The Nursing Process Dr Abdalkarim Radwan Resources Andrea

The Nursing Process Dr. Abdalkarim Radwan

Resources ¢ ¢ Andrea Ackermann, Mount St. Mary College, Critical-thinking-the-nursingprocess 2001. http: //www. umanitoba. ca/nursing/courses/1 28, (2005) Sara-jo Wiscombe, Nursing Process , Wallace Community College , May 22, 2001. Tucker C, MODULE A INTRODUCTION TO NURSING Process, August 21, 2002. Dr. Abdalkarim Radwan

Dr. Abdalkarim Radwan

The Nursing Process ¢An organizational framework for the practice of nursing ¢Orderly, systematic ¢Central to all nursing care ¢Encompasses all steps taken by the nurse in caring for a patient Dr. Abdalkarim Radwan

Definition of the Nursing Process ¢ An organized sequence of problemsolving steps used to identify and to manage the health problems of clients ¢ It is accepted for clinical practice established by the American Nurses Association Dr. Abdalkarim Radwan

Benefits of Nursing Process ¢ ¢ ¢ ¢ Provides an orderly & systematic method for planning & providing care Enhances nursing efficiency by standardizing nursing practice Facilitates documentation of care Provides a unity of language for the nursing profession Is economical Stresses the independent function of nurses Increases care quality through the use of deliberate actions Dr. Abdalkarim Radwan

The Nursing Process Utilizes The Following ¢Assessment ¢Nursing Diagnosis ¢Planning ¢Implementation ¢Evaluation Dr. Abdalkarim Radwan

Characteristics of the Nursing Process ¢ Within the legal scope of nursing ¢ Based on knowledge-requiring critical thinking ¢ Planned-organized and systematic ¢ Client-centered ¢ Goal-directed ¢ Prioritized ¢ Dynamic Dr. Abdalkarim Radwan

Benefits of using the nursing process ¢ ¢ Continuity of care Prevention of duplication Individualized care Standards of care ¢ Increased client participation ¢ Collaboration of care Dr. Abdalkarim Radwan

Being Accountable Using critical thinking before taking actions ¢ Being responsible for your actions ¢ Entering the professional role ¢ Working at the level of your peers ¢ Using the nursing process ¢ Dr. Abdalkarim Radwan

Something to think about: ¢ Nurses are responsible for a unique dimension of healthcare – “ the diagnosis and treatment of human responses to actual or potential health problems” Dr. Abdalkarim Radwan

MARTHA ROGERS, NURSE THEORIST ¢“When an apple is cut, others seeds in the apple. We, as nurses, see apples in the seeds. ” Dr. Abdalkarim Radwan

What Are Your Responsibilities? ¢ ¢ ¢ Recognize health problems. Anticipate complications. Initiate actions to ensure appropriate and timely treatment. Begin to think CRITICALLY !!!!!! Dr. Abdalkarim Radwan

Critical Thinking ¢ MENTAL OPERATIONS –decision making & reasoning ¢ KNOWLEDGE-having the facts & understanding the reason behind the knowledge ¢ ATTITUDES- curious/open-minded/nonjudgmental…. Dr. Abdalkarim Radwan

Critical Thinking Critical thinking in nursing is an essential component of professional accountability and quality nursing care. ¢ ¢ Critical thinking is careful, deliberate, and goal directed. Dr. Abdalkarim Radwan

Assessment of Well-Being ¢ According to the World Health Organization is well-being in these domains: l Emotional l Physical l Social l Spiritual Dr. Abdalkarim Radwan

Lets Get Started : l l l l Nurse collects background info from previous charts Ensure environment is conducive Arrange seating Allow adequate time Nurse introduces self Identifies purpose of interview Ensure confidentiality of information Provide for patient needs before starting Dr. Abdalkarim Radwan

TYPES OF INTERVIEWS ¢ ¢ DIRECTED NON-DIRECTED THINGS THAT IMPAIR COMMUNICATION: ¢ PRESENTING QUICK SOLUTIONS ¢ UNWARRANTED CHEERFULNESS ¢ FALSE REASSURANCE ¢ GIVING ADVICE ¢ CHANGING THE SUBJECT Dr. Abdalkarim Radwan

ASSESSMENT ¢ Observation ¢ Interview l Types of questions l Environment (physical and emotional) Spiritual conciderations ¢ Examination Dr. Abdalkarim Radwan

Types of Data To Collect: ¢ Objective data-observable and measurable facts (Signs) ¢ Subjective data-information that only the client feels and can describe (Symptoms) Dr. Abdalkarim Radwan

CULTURAL DIVERSITY MUST PROVIDE CARE CONGRUENT WITH A CLIENT’S EXPECTATIONS ¢ “This is not about you” ? ¢ Respect INDIVIDUAL’S DIFFERENCES, What is the significance of the problem or illness to the client? ¢ What does it mean in the family/community? ¢ Dr. Abdalkarim Radwan

