Title: Nursing Process: Foundation for Practice
1Nursing Process Foundation for Practice
- NPN 105
- Joyce Smith RN, BSN
2What is the Nursing Process?
- It is a systematic method that directs the nurse
and patient in planning patient care, and enables
you to organize and deliver nursing care - It is patient centered and outcome oriented
- The steps are interrelated and dependent on the
accuracy of each of the preceding steps - It is used to identify, diagnose, and treat human
responses to health and illness
3Together the nurse and the patient accomplish
the following
- Assess the patient to determine need for nursing
care - Determine nursing diagnoses for actual and
potential health problems - Identify expected out comes and plan care
- Implement care
- Evaluate the results
4Five Steps of the Nursing Process
- Assessment collection of patient data
- Diagnosis identifies patients strengths and
potential problems - Planning develop the specific holistic desired
goals and nursing interventions to assist the
patient - Implementation carry out the plan of care
- Evaluation determine the effectiveness of the
plan of care
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6Assessment Phase One of the Nursing Process
- Purpose
- Establish a baseline of information on the client
and develop a data base - Determine clients normal function
- Determine clients risk for dysfunction
- Determine presence or absence of dysfunction
- Determine clients strengths
- Provide data for diagnostic phase
7Unique Focus of Nursing Assessment
- Nursing assessments do not duplicate medical
assessments - Medical assessments target data pointing to
pathologic conditions - Nursing assessments focus oh the patients
responses to health problems or potential health
problems
8Assessment
- The purpose is to establish a database by
- Collecting data
- Subjective versus objective
- Interviewing and taking a health history
- Subjective and organized
- Performing a physical examination
- Vital signs, patients behavior, diagnostic and
laboratory data, medical records
9Approaches for Data Collection
- Gordons 11 Functional Health Patterns
- Uses a series of questions which assist in
formulating a nursing diagnosis - Problem focused assessment
- Focuses on the patients problem and develop you
plan of care around the problem
10Gordons Health Patterns
- Health perception-management
- Nutritional-metabolic
- Elimination
- Activity-exercise
- Sleep-rest
- Cognitive -perceptual
- Self-perception-self-concept
- Role-relationship
- Sexuality-reproductive
- Coping-stress-tolerance
- Value-belief
11Types of Nursing Assessments
- Initial assessment
- Focused assessment
- Emergency assessment
- Time-lapsed assessment
12Types of Data
- Subjective Data
- Information perceived only the affected person
- Cannot be perceived or verified by another person
- Examples feeling nervous, nauseated, chilly
13Types of Data
- Objective Data
- Observable and measurable data
- Data that can be see, heard or felt by someone
other than the person experiencing it - Examples elevated temperature (gt101 F), moist
skin, refusal to eat, vital signs
14Characteristics of Data
- Complete
- Factual and accurate
- Relevant
15Components of Data Collection
- Interview
- Orientation phase
- Working phase
- Termination
16Sources of Data
- Primary
- patient
- Secondary
- Family members
- Significant other
- Other healthcare professionals
- Health records
17Components of Data Collection
- Nursing History
- Biographical information
- Reasons for seeking healthcare
- Present illness or health concern
- Health history
- Environmental history
- Psychosocial and cultural history
- Review of systems or functional health patterns
18Interpreting Assessment Data
- Data interpretation and validation
- Data clustering
- Data documentation
19Diagnosis Phase 2 of the Nursing Process
- Data is useless if not used
- An important part of nursing practice is
determining what the client needs - Developing a nursing diagnosis is the next step
in planning for the care of the patient - Looking at the data, we can see both problems
treated by nursing (nursing diagnosis) and
treated by other disciplines (collaborative
problems). - Nursing diagnosis are not medical diagnosis
20Purpose of a Nursing Diagnosis
- 1. Identify how and individual, group or
community responds to an actual or potential
