The Nursing Process NUR 403 Foundations of Nursing

The Nursing Process NUR 403 Foundations of Nursing Practice SP 10 1

The Nursing Process is. . . “A systematic, rationale method of planning and providing individualized nursing care. Its purpose is to identify client’s health status, actual or potential healthcare problems or needs, to establish plans to meet those needs and to deliver specific nursing interventions to meet those 2

The Nursing Process is. . . The set of activities that professional nurses perform to determine the needs of the patient and make a judgment to provide the care that is needed. 3

Your legal and professional accountability and the nursing of process CA BRN Standards of Competent Performance: RN shall be considered to be competent when he/ she consistently demonstrates the ability to transfer scientific knowledge…in applying the nursing process: 4

Standards of Competent Performance (Board of Registered Nursing) Formulates nursing diagnosis, through observation and interpretation of information. Formulates a care plan in collaboration with the client. Performs skills essential to the nursing actions to be taken. Delegates tasks to subordinates Evaluates the effectiveness of the care plan Acts as the client’s advocate. 5

American Nurses Association Standards of Practice The collection of data is systematic Derive nursing diagnosis from data Plan nursing care including goals Plan includes priorities and nursing approaches Nursing actions provide for client participation in health promotion, maintenance, and restoration Evaluation of progress or lack of 6

Problem-Solving & Priority Setting: Determine client health values & beliefs Establish priorities from highest to lowest Determine urgency or the problem Problem-Solving: Once problem is identified, collect data Analyze the data & identify an action-plan Implement the plan, observing initial responses Evaluate the results 7

Steps of the Nursing Process Assessment Diagnosis Planning Implementation Evaluation 8

The Nursing Process Otten/403 9

The Nursing Process

Assessment Phase

Assessment Data Subjective Data - The client states “. . . ” Objective Data - Vital signs - Physical assessments - Previous documentation

Examples of Data Temp of 102 degree “I feel tired” WBC 24, 000/mm 3 “I need help to walk” B/P 180/96 “My leg hurts” Redness and swelling in R ankle 13

Diagnosi s Phase

A Nursing Diagnosis is. . . A description of the client’s response to a disease state, process, condition or situation. It is “a clinical judgment about an individual, family or community responses to actual/potential health problems/life processes. Nursing diagnoses provide the basis for selection of nursing interventions to achieve desired client outcomes”. (NANDA, 1990) 15

Comparing Nursing & Medical Diagnoses Nursing Diagnosis Describes a response to a disease process, condition or situation Medical Diagnosis Describes a specific disease process Oriented to individual changes as client changes Oriented to pathology & remains constant Compliments medical diagnoses Teaches client re selfcare Well defined classification system Teaches clients about treatments 16

Advantages & Disadvantages of Nursing Diagnoses Advantages: Provides a common language for nurses Outcome-oriented Efficient, Organized , Systematic, and Goal Directed Disadvantages: Inconsistently used Not always formally recognized (by MDs. ) Some problems don’t fit diagnostic statements as outlined by NANDA 17

Two Types of Nursing Diagnoses Actual Problems: Altered Nutrition, less than body requirements related to poor oral intake as evidenced by weight loss of 12 lbs. in two weeks. Potential Problems: High risk for infection (Potential for) related to decreased primary defenses. 18

Components of a Nursing Diagnosis Actual Problem (3 Part Statement) Diagnostic Label/Statement (Problem Statement): “ Activity Intolerance” “Impaired Physical Mobility” (identifies unhealthy responses, what needs change) Etiology (Contributing Factors) “… related to ________” (identifies factors causing undesirable response) Defining Characteristics (Manifestations) 19

Components of a Nursing Diagnosis Potential Problems (2 Part Statement) Diagnostic Label/Statement Etiology (Contributing Factors) 20

Planning Phase

Planning Phase: Goals & Outcomes Goals are broad statements about the effects of nursing interventions on the client (overall, nonmeasurable statements) Outcomes are specific, measurable criteria used to evaluate whether goals have been met based on specific nursing interventions 22

Outcome Statements (Criteria) Outcomes are derived from the diagnosis Outcomes are measurable/behavioral Outcomes are realistic compared to the client’s self-care abilities Outcomes have a time-frame for completion 23

Planning Phase: Interventions should be developed which are consistent with the established plan of care Interventions should be implemented in a safe, appropriate manner based on sound nursing theory and 24

Planning Phase: Interventions should always be documented in the medical record Interventions should be realistic for client, based on abilities and resources 25

