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The Nursing Process

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Nursing Diagnosis ... The name of the nursing diagnosis is linked to the etiology with the phrase ' ... American Nursing Diagnosis Association. Identifies ... – PowerPoint PPT presentation

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Title: The Nursing Process


1
The Nursing Process
2
Resources
  • Andrea Ackermann, Mount St. Mary College,
    Critical-thinking-the-nursing-process 2001.
  • http//www.umanitoba.ca/nursing/courses/128,(2005)
  • Sara-jo Wiscombe, Nursing Process ,Wallace
    Community College ,May 22,2001.
  • Tucker C, MODULE A INTRODUCTION TO NURSING
    Process, August 21, 2002 .

3
(No Transcript)
4
The Nursing Process
  • An organizational framework for the practice of
    nursing
  • Orderly, systematic
  • Central to all nursing care
  • Encompasses all steps taken by the nurse in
    caring for a patient

5
Definition of the Nursing Process
  • An organized sequence of problem-solving steps
    used to identify and to manage the health
    problems of clients
  • It is accepted for clinical practice established
    by the American Nurses Association

6
Benefits of Nursing Process
  • Provides an orderly systematic method for
    planning providing care
  • Enhances nursing efficiency by standardizing
    nursing practice
  • Facilitates documentation of care
  • Provides a unity of language for the nursing
    profession
  • Is economical
  • Stresses the independent function of nurses
  • Increases care quality through the use of
    deliberate actions

7
The Nursing Process Utilizes The Following
  • Assessment
  • Nursing Diagnosis
  • Planning
  • Implementation
  • Evaluation

8
Characteristics of the Nursing Process
  • Within the legal scope of nursing
  • Based on knowledge-requiring critical thinking
  • Planned-organized and systematic
  • Client-centered
  • Goal-directed
  • Prioritized
  • Dynamic

9
Benefits of using the nursing process
  • Continuity of care
  • Prevention of duplication
  • Individualized care
  • Standards of care
  • Increased client participation
  • Collaboration of care

10
Being Accountable
  • Using critical thinking before taking actions
  • Being responsible for your actions
  • Entering the professional role
  • Working at the level of your peers
  • Using the nursing process

11
Something to think about
  • Nurses are responsible for a unique dimension of
    healthcare the diagnosis and treatment of
    human responses to actual or potential health
    problems

12
MARTHA ROGERS, NURSE THEORIST
  • When an apple is cut, others see seeds in the
    apple. We, as nurses, see apples in the seeds.

13
What Are Your Responsibilities?
  • Recognize health problems.
  • Anticipate complications.
  • Initiate actions to ensure appropriate and timely
    treatment.
  • Begin to think CRITICALLY !!!!!!

14
Critical Thinking
  • MENTAL OPERATIONS decision making reasoning
  • KNOWLEDGE-having the facts understanding the
    reason behind the knowledge
  • ATTITUDES- curious/open-minded/non-judgmental.

15
Critical Thinking
  • Critical thinking in nursing is an essential
    component of professional accountability and
    quality nursing care.
  • Critical thinking is careful, deliberate, and
    goal directed.

16
Assessment of Well-Being
  • According to the World Health Organization is
    well-being in these domains
  • Emotional
  • Physical
  • Social
  • Spiritual

17
Lets Get Started
  • Nurse collects background info from previous
    charts
  • Ensure environment is conducive
  • Arrange seating
  • Allow adequate time
  • Nurse introduces self
  • Identifies purpose of interview
  • Ensure confidentiality of information
  • Provide for patient needs before starting

18
TYPES OF INTERVIEWS
  • DIRECTED
  • NON-DIRECTED
  • THINGS THAT IMPAIR COMMUNICATION
  • PRESENTING QUICK SOLUTIONS
  • UNWARRANTED CHEERFULNESS
  • FALSE REASSURANCE
  • GIVING ADVICE
  • CHANGING THE SUBJECT

19
ASSESSMENT
  • Observation
  • Interview
  • Types of questions
  • Environment (physical and emotional) Spiritual
    conciderations
  • Examination

20
Types of Data To Collect
  • Objective data-observable and measurable facts
    (Signs)
  • Subjective data-information that only the client
    feels and can describe (Symptoms)

21
CULTURAL DIVERSITY
  • MUST PROVIDE CARE CONGRUENT WITH A CLIENTS
    EXPECTATIONS
  • This is not about you ?
  • Respect INDIVIDUALS DIFFERENCES, What is the
    significance of the problem or illness to the
    client?
  • What does it mean in the family/community?

