Nursing Process: Foundation for Practice

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Nursing Process Foundation for Practice

• NPN 105
• Joyce Smith RN, BSN

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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

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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

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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

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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

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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

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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

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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

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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

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Types of Nursing Assessments

• Initial assessment
• Focused assessment
• Emergency assessment
• Time-lapsed assessment

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Types of Data

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

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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

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Characteristics of Data

• Complete
• Factual and accurate
• Relevant

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Components of Data Collection

• Interview
• Orientation phase
• Working phase
• Termination

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Sources of Data

• Primary
• patient
• Secondary
• Family members
• Significant other
• Other healthcare professionals
• Health records

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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

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Interpreting Assessment Data

• Data interpretation and validation
• Data clustering
• Data documentation

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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

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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

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Health Problem

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

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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

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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

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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

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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

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Nursing Diagnosis

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

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Nursing Diagnosis

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

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NANDA

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

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NANDA

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

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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

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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

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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

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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

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Nursing Diagnosis

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

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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

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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

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Nursing Diagnosis

• Types of diagnoses
• Actual
• Risk
• Wellness

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What a Nursing Diagnosis is Not

• A nursing diagnosis is NOT a medical diagnosis
• A nursing diagnosis is NOT a statement of patient
  need

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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