Fundamental Nursing Skills and Concepts

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Fundamental Nursing Skills and Concepts

• Chapter 2
• Page 16

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Definition of the Nursing Process

• An organized sequence of problem-solving steps
  used to identify and to manage the health
  problems of clients. These steps assure high
  quality, efficient care in the minimum amount of
  time with maximum efficiency.
• It is accepted for clinical practice established
  by the American Nurses Association
• Nursing process is a set of actions leading to a
  particular outcome or goal.

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The nursing process

• Organized sequence of problem solving steps, used
  to identify and manage health problems of
  patients.
• Assessment-collect data. Subjective data is
  patient based, called symptoms. Something the pt.
  tells you, I itch, I have a headache, I have
  pain. Objective data- is
  observable and measureable, these are signs. Such
  as temp., B/P, lab reports.
• Secondary source-family, reports, test results,
  current and past medical records.
• Collect and organize data, using nursing
  knowledge and past experience, cluster related
  data. Pg.20 box 2-3

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The nursing process

• Diagnosis- 1. analyze data-is it normal or
  abnormal findings? A nursing dx. is a health
  issue that can be prevented, reduced, resolved or
  enhanced through independent nursing measures.
• Catagories of nsg. dx. Are actual, risk,
  possible, syndrome and wellness. Top pg. 20
• 2 Identify nursing dx. collaborative problems,
  physiologic complications whose tx. requires both
  nurse and physician prescribed interventions.
  NANDA, pg. 20a and well laid out on back cover
  shows NSG Dx.

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The nursing process

• Planning-
• 1. prioritize problem, est. goals (short long
  term goals) always timed.
• 2. identify measureable outcomes(goals),
  involves critical thinking.
• 3. select nursing interventions that are
  appropriate.
• 4. document the plan of care. Please always
  consult with the patient in the planning of care.
  Planning is accompanied by a target date.

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The nursing process

• Implementation-
• Carry out the plan of care. Nurse implements
  medical and nursing orders.
• Document the nursing care and patient responses,
  shows if the plan is effective or not.

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The nursing process

• Evaluation-
• Monitor patient outcomes.
• Resolve, continue, revise the current plan of
  care.
• Needs not met, may need to re-assess, plan care,
  and implement other interventions to meet the
  goal for better outcomes.

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Characteristics of the Nursing Process

• Within the legal scope of nursing -as defined by
  the Nurse Practice Act. Describes nursing in
  terms of an independent problem solving role,
  that involves the dx. and tx. of human
  responses to actual or potential health problems.
  Top pg. 20 shows categories of nsg. dx.
• Based on knowledge-requiring critical thinking-
  the ability to identify and resolve pt. problems
  requires critical thinking, (process of objective
  reasoning, analyzing facts to reach a valid
  conclusion).
• Planned-organized and systematic

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Characteristics of the Nursing Process

• Client-centered- the patient and, or, family need
  to take part.
• Goal-directed-to achieve certain goals and
  outcomes. The greatest problem has the highest
  priority.
• Prioritized-greatest threat to health are the
  problems that need to be resolved first.
• Dynamic-changing, evaluation, begin the process
  again. Accomplished your goal? Initiate a new
  one, or move down to second problem on the list.
  It is a continuous loop. Did not accomplish your
  goal? Rethink it, re-assess, make new
  interventions to get the problem resolved, and
  implemented. Evaluate the outcome.

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What are the steps of the Nursing Process

• Assessment
• Diagnosis
• Planning
• Implementation
• Evaluation

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Assessment

• Systematic collection of facts or data
• Gather data-page 19 good admission assessment
  record tool. Data collection begins with first
  contact, and is ongoing.

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Types of Data

• Objective data-observable and measurable facts
  (Signs)- v/s, lab reports, gives you signs of a
  disorder.
• Subjective data-information that only the client
  feels and can describe (Symptoms) feels pain,
  itch, has headache.

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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

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Types of Assessments

• Data base assessment-initial assessment about the
  pts. physical, emotional, social and spiritual
  health. Lengthy and comprehensive.
• Focus assessment-information that provides more
  details about specific problems (ie.
  Constipation).

