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Nursing Process

Professional Nursing

Assessing: The primary source of information is the patient. Four types of nursing assessments: Initial comprehensive, Focused, Emergency, Time-lapsed.
Initial comprehensive: performed shortly after admission (check institution’s policy on time interval).
Focused: gather data about specific problem that has already been identified – what are the symptoms, when did they start, what makes them better or worse?
Emergency: done during a crisis (patient choking at the table, bleeding patient in the ED w/ stab wound).
Time-Lapsed: compares a patient’s current status to baseline data, Performed to reassess health status and make necessary revisions in plan of care.
Objective Data: Observable and measurable data that can be seen, heard, or felt by someone other than the person experiencing them. For example, elevated temperature, skin moisture, vomiting.
Subjective Data: Information perceived only by the affected person. For example, pain experience, feeling dizzy, feeling anxious.
Sources of Data: Patient - Always the primary source of information. Mistakes often occur when we fail to listen to them! Other sources: Family and significant others, Patient record, Other healthcare professionals, Nursing and other healthcare literature.
Assessment Characteristics of Data: purposeful, complete, factual and accurate, relevant.
Purposeful: When you prepare for data collection, you identify the PURPOSE of the assessment (whether its comprehensive, focused emergency or time- lapsed).
Complete: Complete data refers to nurses need to understand the “whys” behind patient data. For example: If a patient gains weight—was it related to an underlying pathological condition or was it intentional?
Factual and Accurate: Data has to be verified and reliable from the family members or patient.
Relevant: Relevant data from sources is obtained and recorded by nurses. Experience teaches nurses what data to record.
Nursing History: Captures and records the uniqueness of the patient so that care can be planned to meet the patient’s needs. Should identify the following: Strengths/weaknesses, health risks, hereditary and environmental factors, potential and existing heath problems.
Four Phases of a Nursing Interview: Preparatory phase, Introduction, Working phase, Termination.
Preparatory Phase: During the Preparatory Phase the nurse reviews all data and does not let his/her own prejudices and stereotypes affect the nurse-patient relationship. During this phase the nurse should assure that the environment is private and relaxed.
Introduction: The Introduction Phase “sets the tone”. The nurse starts the conversation by introducing himself/herself (name in full with status). First impressions are crucial.
Working: The Working Phase is when the nurse gathers information needed to form the subjective data.
Termination: The Termination Phase is the conclusion and it is recommended to put closer on the conversation by highlighting what was said and let the patient know what to expect next….ie tests, more physicians, lab draw ect.
Focus of the Diagnosis: To identify the nursing’s unique concern for the patient (i.e. what is it about the patient that gives rise to a need for nursing versus a medical need).
Focus of the Diagnosis: (cont) If the nurse identifies problems that are better treated by other members of the health care team, then the findings are reported to these members.
Types of Diagnoses: nursing diagnosis, medical diagnoses, collaborative problems.
Nursing Diagnosis: Describes patient problems nurses can treat independently.
Medical Diagnoses: Describes problems for which the physician directs the primary treatment.
Collaborative Problems: Managed by using physician-prescribed and nursing-prescribed interventions.
Nursing Diagnosis: Describes a patients response to a health problem. Situations nurses can treat. Takes into account how the health problem affects the whole person or family. There may be several nsg dx for a medical problem.
Medical Diagnosis: Describes a disease or pathology. Conditions MD treats. MD cares for a patient with Congestive Heart Failure (CHF). Treats the pathology of the disease with meds, oxygen, diet & fluid restriction etc. IS NEVER USED IN NURSING DIAGNOSIS.
Collaborative Problems: certain physiologic complications that nurses monitor to detect onset or changes in status. They use physician –prescribed and nurse interventions to minimize the complications of the event.
Types of Nursing Diagnoses: actual, risk, possible, wellness, syndrome.
Actual: problem that has been validated by the presence of major defining characteristics.
Risk: clinical judgment that an individual, family, or community is more vulnerable to develop the problem than others in the same/similar situation.
Possible: describe suspected problem for which additional data are needed.
Wellness: Clinical judgments about an individual, group or community in transition from a specific level of wellness to a higher level of wellness.
Syndrome: comprise a cluster or actual nursing diagnosis that are predicted to be present because of a certain event or situation .
Formulation of Nursing Diagnoses: problem statement, etiology, & defining characteristics
Problem Statement: Identifies what is unhealthy about the patient, indicating the need for change. Clear, concise statement of the patient’s health problem. Suggests patient outcomes /expectations of change.
Etiology: Identifies the factors that are maintaining the unhealthy state or response. Contributing or causative factors. Suggest the appropriate nursing measures.
Defining Characteristics: Subjective or objective data that signal the existence of the actual or potential health problem. Cues that reflect the existence of a problem. Suggest evaluative criteria. Identified by NANDA.
Comprehensive Planning: initial, ongoing, discharge
Initial: developed by the nurse who performs the admission history and physical assessment.
