fundamentals of nursing ii nursing process dr naiema gaber
TRANSCRIPT
Fundamentals of Nursing II
NURSING PROCESS
DR NAIEMA GABER
Learning objectives
Define nursing process.
Detect the importance and purposes of NP
Identify the components of NP
Determine the characteristics of NP
Discuss the five steps of nursing process
Document following the standard criteria
PREPARED BY:MS/NAWAL GAMEL ABDULGHANI
Unit1:the Nursing process &critical thinking
Definition of Nursing Process
An organized sequence of problem-solving steps used to identify and to manage the health problems of clients.
A systemic, rational method of providing individualized nursing care.
Medical vs. Nursing Assessments:
Medical assessmentsFocus on the client’s disease.
Nursing assessmentsFocus on the client’s response to disease.
The Purposes of Nursing Process:
To Identify the client’s health status & actual or potential health care problems.
To establish nursing plan to meet the identified health needs.
Characteristics of nursing process
1.Open, flexible2. Humanistic and individualized.3.Cyclical and ongoing4.Client centered.5. Goal directed.6.Emphasizes feedback and validation
Why do we learn Nursing Process ?
To practice universal standards of care to meet client’s health needs
Practice and improve critical thinking skills
Benefits of Nursing Process
Provides a systematic method for providing care.
Increases care quality
Enhances nursing efficiency by standardizing nursing practice.
Facilitates documentation of care.
Provides a unity of language for the nursing profession.
Is economical.Emphasize the independent function of nurses.
Using the nursing processUsing critical thinking before taking actions
Being responsible for your actionsEntering the professional role on the practical areas.
Working at the level of peers
Being Accountable
Recognize health problems. Anticipate complications. Initiate actions to ensure appropriate
and timely treatment.
Begin to think CRITICALLY !!!!!!
What Are Your Responsibilities?
Evaluation
Implementation
Planning
Diagnosis
Assessment
DIGNOSISi.D problemFormulate
nursing diagnosis
Assessment:Assessment: the
first step in NP
it is the process of gathering, verifying and communicating data about a client”.
It describes client’s health problems or response for nursing therapy given.
It starts by wards give additional meaning to the diagnosis as altered, impaired, decreased, ineffective, acute, chronic….
Types of Nursing Assessments
Comprehensive initial Comprehensive initial ( provide baseline client data shortly after admission)
Focused- limited Focused- limited in the scope targets a particular need or health care concern.
Ongoing – systematic Ongoing – systematic monitoring & observation related to specific problem.
1-Data collection
2-Confirm the data is accurate
Assessment Steps
3-Organize the data
4-Interpret the data
1--Data Data collectioncollection::
Data collection : it is the process of gathering information about a client’s health status.
Type of data collection:Objective data(signs)
Observable and measurable data that can be seen, heard, or felt by someone other than the person experiencing them
E.g., elevated temperature, skin moisture, vomiting
Subjective data(symptoms) Information perceived only by the affected personE.g., pain experience, feeling dizzy, feeling anxious
2-Confirm that data is accurate
Sources of Data
4-OtherHealthcareprofessional
s
3-Patient record
2-Family and
significant others
1-Patient5-Nursing and
OtherHealthcareliterature
33--Organizing DataOrganizing Data
Assessment models:Assessment models:Wellness Models Maslow’s Hierarchy of NeedsBody Systems ModelNeman’s System model.
44 - -Validating DataValidating Data
Is the act of “double-checking” or verifying data to confirm that they are accurate.
How to differentiate the(cues) and (inferences)??
CuesCues = signs and = signs and symptomssymptoms
InferenceInference = = what you think,a judgment about the cues
Swollen finger
Misshapen
Reddened
Painful
Broken finger
DocumentinDocumenting Datag Data
Enter initial database into computer or record in ink on designated forms the same day patient is admitted.
Summarize objective and subjective data in concise, comprehensive, and easily retrievable manner.
Use correct grammar and standard medical abbreviations.
Whenever possible, use patient’s own words. Avoid non-specific terms, individual
interpretation or definition.
2- Nursing diagnosis2- Nursing diagnosis
DIAGNOSIS
National American Nursing National American Nursing Diagnosis Association-------Diagnosis Association-------NANDA
1973 First national First national conference of nursing diagnosis
1985 named NANDAnamed NANDA
1990 1990 ANA endorsed it as official diagnosis taxonom.…Is incorporated in ANA standards of practice
Meets every two years
Local chapters 148 diagnoses +16 Carpenito
1953 term first usedterm first used
Nursing Diagnosis
A clinical judgment about individual, family, or community responses to actual or potential health problems/ life processes.
A nursing diagnosis provides the basis for selection of nursing interventions to achieve outcomes for which the nurse is accountable.
Steps of Nursing DIAGNOSISSteps of Nursing DIAGNOSIS
Sort, cluster, analyze informationIdentify potential problems and strengths
Write statement of problem or strength
Example: Example: Risk of infection related Risk of infection related to compromised nutritionto compromised nutrition
Medical DiagnosisNursing diagnosis•Identifies conditions theMD is licensed &qualifiedto treat
•Identifies situations thenurse is licensed andqualified to treat
•Focuses on the illness,injury, or disease process
•Focuses on the client’sresponses to actual orpotential health problems
•Remains constant until acure is effected
•Doesn’t remain constant until a cure is effected
Types of Nursing Diagnoses
1-Actual nursing diagnosis – a problem exists.Composed of the problem statement, related factorsand signs & symptoms2- Risk nursing diagnosis – indicates the problemdoesn’t exist but has special risk factors3-Wellness nursing diagnosis – indicates the client’sdesire to attain a higher level of wellness in somearea of function.4-possible nursing diagnosis.5- syndrome nursing diagnosis
Components of the Nursing Diagnosis
A-Two-part StatementA-Two-part Statement1. Problem statement – describes the client’s
response to an actual or potential health problem (diagnostic label)
2. Etiology – cause of the problem The diagnostic label & etiology are linked
by the terminology Related to (R/T)Example:Ineffective breathing pattern R/T
neuromuscular impairment.