health and life processes - 2. Identify factors that contribute to or cause
health problems (etiology). - 3. Identify resources or strengths the
individual, group or community can utilize to
prevent or resolve problems
21Health Problem
- A condition that necessitates intervention to
prevent or resolve the disease or illness or to
promote coping and wellness
22Health Problems for Nursing Focus
- Monitoring for changes in health status
- Promoting safety and preventing harm
- Identifying and meeting learning needs
- Tailoring treatment and medication regimens for
each individual
23Health Problems for Nursing Focus
- Promoting comfort and managing pain
- Promoting health and a sense of well being
- Recognizing and addressing barriers to an
independent, healthy lifestyles - Determining human responses
24Nursing Diagnosis
- A clinical judgment about individual, family, or
community responses to actual and potential
health problems or life processes - The goal of a nursing diagnosis is to identify
actual and potential responses
25Medical Diagnosis
- Identification of a disease condition based on a
specific evaluation of physical signs, symptoms,
history, diagnostic tests, and procedures - The goals of a medical diagnosis is to identify
the cause of a illness or injury and design a
treatment plan
26Nursing Diagnosis
- Actual or potential health problems that can be
prevented or resolved by independent nursing
interventions
27Nursing Diagnosis
- Nursing diagnoses provide the basis for selecting
nursing interventions that will achieve valued
patient outcomes for which the nurse is
responsible
28NANDA
- NANDA North American Nursing Diagnosis
Association - Established in 1973 to identify standards and
classify health problems treated by nurses
29NANDA
- NANDA conferences are held every two years to
continue progress in defining, classifying and
describing diagnoses
30NANDAS Definition of Nursing Diagnosis
- Nursing diagnosis is a clinical judgment about
individual, family, or potential health
problems/life processes. Nursing diagnosis
provides the basis for selection of nursing
interventions to achieve outcomes for which the
nurse is accountable
31Nursing Diagnosis
- Clinical judgment about individual, family or
community - Response to actual or potential health or life
process - Provides basis for nursing interventions
- Label and action of describing functional
problems - Identify and synthesize information gathered
during assessment
32Nursing Diagnosis vs. Medical Diagnosis
- Medical diagnosis
- Identify disease
- Nursing diagnosis
- Focus on unhealthy response to health or illness
- Medical diagnosis
- Physician directs treatment
- Nursing diagnosis
- Nurse treats problem within scope of independent
nursing practice
33Nursing Diagnosis vs. Medical Diagnosis
- Medical Diagnosis
- Remains the same as long as the disease is
present - Nursing Diagnosis
- May change from day to day as the patients
responses change
34Nursing Diagnosis
- Medical Diagnosis
- Myocardial infarction
- Nursing Diagnosis
- Fear
- Altered health maintenance
- Knowledge deficit
- Pain
- Altered tissue perfusion
35Development of Nursing Diagnosis
- Assess the patient
- Review data and find actual and potential
problems - Use diagnostic reasoning to identify patient
needs - Arrange data in clusters or defining
characteristics - Use all data available
- Reach conclusions for patient needs
- Determine Nursing Diagnosis according to NANDA
approved diagnoses
36Components of a Nursing Diagnosis
- Diagnostic label name of the nursing diagnosis
with descriptors - Related factors includes factors which
contribute to the problem and are not the cause
,but are associated with it. THESE ARE NOT
MEDICAL DIAGNOSIS. - Defining characteristics - Assessment data which
supports the nursing diagnosis - Subjective data what the patients tells you
- Objective data what you observe or data
obtained - Risk factors clues which point to potential
problems
37Nursing Diagnosis
- Types of diagnoses
- Actual
- Risk
- Wellness
38What a Nursing Diagnosis is Not
- A nursing diagnosis is NOT a medical diagnosis
- A nursing diagnosis is NOT a statement of patient
need
39Legal Ramifications of Nursing Diagnosis
- A nurse
- Can only identify problems within the scope of
practice - Cannot diagnose or treat medical disease
- Must identify problems within his/her scope o
practice, abilities and education