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FoundationVII
Nursing Process I & II Ch. 7, 8
| Question | Answer |
|---|---|
| Nursing Process Definition | A special approach for selecting, organizing, and delivering appropriate nursing care to a patient. A variation of scientific reasoning. |
| How the nursing process is used | You as a nurse will collect data through physical assessment. The nursing process is critical to providing timely and appropriate care to patients. |
| Assessment Purpose: | To establish a patient database. |
| Sources of Data | Patient. Family and significant others. Health care team. Medical Records |
| Step One in Data Collection | Interview and Health History. Introduce yourself, explain your role. Establish a caring, therapeutic relationship. Explore the patient’s goals and expectations. Determine which areas need further exploration |
| Orientation Phase | The introduction |
| Working part of the interview | Gather info regarding the patient’s history |
| Termination Phase | Give your patient clues that the interview is coming to an end. Example: “We’ll be finished in 4-6 minutes”. |
| Validate any significant Subjective Data | When clients give you personal health history which is Subjective data be sure to validate it. |
| Interviewing Techniques | Manner is just as important as the questions asked. Good environment free of distractions. Timing is important. Use open and closed-ended questions. Use of “Back-Channeling”: go on, continue. |
| Validating Subjective Data | Physical Exam. Observance of Patient Behaviors. Review objective data: to include diagnostic and lab data |
| Nursing Judgments | “The successful analysis and interpretation of assessment data requires critical thinking. When you correctly analyze data, you will make necessary clinical decisions about your patient’s care... |
| Nursing Judgments | ..these decisions are either in the form of nursing diagnoses or in the form of collaborative problems that require treatment from several disciplines.” |
| Steps to Nursing Judgment | Data Validation. Analysis and Interpretation. Data Clustering. Data Documentation |
| Nursing Diagnosis | Second step of the nursing process. Gives meaning to the data you collect and organize during assessment. |
| Nursing Diagnosis | “The process of diagnosing is the result of your analysis of data and your resultant identification of specific patient responses to health care problems”. |
| Nursing Diagnosis | A clinical judgment about individual, family, or community responses to actual and potential health problems or life processes. Identification of nursing diagnoses leads to the development of an individualized plan of care |
| Medical Diagnosis | The identification of a disease condition based on a specific evaluation of physical signs, symptoms, history, diagnostic tests, and procedures. |
| Collaborative Problem | A physiological complication that nurses monitor to detect the onset or changes in a patient’s status. Some examples: Bleeding, infection, cardiac arrythmias. |
| Clustering Data | Helps us to look at the complete picture of the patient’s health status. |
| Nursing Diagnoses | Give us the basis for our nursing interventions to achieve outcomes for which the nurse is accountable. Focus on the patient’s actual or potential response to a health problem rather than on the physiological even, complication, or disease. |
| What nurse’s treat | Nurses do not independently treat medical diagnoses. Nurses do manage therapies for medical conditions. Collaboration between medicine and nursing is essential to quality patient care |
| Identification of Nursing Diagnoses | Leads to the development of an individualized plan of care. Example: Medical DX: Ruptured Appendix. Nursing DX: Impaired physical mobility related to painful incision. |
| Purposes of Formal Nursing Diagnostic Statements | Common language. Distinguishes the nurse’s role from that of the physician. Helps nurses focus on the scope of nursing practice |
| The Diagnostic Process | Flows from the assessment process and includes decision-making steps. Steps include: Data clustering. Identifying patient needs. Formulation of the diagnosis or problem |
| Clusters and pattern of data | Often contain Defining Characteristics. Are the clinical criteria or assessment findings that support an actual nursing diagnosis. Carefully examine defining characteristics that either support or eliminate a nursing diagnosis. |
| As You Analyze Data | Begin to think of Nursing Diagnoses that will apply to your patient |
| Clinical Criteria | Includes: Objective or subjective signs and symptoms, clusters of signs and symptoms and/or Risk Factors |
| Review the data | Compare and contrast the patient’s data with baseline data. Use accepted norms as the basis for comparison and judgment. Think about problems your patient has and select NANDA Nursing Diagnoses that apply to those problems. Move from general to specific |