COMMON Challenges: Defense Mechanisms COMPENSATION ¢ DENIAL ¢ DISPLACEMENT RATIONALIZATION ¢ ¢ ¢ Dr. Abdalkarim Radwan PROJECTION REPRESSION SUPPRESSION REGRESSION

Continued THE NURSING PROCESS HELPS NURSES UNDERSTAND THE STRATEGIES CLIENTS USE IN their attempt at coping: This knowledge will help you FURTHER INDIVIDUALIZE THEIR CARE ¢ Dr. Abdalkarim Radwan

Resources ¢ ¢ ¢ Client Other individuals Previous records Consultations Diagnostics studies Relevant literature Dr. Abdalkarim Radwan

Assessment ¢ ¢ Data base assessment – comprehensive information you gather on initial contact with the person to assess all aspects of health status. Focus assessment – the data you gather to determine the status of a specific condition. Dr. Abdalkarim Radwan

Sources of Data ¢ Primary source: Client ¢ Secondary source: Client’s family, reports, test results, information in current and past medical records, and discussions with other health care workers Dr. Abdalkarim Radwan

Disease Prevention ¢ ¢ ¢ Primary prevention – protection from a disease while still in a healthy state. Secondary prevention – early detection and treatment of disease. Tertiary prevention – prevent complications and to maintain health once the disease process has occurred. Dr. Abdalkarim Radwan

Verifying Data ¢ ¢ ¢ ¢ Essential in critical thinking!!!!! Measurable data Double check personal observations Double check equipment Check with experts and team members Recheck out-liers Compare objective and subjective data Clarify statements Dr. Abdalkarim Radwan

Planning ¢ Establish the goals, interventions and outcomes Dr. Abdalkarim Radwan

General Guidelines for Setting Priorities 1. 2. 3. 4. Take care of immediate life-threatening issues. Safety issues. Patient-identified issues. Nurse-identified priorities based on the overall picture, the patient as a whole person, and availability of time and resources. Dr. Abdalkarim Radwan

Nurse Identified Priorities ¢ ¢ ¢ Composite of all patient’s strengths and health concerns. Moral and ethical issues. Time, resources, and setting. Hierarchy of needs. Interdisciplinary planning. Dr. Abdalkarim Radwan

Identifying Client-centered Outcomes ¢ ¢ ¢ Ø State what the patient will do or experience at the completion of care. Give direction to the patient’s overall care. Patient behaviors not nurse behaviors!! “The patient will…” Dr. Abdalkarim Radwan

DIAGNOSIS Sort, cluster, analyze information ¢ Identify potential problems and strengths ¢ Write statement of problem or strength ¢ Risk of infection related to compromised nutrition ¢ Dr. Abdalkarim Radwan

Nursing Diagnosis (cont. ) Potential for effective breastfeeding related to knowledge level and support system ¢ Prioritize the problems ¢ Not a medical diagnosis ¢ Dr. Abdalkarim Radwan

Steps for deriving outcomes from Nursing Diagnosis ¢ Ø Ø Look at the first clause of the nursing dx and restate in a statement that describes improvement, control or absence of the problem. Risk for infection r/t surgical procedure. The client will demonstrate no signs or symptoms of infection. Dr. Abdalkarim Radwan

Components of Outcomes ¢ ¢ ¢ Subject: who is the person expected to achieve the outcome? Verb: what actions must the person take to achieve the outcome? Condition: under what circumstances is the person to perform the actions? Performance criteria: how well is the person to perform the actions? Target time: by when is the person expected to be able to perform the actions? Dr. Abdalkarim Radwan

Nursing Interventions ¢ ¢ 1. 2. 3. 4. 5. Road maps directing the best ways to provide nursing care. Evidence based nursing. Monitor health status. Minimize risks. Resolve or control a problem. Assist with ADLs. Promote optimum health and independence. Dr. Abdalkarim Radwan

Interventions ¢ Direct interventions: actions performed through interaction with clients. ¢ Indirect interventions: actions performed away from the client, on behalf of a client or group of clients. Dr. Abdalkarim Radwan

Nursing Diagnosis ¢ Health issue that can be prevented, reduced, resolved, or enhanced through independent nursing measures Dr. Abdalkarim Radwan

Documenting the Plan of Care ¢ ¢ 1. 2. 3. To ensure continuity of care, the plan must be written and shared with all health care personnel caring for the client. Consists of: Prioritized nursing diagnostic statements. Outcomes. Interventions. Dr. Abdalkarim Radwan

Documentation Clear and concise ¢ Appropriate terminology ¢ l ¢ Usually on a designated form Physical assessment l Usually by Review of Systems • Overview of symptoms • Diet • Each body system Dr. Abdalkarim Radwan