Types of Nursing Interventions Independent: Able to be implemented without a physician’s order Dependent: Must have or obtain physician’s order to implement this intervention Collaborative: Combination of dependent/independent nursing intervention 26

Types of Nursing Functions Independent: functions that are within scope of nursing practice. Assessment - history and physical Nursing diagnosis, which require nursing interventions Nursing actions Referrals to other health members Evaluation of patient’s responses 27

Types of Nursing Functions Interdependent: activities that are carried out in conjunction with other health team members. RN works with a dietician to help a diabetic patient control blood sugar. RN works with PT to help improve patient’s ambulation. 28

Nursing Functions Dependent: activities performed based on the physician’s orders Administration of medication Carrying out specific treatments 29

Independent? Interdependent? Dependent? Patient has a B/P of 160/100, the RN Retakes the B/P; ask the pt what he was doing. Asks the pt. how he is feeling, notes changes Checks B/P with the previous B/P readings. Checks the MD’s order for any related orders. Gives treatments ordered by the MD. 30

Focus of Patient Care Medicine and Nursing Patient reports, “It feels like my chest is being crushed” Observations show facial grimace, SOB (shortness of breath), and diaphoresis (perspiring) 31

Focus of Patient Care Goal of Medicine: cure, treat disease, heal physiologic being Goal of Nursing: works with the whole person 32

Focus of Patient Care Medical interpretation of pain: diminished blood flow from coronary arteries to myocardium Probable Diagnosis: Myocardial Nursing interpretation: Pain in the chest Probable Nursing Diagnosis: chest pain 33

Focus of Patient Care Medical Plan: dependent functions Bedrest Vital Signs q 15 min. Morphine 2 mg IV prn NTG 1/200 gr SL prn Nursing Plan: independent functions Monitor EKG and dysrhythmia Assess chest pain Employ comfort measures, allow rest Alleviate anxiety 34

Implementation Phase

Implementation Skills (3) Require cognitive skills (problemsolving, creative & critical thinking skills) Require interpersonal skills (verbal/non-verbal communication, teaching, caring etc. ) Require technical skills (“hands-on” psychomotor skills, tasks, procedures) 36

Evaluation Phase

The Nursing Process STEP 5 Evaluation— determining the client’s progress monitoring the client’s response Otten/403 38

Evaluation Process Compare the actual to expected outcomes - Did my client achieve their outcomes? - If not, determine why outcomes were unmet Were the outcomes realistic? Correct problem? Enough time to achieve outcomes? If you determine the outcomes to be appropriate, assess the interventions -Were the interventions appropriate? Were they completed? Does the client require other nursing interventions? If everything looks good, continue with plan of care, observing for improvement 39

Purposes of a Written Care Plan Provides direction & individualizes client care Provides for continuity of care Provides direction for follow-up & documentation Provides assistance in assigning staff Provides information for 40

Mrs. Ida Hubert, 67 y. o. Admitted to the unit with diagnosis of lung cancer with bone metastases 3 days ago Meds: morphine 180 mg daily; Tylenol 650 mg +Oxycodone 10 mg q 6 h p. r. n. Morning report: Mrs. Huber had been restless all night 41

What assessments would you want to make in your preparation for her care? Chart review: Has been taking narcotics for 2 months; spends most of her days in bed 42

Assessment of Mrs. Hubert Patient interview: Alert and responsive “Couldn’t sleep or rest; just couldn’t get into a comfortable position. ” Had trouble describing her discomfort. Reported decreased appetite, ate 3 small meals/day, one 8 oz can of supplement. Said she is drinking very little fluids 43

Assessment of Mrs. Hubert Measurements: V. S. were stable Had active bowel sounds, abdomen nontender to palpation, but noted a firm area in LLQ. Said she had not had a BM since admission (3 days ago). What nursing diagnosis might be appropriate for Mrs. Hubert? 44

Critical Thinking: What is it? Critical thinking is “making decisions based on reason, reflection, knowledge and instinct derived from experience. Critical thinking helps nurses make patient-care decisions by helping them to think creatively, and explore new ideas and alternative ways of solving problems. (Catalano, 1996) 45

The Critical Thinking Process Identify the problem Identifying the underlying beliefs (patient, personal and other healthcare providers) Find support for the beliefs (accurate, timely, consistent literature/research) Evaluate the situation for possible solutions and weigh the solutions against the beliefs and values Present a course of action 46

Steps Subjective Assessment Objective Diagnosis Assessment Plan Implementation Plan Evaluation