Nursing Process

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Nursing Process

• Roy, C. Andrews, H.A. (1999). The Roy
  Adaptation Model. (2nd. ed.). Norwalk, Conn
  Appleton Lange.
• Chapter 3

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Nursing Process

• Assess of behavior
• Assessment of stimuli
• Nursing diagnosis

• Goal setting
• Intervention
• Evaluation

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FIRST LEVEL ASSESSMENT

• Gather info in each mode
• Behaviors Internal, External, Verbal, Nonverbal

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FIRST LEVEL ASSESSMENT

• Objective
• Subjective

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FIRST LEVEL ASSESSMENT

• Nurse uses skills observation, measurement, and
  interviewing.

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FIRST LEVEL ASSESSMENT

• Assess behavior, compare to criteria, identify
  strengths and strains of coping process.
• Make judgment

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FIRST LEVEL ASSESSMENT

• Adaptation difficulty indicated by regulator
  activity with cognator ineffectiveness

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Pronounced Regulator ActivityExamples

• Increased heart rate or B/P
• Tension
• Loss of appetite
• Increase in serum cortisol.

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Cognator Ineffectiveness Examples

• Faulty perception/information processing
• Ineffective learning
• Poor Judgment
• Inappropriate Affect

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Adaptive/To be Supported/Ineffective

• Adaptive
• Ineffective
• Adaptive To Be Supported (TU category)Adaptive
  behavior that needs support to continue or almost
  adaptive but needs increase or decrease to be
  adaptive

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Second Level Assessment

• Stimuli Provokes a response, internal or
  external, environment

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Second Level Assessment

• Focal
• Contextual
• Residual

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Common Stimuli

• Culture
• Family
• Developmental Stage
• Lack of integrity of function
• Environmental Setting

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Nursing Diagnosis

• Statement of behaviors within one mode with their
  most relevant stimuli orIneffective behavior
  related to focal stimulus USE THIS METHOD ONLY
  FOR NSG 1012

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Nursing Diagnosis

• Summary label for behaviors in one mode with
  relevant stimuli
• A label that summaries a behavioral pattern when
  more than one mode is being affected by the same
  stimuli

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Goals

• Goals of nursing to maintain and enhance adaptive
  behavior and to change ineffective behavior to
  adaptive

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Goals

• Specific goals--use client behavior as the focus
• Realistic
• Measurable

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Goals

• Identifies behavior
• Change expected
• Time frame

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Cognitive Verbs

• Define
• List
• Name
• Recognize
• Identify

• State
• Compare
• Plan
• Describe
• Explain

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Affective Verbs

• Express
• Share
• Verbalize
• Reply
• Choose

• Value
• Exhibit
• Demonstrate
• Follow
• Select

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Psychomotor Verbs

• Demonstrate
• Use
• Measure
• Perform
• Record

• Plan
• Write
• Walk
• Drink
• Follow

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Interventions

• Nurse manipulates focal and contextual
  stimuli--altering, increasing, decreasing,
  removing, or maintaining.
• Validate residual stimuli

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Evaluation

• Judging the effectiveness of the intervention in
  relation to the persons behavior.
• Use observation, measurement and interview
  methods.

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Evaluation

• Was client goal met
• NOT was nursing interventions done.
• May need to modify goal and/or interventions

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Goal Example

• The client will state causative factors and
  methods of preventing anginal attacks, in one
  week.
• Who, will do, what

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Evaluation Example

• In one week, the nurse will ask the client
  causative factors and methods of preventing
  anginal attacks and the client will list most the
  factors and methods.