Documentation Use patient’s own words in subjective data – enclose in “ ___” (quotation marks) ¢ Avoid generalizations – be specific ¢ Don’t make summative statements – describe - e. g. patient is being ornery should be patient resists instruction or patient states “Don’t talk to me, I don’t care about that” ¢ Dr. Abdalkarim Radwan

Evaluation 1. 2. 3. Determining outcome achievement Identifying the variables affecting outcome achievement Deciding whether to continue, modify, or terminate the plan Dr. Abdalkarim Radwan

Determining Outcome Achievement ¢ ¢ ¢ Must be aware of outcomes set for the client. Must be sure patient is ready for evaluation. Is patient able to meet outcome criteria? Is it: Completely met? Partially met? Not met at all? Record in progress in notes. Update care plan. Dr. Abdalkarim Radwan

Identifying Variable Affecting Outcome Achievement ¢ Maintain individuality of care plan: 1. Is the plan realistic for the client? 2. Is the plan appropriate at the time for this particular client? 3. Were changes made in the plan when needed? 4. How does the client feel about the plan? Dr. Abdalkarim Radwan

Predict, Prevent, and Manage ¢ ¢ Focus on early intervention Based on research Predict and anticipate problems Look for risk factors Dr. Abdalkarim Radwan

Diagnostic Statements ¢ Name of the health-related issue or problem as identified in the NANDA list ¢ Etiology (its cause) ¢ Signs and Symptoms ¢ The name of the nursing diagnosis is linked to the etiology with the phrase “related to, ” and the signs and symptoms are identified with the phrase “as manifested (or evidenced) by” Dr. Abdalkarim Radwan

Collaborative Problems. Nurse’s Responsibility ¢ Correlating medical diagnoses or medical treatment measures with the risk for unique complications ¢ Documenting the complications for which clients are at risk ¢ Making pertinent assessments to detect complications Dr. Abdalkarim Radwan

Continued Reporting trends that suggest development of complications ¢ Managing the emerging problem with nurse- and physician-prescribed measures ¢ Evaluating the outcomes ¢ Dr. Abdalkarim Radwan

The Nursing Process Nursing Diagnosis ¢ Judgment or conclusion about the risk for— or actual—need/problem of the patient ¢ NANDA format Dr. Abdalkarim Radwan

NANDA – North American Nursing Diagnosis Association ¢ ¢ ¢ Identifies nursing functions Creates classification system Establishes diagnostic labels Risk of infection related to compromised nutritional state Potential complication of seizure disorder related to medication compliance Dr. Abdalkarim Radwan

Planning ¢ The process of prioritizing nursing diagnoses and collaborative problems, identifying measurable goals or outcomes, selecting appropriate interventions, and documenting the plan of care. ¢ The nurse consults with the client while developing and revising the plan. Dr. Abdalkarim Radwan

Setting Priorities ¢ Determine problems that require immediate action ¢ Maslow’s Hierarchy of Human Needs Dr. Abdalkarim Radwan

Short-Term Goals ¢ Outcomes achievable in a few days or 1 week ¢ Developed form the problem portion of the diagnostic statement ¢ Client-centered ¢ Measurable ¢ Realistic ¢ Accompanied by a target date Dr. Abdalkarim Radwan

Long-Term Goals ¢ Desirable outcomes that take weeks or months to accomplish for client’s with chronic health problems Dr. Abdalkarim Radwan

The Nursing Process Planning ¢ Identification of goals and outcome criteria ¢ Prioritization ¢ Time frame Dr. Abdalkarim Radwan

Selecting Nursing Interventions ¢ Planning the measures that the client and nurse will use to accomplish identified goals involves critical thinking. ¢ Nursing interventions are directed at eliminating the etiologies. Dr. Abdalkarim Radwan

Selecting an intervention The nurse selects strategies based on the knowledge that certain nursing actions produce desired effects. ¢ Nursing interventions must be safe, within the legal scope of nursing practice, and compatible with medical orders. ¢ Dr. Abdalkarim Radwan

Communicating The Plan ¢ The nurse shares the plan of care with nursing team members, the client, and client’s family. ¢ The plan is a permanent part of the record. Dr. Abdalkarim Radwan

Evaluation ¢ The way nurses determine whether a client has reached a goal. ¢ It is the analysis of the client’s response, evaluation helps to determine the effectiveness of nursing care. Dr. Abdalkarim Radwan

The Nursing Process Evaluation ¢Ongoing part of the nursing process ¢Determining the status of the goals and outcomes of care ¢Monitoring the patient’s response to drug therapy Dr. Abdalkarim Radwan

Documentation Clear and concise ¢ Appropriate terminology ¢ l ¢ Usually on a designated form Physical assessment l Usually by Review of Systems • Overview of symptoms • Diet • Each body system Dr. Abdalkarim Radwan