Transcript 7..nursing process

M.N.Priyadarshanie
BSc. In Nursing
 Specific
to the nursing profession
 A framework for critical thinking
 It’s purpose is to:
“Diagnose and treat human responses to
actual or potential health problems”
 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
 ID
problem
 Collect data
 Form hypothesis
 Plan of action
 Hypothesis testing
 Interpret results
 Evaluate findings
 Provides
individualized
care
 Client is an active
participant
 Promotes continuity of
care
 Provides more
effective
communication among
nurses and healthcare
professionals
 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
Assessment
Nursing
Diagnosis
Planning
Implementing
Evaluating
 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 - observable data (sign)

Blood Pressure 130/80
 Nursing
Interview (history)
 Health Assessment -Review of Systems
 Physical Exam
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Inspection
Palpation
Percussion
Auscultation
Make
sure information is
complete & accurate
Validate problems
Interpret and analyze data
Compare to “standard norms”
Organize and cluster data
 Obtain
info from nursing assessment, history and
physical (H&P) etc…...
01.
 Client diagnosed with hypertension
 B/P 160/90 mmHg
 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”
 Second
step of the Nursing Process
 Interpret
 Identify
& analyze clustered data
client’s problems and strengths
 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
Within
the scope
of nursing practice
Identify responses
to health and
illness
Can change from
day to day
Within
the scope
of medical
practice
Focuses on curing
pathology
Stays the same as
long as the
disease is present
 Composed
of 3 parts:
 Problem statement- the client’s response to a
problem
 Etiology- what’s causing/contributing to the
client’s problem
 Defining Characteristics- what’s the evidence of
the problem
 Problem(
Diagnostic Label)-based on your
assessment of client…(gathered information),
pick a problem from the NANDA list...
 Etiology- determine what the problem is caused
by or related to (R/T)...
 Defining characteristics- then state as evidenced
by (AEB) the specific facts the problem is based
on...
 Ineffective
therapeutic regimen
management
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”.
 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
Family coping: potential for growth RT
unexpected birth of twins.
 Require
both nursing interventions and medical
interventions
EXAMPLE: Client admitted with medical dx of
pneumonia
Collaborative problem = respiratory insufficiency
Nsg interventions: Raise HOB, Encourage C&DB
MD interventions: Antibiotics IV, O2 therapy
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.
Prioritize
list of
client’s nursing
diagnoses using
Maslow
Rank as high,
intermediate or low
Client specific
Priorities can change
Goal and outcome
statements are client
focused.
 Worded positively
 Measurable, specific
observable, timelimited, and realistic
 Goal = broad
statement
 Expected outcome =
objective criterion for
measurement of goal
 Utilize NOC as
standard

EXAMPLE
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.

Short
term goals
Long term goals
Cognitive goals
Psychomotor goals
Affective goals
Specific
Measurable
Attainable
Relevant
Time Bound
Pt
Pt
Pt
Pt
Pt
will
will
will
will
will
walk 50 ft.
eat 75% of meal
be OOB 2-4hrs
maintain HR<100
state pain level is acceptable 6 (0-10)
 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.
 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
 The
fourth step in the Nursing Process
 This is the “Doing” step
 Carrying out 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
 Teach
potential
 Monitor VS q4h
complications of
 Maintain prescribed
hypertension to
diet (2 Gm Na)
instill importance of
 Teach client amount of
maintaining Na
sodium restriction,
restrictions
foods high in sodium,
 Assess for cultural
use of nutrition labels,
factors affecting
food preparation and
dietary regime
sodium substitutes
 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.
 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.
 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.
 Outcome
criteria met? Problem resolved!
 Outcome criteria not fully met? Continue
plan of care- ongoing.
 Outcome criteria unobtainable- review each
previous step of NCP and determine if
modification of the NCP is needed.
 Were the nsg interventions
appropriate/effective?
Factors that impede goal attainment:
 Incomplete
database
 Unrealistic client outcomes
 Nonspecific nsg interventions
 Inadequate time for clients to achieve
outcomes.
Identify which stage of the nursing process
is being described below:
 The
nurse writes nursing interventions
 A goal is agreed upon
 The nurse performs a physical assessment
 A revision is made to the NCP
 The nurse administers antibiotic medication
 A statement is written that outlines the
clients response to a potential health
problem
 RR
22/min, even unlabored
 “I can only walk 3 blocks before my legs
start to hurt”
 Pain rated 3 on a scale of 0-10
 Skin pink, warm and dry
 Urine output 300ml/8 hr
 “My wife doesn’t come to visit very
often”
 Dressing clean, dry and intact.
 Which
of following, the nurse records the
following data in the client’s medical record:
 A.Breath sounds clear to auscultation
 B.Amber urine in sufficient quantities
 C.Pain intensity 8 out of 10
 D.Skin warm and dry
 When
interviewing a client, the nurse
uses the following open-ended style
sentence:
 A.Do you have any concerns right now?
 B.Is your family worried about you being
in the hospital?
 C.How many times do you get up to go to
the bathroom at night?
 D.What do you mean when you say, “I
don’t feel quite right?”
In order for an actual nursing diagnosis to be
valid it must have one or more supporting:
 A.Laboratory results
 B.Diagnostic data
 C.Defining characteristics
 D.Medical diagnoses
Nursing diagnoses are aimed at identifying
client problems that are treatable by
_______.
 A.The physician
 B.The nurse
 C.Invasive techniques
 D.Complementary strategies
 82
y/o male w/30 + year history of COPD presents
to the ER with C/O SOB and chest pain and now is
to be admitted to your unit. He has a IV at TKO and
O2 per NP at 2L. He was given a Nitro and an
aspirin in the ER.
 Admitting
Dx: CHF, R/O MI
 Past Medical Hx: Mild CHF, COPD x 30 years, CAD,
HTN
 PE: Skin pink and dry, brisk capillary refill,
oriented x 4, S3 heart sounds, SOB with any
exertion, audible expiatory and inspiratory
wheezes, crackles at bases bilaterally, 1+ pitting
edema to mid calf.
 Formulate complete nursing care plan based on
above case scenario.
 50
year age male patient admitted to the
emergency room with the complaining of severe
vomiting from the early in the morning. She
complained of loss of appetite since last wk and
complained right site abdominal pain. His BP was
140/90mmHg and HR was 102bt /mint, RR22brt/mnt. Wt- 40kg. After complete assessment
and USS result taking, Dr. diagnosed as
Appendicities is the problem with the patient.
Arrange 3 complete nursing care plans .
45 years woman admitted to a hospital c/o
severe SOB. Her signs and symptoms were ascitis,
pitting edema(+2). She was complaining of severe
vomiting from the morning. She was diagnosed as
chronic renal failure. Her temperature 37.80C.HR- 100bts/mint, spo2-93%.RR24BRT/MINT
* Arrange 3 complete nursing care plans.

 53
years old women admitted to your ward
complaining of urinary incontinence since last
week. She had 5 children and with cough, she
passed urine accidently. She was worrying a lot
and she looked so nervous and tired. She told
that, she is not having any idea of the
condition. her bp- 110/70mmHg, HR104bts/mint, RR – 23bts/mint. Arrange 3
complete nursing care plans.