The Nursing Process

 

 The Nursing Process

Assessing : Collecting Data: – Subjec Subjectiv tive e Data Data (sympto (symptoms) ms),, Obj Object ective ive Data Data (sig (signs) ns) – Pr Prim imar ary y sou sourrce is th the e cli clien entt – Secondar Secondary y source source is famil family y or anyone anyone else else that that is not the the client client – Collect Collect data data by by observ observing ing which which uses uses your your sense senses s or thro through ugh an interview ○ Interview is planned communication with a purpose ○ Directive interview - Nurse directs interview, client responds responds to questions and has limited chances to discuss concerns. ○ Nondirective Nondirecti ve interview – rapport-building rapport-building where the client is in control of the purpose, subject, and pace. ○ Questions :  Open-ended – invites client to discover and explore, elaborate, clarify, or illustrate their thoughts or feelings. “How have have you been feeling lately?” lately?”  Closed-ended – used in directive interviewing, interviewing, and are questions that require a yes or no answer.  Neutral question – a question that the client can answer without direction. direction. “Why do you think you had the operation?”  Leading question – directs the clients answer. “You’re stressed about surgery tomorrow, aren’t you?” Organizing Data: – – –

Using Using a writt written en o orr compute computerized rized format format that that orga organize nizes s the the assessment data. Most schools schools of nursi nursing ng and and health health cause cause agencie agencies s have have develop developed ed their own structured assessment format. Frameworks: ○ Gordon – 11 functional health patterns ○ Orem – 8 universal self-care requisites of humans ○ Roy’s adaptation model ○ Maslow’s hierarchy of needs

Validating Data:

 

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Double Double checkin checking g data to ensur ensure e that that the assessme assessment nt info info is correct, correct, and to ensure that the subjective and objective data agree, as well as to obtain additional info that may have been over looked. Cues Cues vs. vs. IIn nfe ferrenc ences es:: ○ Cues – subjective or objective data that can be directly observed by the nurse, either what the client says or what the nurse can see. ○ Inferences – nurses interpretations or conclusions based on the cues. (A nurse observes observes the cues that that an incision is red, hot, and swollen; the nurse makes the inference that the incision is infected.) You don’t don’t have have to check check all data data (like (like birth birth dates, dates, height, height, weight weight and most lab studies)

Documenting Data: –

Data is recor recorded ded in in a factu factual al manne mannerr and and not not interpr interpreted eted by the the nurse. ○  The nurse records the client’s breakfast intake (objective) as “coffee 240 mL, 1 egg, and 1 slice of toast”

Diagnoses : –

Diag iagnos osti tic c Labe Labells ○ Describes the client’s health problem or response for which nursing therapy is given. ○ Qualifiers – additional info  Deficient, Impaired, Decreased, Ineffective, Compromised. ○ Etiology – Related factors and risk factors. ○ Example of Label :   Activity Intolerance related to Generalized weakness

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Defining Defining character characteristi istics cs – c clust lusters ers of of s/s that indicate indicate the the presen presence ce of a particular diagnostic diagnostic label. ○ Actual nursing diagnoses – signs and symptoms ○ Risk nursing diagnoses – no-subjective or objective signs are present. Differe Differentia ntiating ting Nursing Nursing Diagnoses Diagnoses from from Medica Medicall Diagn Diagnoses oses ○ A client’s medical diagnosis remains remains the same for as long as the disease process is present, but nursing diagnoses change as the client’s responses change. change. ○ Independent function – areas of health care that are unique to nursing and separate and distinct from medical management.

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Dependent function- Nurses are obligated to carry out physician-prescribed therapies and treatments. Differe Differentia ntiating ting Nursing Nursing Diagnos Diagnoses es from from Collab Collaborat orative ive Prob Problems lems ○ Collaborative – monitoring the client’s condition and preventing development development of the potential complication and using physician-prescribed physician-prescribed interventions. ○

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Nursing involve from oneDiagnoses person to –the next. the human response, which vary  More individualized. individualized. Analyzing Data: –

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Comp Compar are e data data aga again inst st sta stand ndar ards ds ○ Growth and development patterns, normal vital signs, and lab values. Clustering Cues ○  The process of grouping cues to determine the relatedness of  facts and see if there are any patterns. Identi Identify fy Gaps Gaps and and inco incons nsist istenc encies ies in data data ○

Conflicting data  Client tells you that they haven’t been to the doctor in 15 years, but then says that they see their doctor every year for a physical.

Indentifying Health Problems, Risks, and Strengths: –

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Dete Determ rmin inin ing g Pro Probl blem ems s and and Risk Risks s ○ Client has no appetite and has not eaten today  Problem/Risk is Imbalanced Nutrition: Less than Body Requirements Det eter erm mine Str Strengt engths hs ○ Anything that is at the client’s advantage 

 The client may be physically fit and there t here for may recover faster.

