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Nursing Process: Foundation for Practice

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Determine nursing diagnoses for actual and potential health problems ... 2. Identify factors that contribute to or cause health problems (etiology) ... – PowerPoint PPT presentation

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Title: Nursing Process: Foundation for Practice


1
Nursing Process Foundation for Practice
  • NPN 105
  • Joyce Smith RN, BSN

2
What 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

3
Together 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

4
Five 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

5
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6
Assessment 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

7
Unique 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

8
Assessment
  • 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

9
Approaches 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

10
Gordons 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

11
Types of Nursing Assessments
  • Initial assessment
  • Focused assessment
  • Emergency assessment
  • Time-lapsed assessment

12
Types of Data
  • Subjective Data
  • Information perceived only the affected person
  • Cannot be perceived or verified by another person
  • Examples feeling nervous, nauseated, chilly

13
Types 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

14
Characteristics of Data
  • Complete
  • Factual and accurate
  • Relevant

15
Components of Data Collection
  • Interview
  • Orientation phase
  • Working phase
  • Termination

16
Sources of Data
  • Primary
  • patient
  • Secondary
  • Family members
  • Significant other
  • Other healthcare professionals
  • Health records

17
Components 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

18
Interpreting Assessment Data
  • Data interpretation and validation
  • Data clustering
  • Data documentation

19
Diagnosis 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

20
Purpose 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

21
Health Problem
  • A condition that necessitates intervention to
    prevent or resolve the disease or illness or to
    promote coping and wellness

22
Health 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

23
Health 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

24
Nursing 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

25
Medical 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

26
Nursing Diagnosis
  • Actual or potential health problems that can be
    prevented or resolved by independent nursing
    interventions

27
Nursing Diagnosis
  • Nursing diagnoses provide the basis for selecting
    nursing interventions that will achieve valued
    patient outcomes for which the nurse is
    responsible

28
NANDA
  • NANDA North American Nursing Diagnosis
    Association
  • Established in 1973 to identify standards and
    classify health problems treated by nurses

29
NANDA
  • NANDA conferences are held every two years to
    continue progress in defining, classifying and
    describing diagnoses

30
NANDAS 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

31
Nursing 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

32
Nursing 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

33
Nursing 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

34
Nursing Diagnosis
  • Medical Diagnosis
  • Myocardial infarction
  • Nursing Diagnosis
  • Fear
  • Altered health maintenance
  • Knowledge deficit
  • Pain
  • Altered tissue perfusion

35
Development 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

36
Components 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

37
Nursing Diagnosis
  • Types of diagnoses
  • Actual
  • Risk
  • Wellness

38
What a Nursing Diagnosis is Not
  • A nursing diagnosis is NOT a medical diagnosis
  • A nursing diagnosis is NOT a statement of patient
    need

39
Legal 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
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