Transcript Nursing Process NUR101 Fall 2010 Lecture #6 and #7

Nursing Process
NUR101
Fall 2010
Lecture #6 and #7
K. Burger, MSEd, MSN, RN, CNE
PPP By: Sharon Niggemeier MSN, RN
Revised KBurger 8/06, 9/08,8/10
Nursing Process
Specific to the nursing profession
 A framework for critical thinking
 It’s purpose is to:
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“Diagnose and treat human responses to
actual or potential health problems”
Nursing Process
Organized framework to guide practice
 Problem solving method - client focused
 Systematic- sequential steps
 Goal oriented- outcome criteria
 Dynamic-always changing, flexible
 Utilizes critical thinking processes

What are some critical thinking
characteristics necessary for
application of Nursing Process?
Knowledge – science & skills
 Standards – use of EBP standards of
practice
 Experience – previous client experiences
 Attitudes – open-mindedness, creativity,
integrity, confidence,
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Scientific Method of problem solving
ID problem
 Collect data
 Form hypothesis
 Plan of action
 Hypothesis testing
 Interpret results
 Evaluate findings
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Advantages of Nursing Process
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Provides
individualized care
Client is an active
participant
Promotes continuity of
care
Provides more
effective
communication among
nurses and healthcare
professionals
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Develops a clear
and efficient plan of
care
Provides personal
satisfaction as you
see client achieve
goals
Professional growth
as you evaluate
effectiveness of your
interventions
5 Steps in the Nursing Process
 Assessment
 Diagnosis
 Planning
 Implementation
 Evaluation
Assessment
First step of the Nursing Process
 Gather Information/Collect Data
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 Primary
Source - Client / Family
 Secondary Source - physical exam, nursing
history, team members, lab reports,
diagnostic tests…..
 Subjective -from the client (symptom)
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“I have a headache”
 Objective
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- observable data (sign)
Blood Pressure 130/80
Assessment-collecting data
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Nursing Interview (history)
History includes: physical, emotional, social,
spiritual, intellectual dimensions.
Considerations for the older adult & cultural
diverse client. Review this section in P & P
Health Assessment:
 Review of Systems
 Inspection
 Palpation
 Percussion
 Auscultation
Assessment-collecting data
 Make
sure information is complete &
accurate
 Validate prn
 Interpret and analyze data
Compare to “standard norms”
 Organize and cluster data
Example of
Focused Assessment
Obtain info from nursing assessment,
history and physical (H&P) etc…...
 Client diagnosed with hypertension
 B/P 160/90
 2 Gm Na diet and antihypertensive
medications were prescribed
 Client statement “ I really don’t watch
my salt” “ It’s hard to do and I just don’t
get it”
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Diagnosis
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Second step of the Nursing Process
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Interpret & analyze clustered data
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Identify client’s problems and strengths
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Formulate Nursing Diagnosis (NANDA :
North American Nursing Diagnosis
Association)-Statement of how the client
is RESPONDING to an actual or potential
problem that requires nursing intervention
Nsg Dx
Within the scope of
nursing practice
 Identify responses
to health and
illness
 Can change from
day to day
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vs
MD Dx
Within the scope of
medical practice
 Focuses on curing
pathology
 Stays the same as
long as the disease
is present
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Formulating a Nursing
Diagnosis
Composed of 3 parts:
 Problem statement [Diagnostic Label]
the client’s response to a problem
 Etiology [Related Factors]
what’s causing/contributing to the
client’s problem
 Signs/Symptoms [Defining Characteristics]
what’s the evidence of the problem
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Nursing Diagnosis
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Problem ( Diagnostic Label)-based on your
assessment of client…(gathered information),
pick a problem from the NANDA list...
Etiology (Related Factors)- determine what
the problem is caused by or related to (R/T)...
Signs/Symptoms (Defining
Characteristics)- state as evidenced by
(AEB) the specific facts the problem is based
on...
Example of Nursing Dx
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Ineffective health maintenance
R/T difficulty maintaining lifestyle changes
and lack of knowledge
AEB B/P= 160/90, dietary sodium
restrictions not being observed, and client
statements of “ I don’t watch my salt” “It’s
hard to do and I just don’t get it”.
