The Nursing Process The Nursing Process A decisionmaking

The Nursing Process

The Nursing Process A decision-making method used by nurses for clinical care Influenced by the following 3 elements: Intuition Expertise Critical thinking

The Nursing Process 6 steps: Assessment Diagnosis Outcome identification Planning Implementation Evaluation

Assessment

Assessment Phase in which the nurse collects enormous amounts of data about clients’ holistic health status Nurses collect data through interactive and interviewing skills and observations of verbal and nonverbal behavior Data obtained from this phase enables nurses to prioritize treatment planning according to clients’ needs or immediate conditions

Assessment Includes the Following Criteria: Physical Psychiatric Psychosocial Mental status Developmental Cultural Spiritual Sexual

Components of Mental Status Assessment Appearance Dress, grooming, hygiene, cosmetics, apparent age, posture, facial expression Behavior/Activity Hypoactivity or hyperactivity, rigid, relaxed, restless or agitated movements, gait and coordination, facial grimacing, gestures, mannerisms, passive, combative, bizarre

Components of Mental Status Assessment Attitude Interactions with the interviewer: cooperative, resistive, friendly, hostile Speech Quantity: poverty of speech or content; hyperverbal or excessive Quality: articulate, congruent, monotonous, talkative, repetitious, spontaneous, confabulations, tangential, circumstantial, pressured Rate: Slowed, rapid

Components of Mental Status Assessment Mood and Affect Mood: sad, fearful, depressed, angry, anxious, ambivalent, happy, ecstatic, grandiose Affect: appropriate, apathetic, constricted blunted, flat, labile, euphoric, bizarre Perceptions Hallucinations, illusions, depersonalization, derealization, distortions

Components of Mental Status Assessment Thoughts (Form and Content): logical vs illogical, loose associations, flight of ideas, blocking, broadcasting, neologisms, word salad, obsessions, ruminations, delusions, abstract vs concrete

Components of Mental Status Assessment Sensorium/Cognition Levels of consciousness, orientation, attention span, recent and remote memory, concentration; ability to comprehend and process information; intelligence

Components of Mental Status Assessment Judgment Ability to assess and evaluate situations, make rational decisions, understand consequences of behavior, and take responsibility for actions Insight Ability to perceive and understand the cause and nature of own and others’ situations

Components of Mental Status Assessment Reliability Interviewer’s impression that individual reported information accurately and completely

Components of the Psychosocial Assessment Stressors Internal: Psychiatric or medical illness, perceived loss of self-concept/self-esteem External: Actual loss—death of a loved one, divorce, lack of support systems, job or financial loss, retirement, dysfunctional family system

Components of the Psychosocial Assessment Coping Skills Adaptation to internal and external stressors; use of functional, adaptive coping mechanisms and techniques; management of ADLs Relationships Attainment and maintenance of satisfying, interpersonal relationships congruent with developmental stage

Components of the Psychosocial Assessment Cultural Ability to adapt and conform to prescribed norms, rules, ethics, and mores of an identified group Spiritual Presence of self-satisfying value-belief system that the individual regards as right, desirable, worthwhile, and comforting

Components of the Psychosocial Assessment Occupational Engagement in useful, rewarding activity, congruent with the developmental stage and societal standards

Age Considerations Elderly RN should be alert to physical limitations Hearing, vision, memory, medical conditions Children Use of story-telling, dolls, drawing, can be useful in assessing painful or sensitive areas

Age Considerations (cont) Adolescent Ensure confidentiality Assess risk factors—HEADSSS H—home environment E—Education A—Activities D—Drug, ETOH, or tobacco use S—Sexuality S—Suicide risk S--Savergy

Assessment The Nurse-Client Interview Most critical process involved in gathering data r/t the overall health status of clients with psych d/os When assessing the mental status, the primary “tool” of evaluation is the nurse interviewer The success of the interview depends on the development of trust, rapport, and respect between the nurse and client

Components of the Nurse. Client Interview Presenting Problem Present Illness Family Hx Childhood/Premorbid Hx Medical Hx Psychosocial/Psychiatric Hx Recent Stressors/Losses Education Legal

Components of the Nurse. Client Interview (cont) Marital Hx Social Hx Support Systems Insight Value-Belief System (Including Spiritual) Special Needs (Including Cultural) Discharge Goals

Verifying Data Family/friends may verify or contradict client’s actions Old charts Lab reports Drug screen

Nursing Diagnosis

NSG Dx Formulated after interpreting the data that was gathered in the assessment phase Involves the application of standardized labels to clients’ health problems and responses to illness and life events

3 Components of a NSG Dx Actual Problem Part 1 NSG Dx Sleep Pattern Disturbance Part 2 Etiologic factor (s) (related to) Depression Part 3 Defining Characteristics Complaints of SCD, DFA, EMA

Outcome Identification

Outcome Identification After identifying signs and sx in the assessment phase, outcomes that the client should meet are established Example: Nsg Dx: Violence, risk for; self-directed Outcomes: Verbalizes absence of suicidal intent

Outcome Identification (cont) Nurses must be able to measure and document pt outcomes influenced nsg care

Planning

Planning The process of planning includes the following: Collaboration with clients, significant others, and treatment team members Identification of priorities of care Identification of nsg interventions that will help the pt meet the outcome criteria

Planning (cont) The Nursing Interventions Classification (NIC) is a research based standardized language of nearly 500 interventions that can be included in a care plan

Implementation

Implementation Setting the plan in motion Areas for intervention Counseling Health teaching Psychobiological interventions Self-care activities Milieu Therapy

Evaluation

Evaluation Does the client reflect outcome targeted? Yes No—if no, then the nurse considers all of the possible reasons why nsg outcomes were not achieved