| Choose the correct diagnostic label | Problem Identification Phase: The general health problem. Formulation of Nursing Diagnoses: the specific health problem |
| NANDA DIAGNOSES | Three types: actual diagnoses, at risk diagnoses, wellness diagnoses |
| Actual Nursing Diagnoses | Describes human response to health conditions or life processes that exist in an individual, family, or community. Supported by defining characteristics that cluster in patterns of related cues or inferences. |
| "Risk Nursing Diagnosis” | Describes human responses to health conditions or life process that have a chance of developing in a vulnerable individual, family, or community. Example: Overweight patient with spinal cord injury is at risk for impaired skin integrity. |
| Vulnerability | This about what things/actions increase the patient’s vulnerability. Physiological, psychosocial, familial, lifestyle, and environmental factors. A “Wellness Nursing Diagnosis” |
| Vulnerability | Describes human responses to levels of wellness in an individual, group, or community that have a readiness for enhancement or improvement. Example: readiness for enhanced family coping related to unexpected birth of twins. |
| Components of Nursing Diagnosis | Nursing diagnosis flows from the assessment and diagnostic process |
| Nursing Diagnosis Two-part Format | The nursing diagnosis is a two-part format that provides a diagnosis with meaning and relevance for a particular patient. |
| Diagnostic Label | The name of the nursing diagnosis as supplied by NANDA International. Diagnostic labels include descriptors. Example: impaired physical mobility, Impaired – is the descriptor |
| Descriptors | Impaired – describes the nature of or change in mobility that best describes the patient’s response Other examples: compromised, decreased, delayed, or effective. |
| Related Factor | A condition or etiology identified from the patient’s assessment data. Associated with the patient’s actual or potential response to a health problem and can change by using nursing interventions. |
| Related Factor | Example: activity intolerance related to generalized weakness. Four categories: Pathophysiological (biological or psychological). Treatment-related Situational (environmental or personal). Maturational ("related to” phrase |
| Related Factor | Not a cause and effect statement: rather it indicates that the etiology contributes to or is associated with the problem. Critical thinking skills are required to individualize the nursing diagnoses and subsequent interventions |
| Etiology | Cause of the nursing diagnosis is always within the domain of nursing practice and a condition that responds to nursing interventions. |
| Risk Factors | Are environmental, physiological, psychological, genetic, or chemical elements that increase the vulnerability of an individual, family, or community to an unhealthful event |
| Support of the Diagnostic Statement | Nursing assessment data must support the diagnostic label and the related factors must support the etiology. Make sure that you have gathered as much objective data and subjective data as you can. |
| Support of the Diagnostic Statement | Make sure your database is complete before making your Nursing Diagnosis. |
| Mind Mapping | A way to graphically represent the connections between concepts. Links together lines of reasoning |
| Diagnostic Errors | Can occur during: Data collection-avoid inaccurate data. Data interpretation-consider conflicting cues. Data Clustering-clustered prematurely. Statement of the nursing diagnosis-Use appropriate, concise and precise language. |
| Plan of Care | Once you assess a patient’s condition and identify appropriate nursing diagnoses, develop a plan of care. The nursing diagnoses, as well as any collaborative problems direct your selection of nursing interventions, goals and outcomes you hope to achieve. |
| Planning | The 3rd step of the nursing process. Identify a set of diagnoses. |
| Planning | Set patient-centered goals and expected outcomes. Prescribe nursing interventions. Successful planning includes. Setting priorities. Modifying and recording relevant information about the patient’s health care needs and clinical management. |
| Setting Priorities | Rank nursing diagnoses in order of importance. Collaborate with your patients to select mutually agreed upon priorities based on urgent matters |
| Classify Priorities | High: Nursing diagnoses that can result in harm. Medium: Involve non-emergent, non-life-threatening needs. Low: Usually directly related to a specific illness or prognosis, but may affect future well-being |
| Goals and Expected Outcomes | Specific statements of patient behavior or physiological responses that you set to achieve as a result of your patient care. Use measurable criteria to evaluate goal achievement. |
| Goals and Expected Outcomes | Example: Patient’s heart rate will return to normal within 10 minutes after exercise |