Types of Nursing Diagnoses
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Actual
Imbalanced nutrition; less than body
requirements RT chronic diarrhea, nausea,
and pain AEB height 5’5” weight 105 lbs.
Risk
Risk for falls RT altered gait and generalized
weakness
Wellness
Readiness for enhanced Family coping:
Health Promotion
Readiness for enhanced immunization status
Planning
Third step of the Nursing Process
 This is when the nurse organizes a nursing
care plan based on the nursing diagnoses.
 Nurse and client formulate goals to help the
client with their problems
 Expected outcomes are identified
 Interventions (nursing orders) are selected
to aid the client reach these goals.
Planning – Begin by
prioritizing client problems
Prioritize list of
client’s nursing
diagnoses using
Maslow
 Rank as high,
intermediate or low
 Client specific
 Priorities can change
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Planning- Types of goals
 Cognitive
 Short
term goals
 Long term goals
goals
 Psychomotor
goals
 Affective goals
Planning
Developing a goal and outcome
statement
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Goal and outcome statements
are client focused.
Worded positively
Measurable, specific
observable, time-limited, and
realistic
Goal = broad statement
Expected outcome = objective
criterion for measurement of
goal
Utilize NOC as standard
EXAMPLE
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Goal:
Client will achieve
therapeutic management of
disease process….
Outcome Statement:
AEB B/P readings of
110-120 / 70-80 and client
statement of understanding
importance of dietary sodium
restrictions by day of
discharge.
Think about this….
We have talked about the difference
between cognitive, psychomotor and
affective goals.
 What type of goal is the statement on the
previous slide?
 Can you think of some goal statements in
the other domains?
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Planning-select interventions
Interventions are selected and written.
 The nurse uses clinical judgment and
professional knowledge to select
appropriate interventions that will aid
the client in reaching their goal.
 Interventions should be examined for
feasibility and acceptability to the client
 Interventions should be written clearly
and specifically.
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Interventions – 3 types
Independent ( Nurse initiated )- any
action the nurse can initiate without
direct supervision
 Dependent ( Physician initiated )nursing actions requiring MD orders
 Collaborative- nursing actions
performed jointly with other health care
team members
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Implemention
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The fourth step in the Nursing Process
This is the “Doing” step
Carrying out or delegating nursing
interventions (orders) selected during the
planning step
This includes monitoring, teaching, further
assessing, reviewing NCP, incorporating
physicians orders and monitoring cost
effectiveness of interventions
Utilize NIC as standard
Delegation
Five Rights
Right task
 Right circumstance
 Right person
 Right communication
 Right supervision
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NCSBN (1995)
Implementing- “Doing”
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Maintain prescribed diet
(2 Gm Na)
Administer
antihypertensive
medications per MD order
Obtain registered
dietician consult to teach
client about sodium
restriction, foods high in
sodium, use of nutrition
labels, food preparation
and sodium substitutes
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Teach potential
complications of
hypertension to instill
importance of
maintaining Na
restrictions
Assess for cultural
factors affecting
dietary regime
Monitor VS q4h
Implementing – “Doing”
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Teach the clienthypertension can’t be
cured but it can be
controlled.
Remind the client to
continue medication
even though no S/S
are present.
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Teach client
importance of life style
changes: (weight
reduction, smoking
cessation, increasing
activity)
Stress the importance
of ongoing follow-up
care even though the
patient feels well.
Think about this….
We have learned about the 3 different
types of nursing interventions:
Independent – Dependent – Collaborative
 Label each of the interventions on the
previous slides as either I – D – or C
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Evaluation
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Final step of the Nursing Process but
also done concurrently throughout client care
A comparison of client behavior and/or
response to the established outcome criteria
Continuous review of the nursing care plan
Examines if nursing interventions are working
Determines changes needed to help client
reach stated goals.
Evaluation
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Outcome criteria met? Problem resolved!
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Outcome criteria not fully met? Continue
plan of care- ongoing.
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Outcome criteria unobtainable- review
each previous step of NCP and determine
if modification of the NCP is needed.