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Organization of Data

• Grouping of related information organizing data,
  use knowledge, previous experiences to group or
  cluster data.
• Organization of assessment data into small groups
  to be analyzed

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Nursing Diagnosis

• Health issue that can be prevented, reduced,
  resolved, or enhanced through independent nursing
  measures
• Nursing Diagnosis Categories
• Actual-problem currently exists
• Risk-potential for developing
• Possible-unsure of existence, further data needed
• Syndrome-cluster of problems present or predicted
  because of an event or situation
• Wellness-healthy person obtains nursing
  assistance to maintain or perform at a higher
  level

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Diagnostic Statements

• Name of the health-related issue or problem as
  identified in the NANDA list
• NANDA North American Nursing Diagnosis
  Association, the authoritative organization for
  developing and approving nsg. dx.
• Unable to find a nsg. dx. that fits the needs of
  your client, may use own terminology when stating
  nsg. dx.
• Nursing diagnosis statement must contain, the
  health related issue, etiology(the cause), signs,
  symptoms. Something the nurse can treat.

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Diagnostic Statements

• 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

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Collaborative Problems

• Physiologic complications whose treatment
  requires both nurse- and physician-prescribed
  interventions.
• They are an interdependent domain of nursing
  practice
• Overlapping problems between nsg. dx. and medical
  dx.
• Complications that need further interventions.
• Top pg. 21, shows an illustration of
  collaborative problems.
• Beyond the realm of the nurse treatment
  independently, this is a Physician / Nurse
  undertaking.

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

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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.

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Setting Priorities

• Determine problems that require immediate action
• Maslows Hierarchy of Human Needs-is a basis to
  use to prioritize , ranking may change.
• Establishing goals- a goal is an expected outcome
  or a desired outcome. Objective Has fever been
  lowered? Has constipation been resolved?

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Short-Term Goals

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

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Long-Term Goals

• Desirable outcomes that take weeks or months to
  accomplish for clients with chronic health
  problems

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Goals for Collaborative Problems

• Goals for collaborative problems are written from
  a nursing rather than from a client perspective.
• The focus on what the nurse will monitor, report,
  record, or do to promote early detection and
  treatment.

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

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Documentation

• Joint Commission on Accreditation of Health Care
  Organizations (JCAHO) requires that every
  patients medical record provide evidence of the
  planned nursing interventions for meeting the
  patients needs.

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Nursing Orders

• Directions for a clients care
• Directions identifying specifically that all team
  members understand what, when, where, and how for
  performing nursing interventions
• Nursing orders are signed to be accountable
• Standards of care- policies that indicate which
  activities will be provided to ensure quality pt
  care.
• Clinical pathways- relieve the nurse from writing
  time consuming care plans

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Communicating The Plan

• The nurse shares the plan of care with nursing
  team members, the client, and clients family.
  Some agencies require the patient sign the plan
  so they are accountable for taking part in their
  own care.
• The plan is a permanent part of the medical
  record.
• The plan is referred to daily, reviewed, revised.
• Change if need be and re-implemented.

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Implementation

• Carrying out the plan of care
• The nurse implements medical orders and nursing
  orders
• Implementation involves the client and one or
  more health care team. Enlist the participation
  by the client. The goals are client based and
  goal directed, so they need to be involved.

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Implementation

• Health care team also transmits the plan of care
  to the on coming staff so continuity of care is
  in progress.
• The information in the chart shows a correlation
  between the plan and the care that has been
  provided. Document nursing care and patient
  responses. The quantity and quality of pts.
  responses. Quote the patient whenever possible to
  get a pts. perspective of his care. Nurses notes
  should reflect a correlation between plan of care
  and the care that was rendered.
• Nurses are accountable for carrying out nursing
  orders and physician orders.

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Documentation

• Open lines of communication among health care
  team
• Shows continuing progress of pt.
• Complies with JACHO
• Facilitates reimbursment to hospital
• If need be, paints with words a good picture of
  the care that was rendered to the patient, if the
  patients record goes to court for some reason.

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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.
• Monitor pt. outcomes. Was the plan effective? Was
  the goals met? Resolve, continue, revise the
  current plan of care to meet the goals needed for
  that individual patient.

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Nursing Process

• Using the nursing process is the standard for
  clinical nursing practice.
• Nurse Practice Act holds nurses accountable for
  demonstration of these aspects when caring for
  patients. To do less implies negligence.
• Sample Nsg. Care Plan page 24

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Aspects of writing the Plan of Care

• Based on your assessment data
• what is obvious
• what is apparent
• The expected outcomes for the problems you found
  in your assessment
• generally are timed
• make sure the outcomes fit with in the
  medical diagnosis realm

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Aspects of writing the Plan of Care

• Nursing interventions specific for achieving
  goals set up in your outcomes phase
• Implement your interventions
• Evaluate the patients response
• problems solved?
• move on to new problem
• problem not solved
• change interventions, re-implement

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Aspects of writing the Plan of Care

• Document
• what your 5 senses told you
• saw, smelled, touched, tasted, heard (always
  in quotes when the patient states)
• Document- your good teaching and the patients or
  / and patients family understanding and response.