Formulating Diagnostic Statements: – –

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Two-p wo-par artt Stat Statem emen entt PE ○ Problem(P) Related to Etiology(E) Thr Three-p ee-par artt Stat Statem emen entt PES PES ○ Problem(P) Related to Etiology(E) as manifested by Signs by  Signs and symptoms(S). OneOne-P Par artt Sta State tem ment ent ○ Nursing intervention can be derived from the label and doesn’t need a etiology.    Health-Seeking Behaviors ( Low-Fat Diet)

 

Avoiding Errors in Diagnostic Reasoning –

Verify, erify, build build a good good knowled knowledge ge base base and acquir acquire e clinical clinical experienc experience, e, know what is normal, consult resources, base diagnoses on patterns- that is, on behavior over time- rather than on an isolated incident, and improve critical thinking skills.

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Nursing Nursing intervent intervention: ion: any treatmen treatmentt based based upon clinical clinical judgment judgment and knowledge, that a nurse performs to enhance patient outcomes Planning : ○ Initial Planning  Done asap  Using client’s body language as well as intuitive kinds of information. ○ Ongoing Planning:  Done by all nurses who work with the client. Determine Determin e whether the client’s health status has changed Set priorities for the client’s care during the shift

Planning:

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Decide which problems to focus on during the shift Coordinate the nurse’s activities so that more than one problem can be addressed at each client contact Discharge Planning:  Process or anticipating and planning for needs after discharge, is a crucial part of comprehensive health case and should be addressed in each client’s care plan. •

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In Info form rmal al Nurs Nursin ing g care care plan plan ○ Strategy for action that exists in the nurse’s mind. Forma ormall Nur Nursi sing ng car care pla plan n ○ Written or computerized guide for organizing information Stan Standa darrdize dized d car care e pla plan n ○ Formal plan that specifies the nursing care for groups of  clients with common needs. ○ Not for individuals ○ Preprinted guides for the nursing care of a client who has a need that arises frequently in the agency. ○ Problem -> Goals/desired outcomes -> Nursing interventions -> Evaluation

 

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Protocols – preprinted to indicate the actions commonly required for a particular group of clients. Ex. An agency may have a protocol for admitting a client to the intensive care unit. Policies/procedures – are developed to govern the handling of frequently occurring situations. •

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Ex. How many visitors are allowed in Standing orders – are written document about policies, rules, regulations, or orders regarding client care. They also give nurses the authority to carry out specific actions under circumstances, often when a physician is not immediately available. In Indi divi vidu dual aliz ized ed car care e plan plan ○ Is tailored to meet the unique needs of a specific client. When nurses nurses use use the the client’s client’s nursing nursing diagn diagnoses oses to develo develop p goals goals and nursing interventions, the result is a holistic, individua individualized lized plan of case that will meet the client’s unique needs. During During plann planning ing phase phase,, the nurse nurse must must decide decide which which of of the client’s client’s 

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problems need individualized plans and which problems can be addressed address ed by standardized standardized plans and routine care, and write unique desired outcomes and nursing interventions for client problems that require nursing attention beyond preplanned, routine care. For orma mats ts for for nur nursi sing ng care care plan plans s ○ Student – have a rationale column ○ Computerized - vi visual sual tool Multidis Multidiscipl ciplinar inary y (collabo (collaborati rative) ve) Care Care Plans Plans – is a standa standardi rdized zed plan plan that outlines the care required for clients with common, predictableusually medical-conditions. medical-conditions. Guid Guidel elin ines es for for wri writi ting ng a care care plan plan ○ Date and sign the plan ○

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Use category headings  “Nursing Diagnoses” “Goals/Desired Outcomes” Use standardized medical or English symbols and key words rather that complete sentences to communicate communicate your ideas. Be specific  When it comes to time Refer to procedure books or other sources of info rather than including all steps on something s omething  Tailor plan to the client  Ask when the best time is for the client to do interventions Ensure that the plan incorporates i ncorporates preven preventive tive and health maintenance aspects as well as restorative ones.

