Transcript Basic Nursing: Foundations of Skills & Concepts Chapter 9 NURSING

Basic Nursing: Foundations of
Skills & Concepts
Chapter 9
NURSING
PROCESS
The Nursing Process
 A systematic method of providing care
to clients.
The 5-Step Nursing Process
Assessment.
 Diagnosis.
 Planning and outcome identification.
 Implementation.
 Evaluation.

Assessment or Data Collection

The first step in the nursing process
involves the following:

Collecting data.
Validating data.
Organizing data.
Interpreting data.
Documenting data




Purpose of Assessment
 To establish a database concerning a
client’s physical, psychosocial, and
emotional health.
 To identify health-promoting behaviors
as well as actual and/or potential health
problems.
Types of Assessment

Comprehensive - Provides baseline data including
complete health history and current needs
assessment.

Focused - Limited in scope in order to focus on a
particular need or concern or potential risk.

Ongoing - Includes systematic monitoring and
observation related to specific problems.
Sources of Data

Primary Source: The client.

Secondary Source: The client’s family
members, other health care providers,
and medical records.
Types of Data

Subjective: Data from client’s (and sometimes
family’s) point of view. Includes feelings, perceptions,
and concerns. Collected by the interview.

Objective: Also called signs. Observable and
measurable data obtained through physical
examination and laboratory and diagnostic testing.
Validating Data
 Validation prevents omissions,
misunderstandings, and incorrect
inferences and conclusions.
Organizing Data
 Collected information must be
organized to be useful.
 Data Clustering is a useful tool to
identify issues.
Interpreting Data
Three critical components:
 Distinguishing between relevant and
irrelevant data
 Determining whether and where there
are gaps in the data
 Identifying patterns of cause and effect
Documenting Data
 Assessment data must be recorded and
reported.
 Accurate and complete recording of
assessment data is essential for
communicating information to health
care team.
Diagnosis

A medical diagnosis is a clinical judgment by the
physician that determines a specific disease,
condition or pathological state.

A nursing diagnosis is a clinical judgment about
individual, family, or community responses to actual
or potential health problems/life processes.
Nursing Diagnosis Questions









Are there problems here?
If so, what are the specific problems?
What are some possible causes?
Is there a situation involving risk factors?
What are the risk factors?
What are the client’s strengths?
What data are available to answer these questions?
Is more data needed?
If so, what are the possible sources of further data?
Nursing Diagnosis is a Two-Part
Statement

A problem statement or diagnostic label
that describes the client’s response to
an actual or potential health problem or
wellness condition.

And the etiology - the related cause or
contributor to the problem.
Nursing Diagnosis is a ThreePart Statement

Includes first two parts of Two-Part
Statement: the diagnostic label and the
etiology.

Also includes defining characteristics,
the collected data, also known as signs
and symptoms, subjective and objective
data, and clinical manifestations.
Types of Nursing Diagnosis

Actual nursing diagnosis: A problem exists; it is
composed of the diagnostic label, related factors,
and signs and symptoms.

Risk nursing diagnosis: A problem does not yet exist,
but special risk factors are present.

Wellness nursing diagnosis: Indicates client’s desire
to attain higher level of wellness in some area of
function.
Planning and Outcome
Identification
 Planning combines with outcome
identification to comprise the third step
of the nursing process.
Three Phases of Planning

Initial Planning: developing a preliminary plan of care
by the nurse who performs the admission
assessment.

Ongoing Planning: continuous updating of client’s
plan of care.

Discharge Planning: Involves critical anticipation and
planning for client’s needs after discharge.
Tasks Involved with Planning

Prioritizing list of nursing diagnoses.

Identifying and writing client-centered long- and
short-term goals and outcomes.

Developing specific nursing interventions.

Recording entire nursing plan in client’s record.
Intervention
 A nursing intervention is an action
performed by the nurse that helps the
client achieve the results specified by
the goals and expected outcomes.
Categories of Nursing
Interventions

Independent: Actions initiated by nurse that do not
require direction or an order from another health care
professional

Interdependent: Actions implemented in collaborative
manner by nurse in conjunction with other health
care professionals

Dependent: Actions that require an order from a
physician or other health care professional.
Types of Nursing Interventions

Specific order - written by physician or nurse
especially for an individual client.

Standing order - A standardized intervention written,
approved and signed by a physician that is kept on
file to be used in predictable situations or in
circumstances requiring immediate attention.

Protocol - A series of standing orders or procedures.
Types of Nursing Interventions



Specific order: written by physician or nurse
especially for an individual client
Standing order: A standardized intervention
written, approved and signed by a physician
that is kept on file to be used in predictable
situations or in circumstances requiring
immediate attention.
Protocol: A series of standing orders or
procedures
The Nursing Care Plan
 A written guide that organizes data
about a client’s care into a formal
statement of the strategies that will be
implemented to help the client achieve
optimal health.
Implementation
 This fourth step of the nursing process
involves the execution of the nursing
care plan derived during the Planning
phase.
Evaluation
 This fifth step of the nursing process,
determining whether client goals have
been met, partially met, or not met.
Nursing Audit
 The process of collecting and analyzing
data to evaluate the effectiveness of
nursing interventions.
The Nursing Process
is Critical Thinking
 Critical thinking, problem-solving, and
decision-making are important in the
use of the nursing process.
 These skills can be learned!