activities Planning nursing interventions
Writing a patient plan of care Patient centered Step-by-step process 4/16/2017 NRS320 Collings2012

Types of Patient Plans of Care
Instructional patient plans of care Instructional concept maps Clinical plans of care 4/16/2017 NRS320 Collings2012

Clinical Patient Plans of Care
Individual Plan of Care Standardized Plan of Care Generic Plan of Care Computerized Plan of Care 4/16/2017 NRS320 Collings2012

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The Goal leads to Interventions
Instructions to Nurses [and HCT] Not Patient instructions [RN will] preface… Include timing …Administer analgesics q 4hrs per orders for pain >4/10 … Assess and document pain at least hourly throughout shift … teach pt/family about pain scale, pain meds [onset and duration, side effects] as indicated by assessment 4/16/2017 NRS320 Collings2012

TYPES OF INTERVENTIONS
NURSE INITIATED INDEPENDENT [focus on these] PHYSICIAN INITIATED DEPENDENT COLLABORATIVE INTERDEPENDENT [referrals, teamwork] 4/16/2017 4/16/2017 NRS320 Collings2012 74

Types of Interventions
Cognitive: Educational: teaching/ pt./family education Supervisory Delegation to UAP Delegation to pt/family [learning for home] Interpersonal: Coordination, advocacy, refferral Support, modeling, listening 4/16/2017 NRS320 Collings2012

Types of Interventions [cont.]
Technical Interventions Maintenance [hygiene, skin care, etc] Help prevent complications, maintain function Monitoring: assess and note changes Communicate to HCT [VS, pulses, bleeding…] Psychomotor : technical interventions Insert Foley, IV, Suction, Assess 4/16/2017 NRS320 Collings2012

Implementation Activities
Reassess During each encounter Set Priorities As condition changes, resources change Perform Interventions Record [document] Interventions 4/16/2017 NRS320 Collings2012

Implementation of plan
The action phase Providing nursing care Delegating appropriate care Maintaining accountability Documenting care provided 4/16/2017 NRS320 Collings2012

Implementing Nursing Care
DECIDING ON Interventions Who can do them? Cannot delegate essential nursing actions like assessment Referral when out of nursing domain/personal ability When? consider patient preference, time, resources New info, feedback, assessment data Schedule multiple patients realistically 4/16/2017 4/16/2017 4/16/2017 NRS320 Collings2012 79 79

Writing INTERVENTIONS
NURSING ORDERS [independent] RN/CNA will REPOSITION EVERY TWO HOURS RN/CNA will provide SKIN CARE TO ALL BONY PROMINENCES WITH REPOSITIONING ASSESSMENTS [pain, skin.. How often? When?] Education [teach pt/ family..] Dependent Orders RN will Administer Percocet 650 mg PO q 4hrs and reassess pain Q 30 min [independent] until <4/10 Interventions should direct team – what/when/how often? 4/16/2017 4/16/2017 4/16/2017 80 NRS320 Collings2012

RATIONALE FOR INTERVENTION
Research Evidence in support of a nursing intervention [for school] Citation Frequent turning and repositioning … can prevent localized obstruction of blood flow caused by increased pressure (Craven, p. 946) Reference Craven, Hirnle & Jensen (2013) Fundamentals of Nursing Human Health and Function (7th Ed.) Philadelphia: Lippincott Williams & Wilkins Why would I need a rationale once my care plans aren’t being graded? Because doing something ‘because that’s the way we always do it’ or because ‘it feels right’ is not sufficient for a profession. Evidence-Based practice! 4/16/2017 NRS320 Collings2012

EVALUATION Was the expected Goal/ Outcome met? How do you know? [AEB]
Goal met/partially met/not met How do you know? [AEB] Will you revise or continue the plan of care? Goal met: pt skin intact at shift change. Continue with plan of care. Goal partially met: pt pain at 6/10 after 30 min. Revision: Reposition q 2 hrs, ice to hip. Pain 4/10 at shift change. 4/16/2017 4/16/2017 82 4/16/2017 82 NRS320 Collings2012

EVALUATION IS ONGOING AS IS THE NURSING PROCESS
EACH CARE PLAN MUST EVOLVE AS THE PATIENT PROGRESSES Based on evaluation (reassessment), the nursing diagnoses, priorities, and interventions will change 4/16/2017 4/16/2017 4/16/2017 NRS320 Collings2012 83 83

Next/ New Nursing Diagnoses ?
Assessment to support DX: Goal Statement Interventions/Implementation Rationale Evaluation Could use confusion, fall risk [safety], continue with pain Need SMART goal statement, interventions w/ rationale if books available, evaluation 4/16/2017 NRS320 Collings2012

Remember: SMART goals help students ADPIE to their diet of P’s , V’S and R’s
Remember these Acronyms: SMART = Specific, Measurable, Attainable, Realistic, Time-specific goals; ADPIE = Assessment, Diagnosis, Planning [goal-setting], Implementation/Intervention, Evaluation; 4 P’s = Position, Potty, Pain, Personal Needs; VS = 5 or 6 VS: TPR, B/P, Pain, [SPO2]. R’s = 5 Rights of medication administration [Right Pt, Right med, right dose, right route, Right time] 4/16/2017 NRS320 Collings2012

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Acronyms ADPIE: nursing process SMART + PC: goals
4 P’s: hourly rounding checks pain, position, potty, personal needs VS: vital signs R’s: rights 7 rights of medication administration 4/16/2017 NRS320 Collings2012

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