22
COMMON ChallengesDefense Mechanisms
  • COMPENSATION
  • DENIAL
  • DISPLACEMENT
  • RATIONALIZATION
  • PROJECTION
  • REPRESSION
  • SUPPRESSION
  • REGRESSION

23
Continued
  • THE NURSING PROCESS HELPS NURSES UNDERSTAND THE
    STRATEGIES CLIENTS USE IN their attempt at
    coping
  • This knowledge will help you FURTHER
    INDIVIDUALIZE THEIR CARE

24
Resources
  • Client
  • Other individuals
  • Previous records
  • Consultations
  • Diagnostics studies
  • Relevant literature

25
Assessment
  • Data base assessment comprehensive information
    you gather on initial contact with the person to
    assess all aspects of health status.
  • Focus assessment the data you gather to
    determine the status of a specific condition.

26
Sources of Data
  • Primary source Client
  • Secondary source Clients family, reports, test
    results, information in current and past medical
    records, and discussions with other health care
    workers

27
Disease Prevention
  • Primary prevention protection from a disease
    while still in a healthy state.
  • Secondary prevention early detection and
    treatment of disease.
  • Tertiary prevention prevent complications and
    to maintain health once the disease process has
    occurred.

28
Verifying Data
  • Essential in critical thinking!!!!!
  • Measurable data
  • Double check personal observations
  • Double check equipment
  • Check with experts and team members
  • Recheck out-liers
  • Compare objective and subjective data
  • Clarify statements

29
Planning
  • Establish the goals, interventions and outcomes

30
General Guidelines for Setting Priorities
  • Take care of immediate
    life-threatening issues.
  • Safety issues.
  • Patient-identified issues.
  • Nurse-identified priorities based on the overall
    picture, the patient as a whole person, and
    availability of time and resources.

31
Nurse Identified Priorities
  • Composite of all patients strengths and health
    concerns.
  • Moral and ethical issues.
  • Time, resources, and setting.
  • Hierarchy of needs.
  • Interdisciplinary planning.

32
Identifying Client-centered Outcomes
  • State what the patient will do
    or experience at the completion
    of care.
  • Give direction to the patients
    overall care.
  • Patient behaviors not nurse behaviors!!
  • The patient will

33
DIAGNOSIS
  • Sort, cluster, analyze information
  • Identify potential problems and strengths
  • Write statement of problem or strength
  • Risk of infection related to compromised nutrition

34
Nursing Diagnosis (cont.)
  • Potential for effective breastfeeding related to
    knowledge level and support system
  • Prioritize the problems
  • Not a medical diagnosis

35
Steps for deriving outcomes from Nursing Diagnosis
  • Look at the first clause of the nursing dx and
    restate in a statement that describes
    improvement, control or absence of the problem.
  • Risk for infection r/t surgical procedure.
  • The client will demonstrate no signs or symptoms
    of infection.

36
Components of Outcomes
  • Subject who is the person expected to achieve
    the outcome?
  • Verb what actions must the person take to
    achieve the outcome?
  • Condition under what circumstances is the person
    to perform the actions?
  • Performance criteria how well is the person to
    perform the actions?
  • Target time by when is the person expected to be
    able to perform the actions?

37
Nursing Interventions
  • Road maps directing the best ways to provide
    nursing care.
  • Evidence based nursing.
  • Monitor health status.
  • Minimize risks.
  • Resolve or control a problem.
  • Assist with ADLs.
  • Promote optimum health and independence.

38
Interventions
  • Direct interventions actions performed
    through interaction with clients.
  • Indirect interventions actions performed
    away from the client, on behalf of
    a client or group of clients.

39
Nursing Diagnosis
  • Health issue that can be prevented, reduced,
    resolved, or enhanced through independent nursing
    measures

40
Documenting the Plan of Care
  • To ensure continuity of care, the plan must be
    written and shared with all health care personnel
    caring for the client.
  • Consists of
  • Prioritized nursing
    diagnostic statements.
  • Outcomes.
  • Interventions.