| Goals of Care | Patient centered goal: a specific and measurable behavior or response. Predicted resolution of a problem. Goals are time limited |
| Short term goals | An objective behavior usually achieved within a short time One week or less |
| Long-term goals | An objective behavior usually obtained over a longer period of time. Days, weeks or months. The patient should be involved in their own personal goal setting. The nurse is an advocate for the client during their goal development |
| Expected Outcome | A specific measurable change in a patient’s status that you expect occur in response to nursing care. Outcomes provide focus or direction for nursing care. More than one expected outcome for each nursing diagnosis or goal |
| Nursing Outcome Classification | The use of a common set of outcomes allows nurses to study the effects of nursing interventions over time and across settings. |
| Nursing Outcome and Goal Guidelines Seven guidelines: | Patient centered. Singular goal or outcome. Observable. Measurable. Time limited. Mutual factors. Realistic |
| Interventions | Critical thinking skills will be used to select interventions that will successfully meet the patient’s established goals and expected outcomes. To select interventions |
| Interventions | Have knowledge of the scientific rationale for the interventions. Possess the necessary psychomotor and interpersonal skills to perform the interventions. |
| Interventions | Be able to function within a particular setting to use the available health care resources effectively |
| 3 Categories of Nursing Interventions | Nurse-initiated interventions. Physician-initiated interventions. Collaborative interventions |
| Factors to consider when selecting Interventions | Characteristics of the nursing diagnosis. Expected outcomes. Evidence base for the intervention. Feasibility. Acceptability to the patient. Your own competency |
| Factors to consider when selecting Interventions | Select interventions that have the best potential for achieving the expected outcomes. You will be responsible for providing a written plan of care for your patients. |
| Care Plans Consists of: | Priortized Nursing diagnoses. Goals. Specific nursing activities and interventions |
| Nursing care plan | A written guideline for coordinating nursing care. Promoting continuity of care. Listing outcome criteria to be used in the evaluation of nursing care |
| Written Care Plans | Organize information. Enhances the continuity of nursing care. Include the patient’s long-term needs |
| Implementation | Fourth step in the nursing process. Involves provision of care to patients |
| Nursing Intervention | Any treatment based upon clinical judgment and knowledge, that a nurse performs to enhance patient outcomes |
| Direct Care Interventions | Treatments performed through interaction with the patient |
| Indirect care interventions | Treatments performed away from the patient but on behalf of the patient. Safety and infection control, documentation, interdisciplinary collaboration. Implementation is continuous with all steps of the nursing process |
| Indirect care interventions | As you carry out an intervention, the patient’s condition can change, requiring further assessment, or the patient may respond to the intervention as expected based on your evaluation. |
| Types of Nursing Interventions | Protocols and Standing Orders. Protocols and standing orders give you the legal protection to intervene appropriately in the patient’s best interest. |
| Types of Nursing Interventions | Never implement any nursing action without determining that it is correct and appropriate. Use sound judgment |
| Implementation Process Anticipate and when possible prevent complication | Reassess the patient. Review and revise the care plan. Organize resources and care delivery |
| Evaluation | Crucial to determine whether after application of the nursing process, a patient’s condition or well-being improves. Evaluation is on-going |
| 5 Elements of the Evaluation Process | Identifying evaluative criteria and standards. Collecting data to determine if you met the criteria or standards. Interpreting and summarizing findings. Documenting findings. Terminating, continuing, or revising the plan of care |
| Looking at results over time | In many clinical situations it is important to collect evaluative measures over a period of time to determine if a pattern of improvement or change exists. |
| Care Plan Revision | Determine whether or not goals of care have been met. Discontinue goals that have been effectively met. Modify the goal or add or change nursing interventions in order to meet the new goal. Redefine priorities as needed |
| Nursing responsibilities | Nurses have the responsibility to obtain correct theoretical knowledge and develop the clinical competencies necessary to safely perform nursing interventions. Nursing responsibility is equally great for all types of interventions |
Created by:
maggardba
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