 

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Ensure that the plan contains interventions interventions for ongoing assessment of the client. Include collaborative and coordination activities in the plan Include plans for the client’s discharge and home care needs

Setting Priorities -establishing a preferential sequence for addressing nursing diagnoses and interventions. ○ ○ ○ ○ ○

Clients health values and beliefs Clients priorities Resources available to the nurse and client Urgency of the health problem Medical treatment plan

Establishing Establishi ng Client Goals/Desired Outcomes ○ ○

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What you want to see happen Include the client in this part Goal must be broad Desired outcome must be specific Nursing Outcomes Classification (NOC)   Taxonomy that describes the client outcomes. Goals and outcomes provide direction for planning interventions,, they serve as a criteria for evaluating client interventions progress, enable client and nurse to determine when the problem has been resolved, and help motivate the client and nurse by providing a sense of achievement. Short-term and long-term goals should be used

Selecting Nursing Interventions and Activities ○

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Independent interventions  Activities that the nurse is licensed to initiate on the basis of their knowledge and skills Dependent interventions  Activities carried carried out under the physicians’ orders or supervision, or according to specific routines. Collaborative interventions  Actions carried out by nurses and other health care providers Consider the consequences of each intervention Makes sure that the intervention is safe and appropriate for the client’s age, health, and condition

 

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Interventions must be congruent with the client’s values and beliefs.

Implementing : –

Skills: ○

Cognitive 

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Intellectual skills including problem solving, decision making, critical thinking, and creativity Interpersonal  Required in all nursing  Verbal and nonverbal, people use when interacting directly with each other  Technical  Hands on skills  Using equipment, giving injections, bandaging, moving, lifting, and repositioning clients.

Reassessing the Client Determining Determin ing the Nurse’s Need for Assistance Implementing Implementin g the Nursing Intervention 

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Base intervention on scientific knowledge, nursing research, and professional standards of care Understand the intervention Adapt to client Use safe care  Teach Be holistic Respect dignity or the client Encourage clients to participate

Even though you delegate care to someone else, you are responsible for making sure that the task was done right and you are responsible for anything that goes wrong.

Document everything

Evaluating: – – – –

Eval Evalua uati tion on is is cont contin inuo uous us Evalu Evaluati ating ng and assess assessing ing phase phase overl overlap ap The desired desired outcomes outcomes are related related to the the collecti collection on of of data data Collecting Data ○ Objective ○

Subjective

 

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Comp Compar arin ing g ○ Goal ○ Goal ○ Goal 

Dat Data a wit with h Out Outco come mes s Met partially met – what changes need to be made? was not met – what changes need to be made? Af After ter goal was met, writes an evaluative statement •

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Consists of two parts ○ Conclusion ○ Supporting data  “Goal Met: Oral intake 300Ml more than output skin turgor resilient mucous membrane moist Relatin elating g Nurs Nursing ing Activi Activitie ties s to Outcom Outcomes es ○ Make sure that it is what you are doing that is bring any change to the client ○ Ask them if they are doing anything extra Drawin Drawing g Conc Conclus lusion ions s about about probl problem em Stat Status us ○ Have actual or potential problems been resolved ○

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Prevention ○ Actual problem still exists even though some goals were met If the the goals goals have have been been partia partially lly met or or when when goals goals have have not not been been met, 2 things may be drawn ○ Care plan needs to be revised ○ Care plan doesn’t need to be revised, because the client merely needs more time to achieve the goals. Continui Continuing, ng, Modifyi Modifying, ng, and and Termi Terminati nating ng the the Nursing Nursing Care Care Plan Plan ○ After drawing drawing conclusions about the statue of the client’s problem, the nurse modifies the care plan as indicated.  Discontinue, Discontinu e, or “goal met” with the date Evalu Evaluati ating ng the Qualit Quality y of of Nur Nursin sing g Care Care ○ Quality-assurance (QA) Program  An ongoing systematic process designed to evaluate and promote excellence in the health care provided to clients. Structure Structur e evaluation – focuses on the setting in which care is given. It answers this question: “what effect does the setting have on the quality of care.” Process Evaluation – Focuses on hoe the care was given. It answers the question, “Is the care relevant to the client’s needs? Is the care •

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appropriate, complete, and timely?”

 

Outcome Evaluation – focuses on demonstrable demonstrable changes in the client’s health status as result of  nursing care. Quality Improvement Improvement  Evaluating and improving the quality of health care based on internal assessment by health care providers •

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and increasing awareness by the public that medical errors are not uncommon and can be lethal. Sentinel Event – is an unexpected occurrence involving death or serious physical or psychological injury. Root cause analysis – process for indentifying the factors that bring about deviations in practices that lead to the event. Quality improvement improvement (QI) – focuses on client care rather than organizational structures, focuses on process rather than individuals, and uses a systematic approach with the intention of improving the quality of  care rather than ensuring the quality of care.

Nursing Audit ○  To examine or review records ○ Retrospective Retr ospective Audit – is the evaluation e valuation of a client’s health record after discharge from as agency. ○ Concurrent Concurr ent audit – is the evaluation of a client’s health care while the client is still receiving care from the agency. ○ Peer review – nurses reviewing other nurses  Individual peer review – focuses on the performance of  an individual nurse  Nursing audits (peer review) – evaluation the nursing care through review of the records. Depends on accurate documentation documentation •