41
Documentation
  • Clear and concise
  • Appropriate terminology
  • Usually on a designated form
  • Physical assessment
  • Usually by Review of Systems
  • Overview of symptoms
  • Diet
  • Each body system

42
Documentation
  • Use patients own words in subjective data
    enclose in ___ (quotation marks)
  • Avoid generalizations be specific
  • Dont make summative statements describe -
    e.g. patient is being ornery should be patient
    resists instruction or patient states Dont talk
    to me, I dont care about that

43
Evaluation
  • Determining outcome achievement
  • Identifying the variables affecting outcome
    achievement
  • Deciding whether to continue, modify, or
    terminate the plan

44
Determining Outcome Achievement
  • Must be aware of outcomes set for the client.
  • Must be sure patient is ready for evaluation.
  • Is patient able to meet outcome criteria?
  • Is it
  • Completely met?
  • Partially met?
  • Not met at all?
  • Record in progress in notes.
  • Update care plan.

45
Identifying Variable Affecting Outcome Achievement
  • Maintain individuality of care plan
  • 1. Is the plan realistic for the client?
  • 2. Is the plan appropriate at the time for
    this particular client?
  • 3. Were changes made in the plan when
    needed?
  • 4. How does the client feel about the plan?

46
Predict, Prevent, and Manage
  • Focus on early intervention
  • Based on research
  • Predict and anticipate problems
  • Look for risk factors

47
Diagnostic Statements
  • Name of the health-related issue or problem as
    identified in the NANDA list
  • Etiology (its cause)
  • Signs and Symptoms
  • The name of the nursing diagnosis is linked to
    the etiology with the phrase related to, and
    the signs and symptoms are identified with the
    phrase as manifested (or evidenced) by

48
Collaborative Problems-Nurses Responsibility
  • Correlating medical diagnoses or medical
    treatment measures with the risk for unique
    complications
  • Documenting the complications for which clients
    are at risk
  • Making pertinent assessments to detect
    complications

49
Continued
  • Reporting trends that suggest development of
    complications
  • Managing the emerging problem with nurse- and
    physician-prescribed measures
  • Evaluating the outcomes

50
The Nursing Process
  • Nursing Diagnosis
  • Judgment or conclusion about the risk foror
    actualneed/problem of the patient
  • NANDA format

51
NANDA North American Nursing Diagnosis
Association
  • Identifies nursing functions
  • Creates classification system
  • Establishes diagnostic labels
  • Risk of infection related to compromised
    nutritional state
  • Potential complication of seizure disorder
    related to medication compliance

52
Planning
  • The process of prioritizing nursing diagnoses and
    collaborative problems, identifying measurable
    goals or outcomes, selecting appropriate
    interventions, and documenting the plan of care.
  • The nurse consults with the client while
    developing and revising the plan.

53
Setting Priorities
  • Determine problems that require immediate action
  • Maslows Hierarchy of Human Needs

54
Short-Term Goals
  • Outcomes achievable in a few days or 1 week
  • Developed form the problem portion of the
    diagnostic statement
  • Client-centered
  • Measurable
  • Realistic
  • Accompanied by a target date

55
Long-Term Goals
  • Desirable outcomes that take weeks or months to
    accomplish for clients with chronic health
    problems

56
The Nursing Process
  • Planning
  • Identification of goals and outcome criteria
  • Prioritization
  • Time frame

57
Selecting Nursing Interventions
  • Planning the measures that the client and nurse
    will use to accomplish identified goals involves
    critical thinking.
  • Nursing interventions are directed at eliminating
    the etiologies.

58
Selecting an intervention
  • The nurse selects strategies based on the
    knowledge that certain nursing actions produce
    desired effects.
  • Nursing interventions must be safe, within the
    legal scope of nursing practice, and compatible
    with medical orders.

59
Communicating The Plan
  • The nurse shares the plan of care with nursing
    team members, the client, and clients family.
  • The plan is a permanent part of the record.

60
Evaluation
  • The way nurses determine whether a client has
    reached a goal.
  • It is the analysis of the clients response,
    evaluation helps to determine the effectiveness
    of nursing care.

61
The Nursing Process
  • Evaluation
  • Ongoing part of the nursing process
  • Determining the status of the goals and outcomes
    of care
  • Monitoring the patients response to drug therapy

62
Documentation
  • Clear and concise
  • Appropriate terminology
  • Usually on a designated form
  • Physical assessment
  • Usually by Review of Systems
  • Overview of symptoms
  • Diet
  • Each body system
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