Ongoing: carries out by any nurse who interacts with the patient.
Discharge: best carried out by the nurse who worked most closely with the patient and family with the social worker and case manager. Discharge planning begins upon admission.
Maslow’s Hierarchy of Human Needs: Because basic needs must be met before one person can focus on higher ones, patients needs may be prioritized according to the following hierarchy: Physiologic needs, Safety needs, Love and belonging needs, Self-esteem needs, Self-actualization needs
Prioritizing Nursing Diagnoses: high priority, medium priority, low priority
High Priority: greatest threat to patient well-being.
Medium Priority: nonthreatening diagnoses.
Low Priority: diagnoses not specifically related to current health problem.
Short Term Goals: Achieved over your time with the patient More specific. Think of it as baby steps Should be attainable and realistic. Patient’s pressure ulcer will decrease to 1 cm by (two days from now).
Long Term Goals: Achieved over weeks or months. Broad statement that reflects resolution or progress towards resolution or prevention of a problem. Should be attainable and realistic. Patient will have intact skin by October 1st.
Categories of Outcomes: cognitive, psychomotor, affective
Cognitive: describes increases in patient knowledge or intellectual behaviors. Example: Within 1 day after teaching, the patient will list three benefits of continuing to apply moist compresses to her leg ulcer after discharge.
Psychomotor: describes patient’s achievement of new skills. Example: the patient will correctly demonstrate application of wet-to-dry dressing on her leg ulcer.
Affective: describes changes in patient values, beliefs, and attitudes. Example: the patient will verbalize valuing heath sufficiently to practice new health behaviors to prevent recurrence of leg ulcer.
Types of Nursing Interventions: Nurse-initiated, physician-initiated, and collaborative
Nurse-Initiated: actions performed by a nurse without a physician’s order. Example: Any treatment, based upon clinical judgment and knowledge, that a nurse performs to enhance patient/client outcomes.
Physician-Initiated: actions initiated by a physician in response to a medical diagnosis but carried out by a nurse under doctor’s orders.
Collaborative: treatments initiated by other providers and carried out by a nurse.
Structured Care Methodologies: procedure, standard of care, algorithm, clinical practice guideline.
Procedure: set of how to action steps.
Standard of Care: description of acceptable level of patient care.
Algorithm: set of steps used to make a decision.
Clinical Practice Guideline: statement outlining appropriate practice for clinical condition or procedure.
Types of Institutional Plans of Care: Kardex plans of care. Computerized plans of care. Case management plans of care (Clinical pathways, care maps), Student plans of care, Concept map care plan
Implementation: carrying out the plan of care.
Nursing Intervention: Any treatment, based upon clinical judgment and knowledge, that a nurse performs to enhance patient/client outcomes.
Types of Nursing Interventions: independent nursing actions and collaborative nursing actions.
Independent nursing actions: nurse-initiated interventions - protocols and standing orders
Protocols: written plans that detail the nursing activities to be executed in specific situations.
Standing orders: allows the nurse to initiate actions that ordinarily require the order or supervision of a physician.
Collaborative nursing actions: Physician-initiated interventions & Collaborative interventions
Physician-initiated interventions: dependent nursing actions, involve carrying out physician-prescribed orders. State Nurse Practice Acts specify from whom nurses can receive orders.
Collaborative interventions: performed jointly by nurses and other members of the healthcare team.
Direct Care Intervention: Treatment performed through interaction with the patient. Includes both physiological and psychosocial nursing actions: both “laying on of hands” actions and those that are more supportive in nature.
Indirect Care Intervention: Treatment performed away from the patient. Include nursing actions aimed at management of the patient care environment and interdisciplinary collaboration. Actions support the effectiveness of direct care interventions.
Evaluation’s Purpose: Purpose is to determine what to do next...
Terminate the plan of care: when each expected outcome is achieved. The plan of care is terminated when the patient has achieved all of its goals.
Modify the plan of care: if there are difficulties achieving the outcomes.
Continue the plan of care: if more time is needed to achieve the outcomes.
How to evaluate outcomes: cognitive, psychomotor, affective, physiologic
Cognitive: asking patient to repeat information or apply new knowledge.
Psychomotor: asking patient to demonstrate new skill.
Affective: observing patient behavior and conversation.
Physiologic: using physical assessment skill to collect and compare data.
It is best to evaluate patient’s outcome achievement early: Celebrating achievement motivates patients. Early recognition of failure to meet outcomes allows for the plan of care to be modified early.
The most common mistake nurses make: is waiting until the day the patient is to be discharged. At that point it’s too late.
If you need to modify the plan: You’ll need to go back through all the stages of the nursing process (ADPIE) and Assess the patient, Determine if the nursing diagnosis is still applicable, Re-evaulate Goals and Plan Interventions.
Intuitive Thinking: occurs when a nurse directly apprehends a situation based on its similarity or dissimilarity to other situations.
Created by: mr209368