Nursing Process NUR101 Fall 2010 Lecture #6 and #7 K. Burger, MSEd, MSN, RN, CNE PPP By: Sharon Niggemeier MSN, RN Revised KBurger 8/06, 9/08,8/10.
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Nursing Process NUR101 Fall 2010 Lecture #6 and #7 K. Burger, MSEd, MSN, RN, CNE PPP By: Sharon Niggemeier MSN, RN Revised KBurger 8/06, 9/08,8/10
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
What are some critical thinking characteristics necessary for application of Nursing Process? Knowledge – science & skills Standards – use of EBP standards of practice Experience – previous client experiences Attitudes – open-mindedness, creativity, integrity, confidence,
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 Diagnosis Planning Implementation Evaluation
Assessment First step of the Nursing Process Gather Information/Collect Data Primary Source - Client / Family Secondary Source - physical exam, nursing history, team members, lab reports, diagnostic tests….. Subjective -from the client (symptom) “I have a headache” Objective - observable data (sign) Blood Pressure 130/80
Assessment-collecting data Nursing Interview (history) History includes: physical, emotional, social, spiritual, intellectual dimensions. Considerations for the older adult & cultural diverse client. Review this section in P & P Health Assessment: Review of Systems Inspection Palpation Percussion 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 Focused 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”
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 [Diagnostic Label] the client’s response to a problem Etiology [Related Factors] what’s causing/contributing to the client’s problem Signs/Symptoms [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 (Related Factors)- determine what the problem is caused by or related to (R/T)... Signs/Symptoms (Defining Characteristics)- state as evidenced by (AEB) the specific facts the problem is based on...
Example of Nursing Dx Ineffective health maintenance 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 Readiness for enhanced Family coping: Health Promotion Readiness for enhanced immunization status
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- Types of goals Short term goals Long term goals Cognitive goals Psychomotor goals Affective goals
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 110-120 / 70-80 and client statement of understanding importance of dietary sodium restrictions by day of discharge.
Think about this…. We have talked about the difference between cognitive, psychomotor and affective goals. What type of goal is the statement on the previous slide? Can you think of some goal statements in the other domains?
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 or delegating 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
Delegation Five Rights Right task Right circumstance Right person Right communication Right supervision NCSBN (1995)
Implementing- “Doing” Maintain prescribed diet (2 Gm Na) Administer antihypertensive medications per MD order Obtain registered dietician consult to teach client about 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 Monitor VS q4h
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.
Think about this…. We have learned about the 3 different types of nursing interventions: Independent – Dependent – Collaborative Label each of the interventions on the previous slides as either I – D – or C
Evaluation 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.