Development of the Nursing Diagnosis
Two-part Statement: Example:
1. Problem statement: Ineffective breathing pattern
2. Link: R/T (related to)
3. Etiology: neuromuscular impairment.
Components of the Nursing Diagnosiscont.
B- Three-part-statementB- Three-part-statement1. Problem statement – describes the
client’s response to an actual or potential health problem (diagnostic label)
2. Etiology – cause of the problem The diagnostic label & etiology are linked
bythe terminology Related to (R/T)3. Defining characteristics
Development of the Nursing Diagnosis
Three-part StatementExample:
1. Problem statement Ineffective breathing pattern
2. LinkR/T (related to) R/T (related to)
3. Etiology neuromuscular impairment.
4. Defining characteristics
(signs & symptoms)
as evidenced by spinal cord injury, poor chest expansion
Development of the Nursing Diagnosis
Two-part Statement = (Risk)Three-part Statement = (actual)
Decreased cardiac output,
related to alterations in rate, rhythm, electrical conduction,
Decreased cardiac output,
related to alterations in
rate, rhythm, electrical
conduction as evidenced
by diminished peripheral
pulses.
Activity intolerance related to
prolonged bed rest/immobility
Activity intolerance related to
prolonged bed rest/immobility as
evidenced by fatigue and
Weakness
ACTUAL DIAGNOSISAn actual diagnosis represents a state that has been clinically
validated by identifiable major defining characteristics. Consists of a label, related factors & defining characteristics.
Three Part Statement P E SP =
Problem ( Precise qualifier / modifiers) Altered High Risk Ineffective
Decreased Deficit Excess Dysfunctional
DisturbanceChronic Less than More than
Anticipatory
Diagnostic Label = Problem + modifier = Chronic Pain
Actual dx.
E = Related FactorsRelated factors are etiological or other contributing
factors that have influenced the health status change.
Etiology sometimes = Causes or factors of risk Chronic pain r/t Altered Tissue perfusion
………. secondary to DiabetesPathophysiologic Alteration in skin Integrity r/t ) caused by(Compromised immune system Inadequate circulationInadequate peripheral circulation
Treatment-relatedMedicationsDiagnostic studies Anxiety r/t )caused by( lack of knowledgeSurgery of how to dress his woundTreatments
SituationalEnvironmental Home Risk for Injury r/t unsteady gaitCommunityInstitutionPersonalLife experiencesRoles
Maturational Nutrition Imbalance : Less than Body Requirements r/t
Age related to inadequate sucking
Etiological Factors
Actual diagnosis.
S = Defining characteristicsS= signs / symptoms
Clinical cues--subjective and objective signs or symptoms that point to the nursing diagnosis
• Are separated into major and minor designations.• Major defined as critical indicators present 80-100 of the time.
•Minor are supporting and present 50-79%
Major defining characteristics must be present for
diagnosis to be valid
Actual diagnosis
P E
Diagnostic Label Related factorimpaired Skin Integrity related to prolonged immobility
SDefining characteristics
as evidenced by a 2 cm sacral lesion
A real problem exists !!!!!!!!A real problem exists !!!!!!!!
RISK DIAGNOSIS
Is a clinical judgment that an individual, family or community is more vulnerable to develop the problem than others in the same or similar situation. .
Two part statement.----- --P ) problem(
No defining characteristics
No signs or symptoms becauseNo problem yetNo problem yet
E ) related risk factor(
Risk nursing diagnosis
P EDiagnostic label Etiological risk factors
Risk for Injury related to lack of awareness of
hazards
Factors present a risk situation for a problem to occur
SYNDROME DIAGNOSIS
Comprise a cluster of actual or risk nursing diagnoses that
are predicted to be present because of a certain event or situation.Nursing Diagnoses Associated with
Disuse SyndromeRisk for ConstipationRisk for Altered Respiratory FunctionRisk for InfectionRisk for ThrombosisRisk for Activity IntoleranceRisk for InjuryRisk for Altered Thought Processes
Common Errors In Diagnostic Statements
1. Don’t use medical terms when writing a diagnosis
I‑ Self‑Care Deficit Hygiene r/t Stroke
C- Self-care Deficit: Hygiene r/t weakness secondary to Stroke
2. Don’t write a diagnosis for an unchangeable situation
I‑ Anxiety r/t impending death aeb stating” I am afraid to die”
C- Anxiety r/t fear of dying
Common errors
3. Use of procedure / treatment instead of a human response
I- Cauterization r/t urinary retention
C- Risk for Infection Transmission r/t device with contaminated drainage: urinary
4. Don’t write diagnoses that are too general
I- Constipation r/t nutritional intake aeb small hard stools
C- Constipation r/t dietary roughage and fluid intake
Common errors
5 .Don’t combine two problems at the same time
I- Pain and Fear r/t to upcoming abdominal
surgery C- Pain r/t tissue trauma secondary to abdominal
surgery aeb “ Pain ranked 4/5”
.
6. Don’t use judgmental/value laden language or make assumptions
I- Spiritual Distress r/t atheism aeb statement “ I don’t believe in God”
C- Spiritual Distress r/t to feelings of rejection aeb “ I don’t think God cares about me”
7. Don’t make statements that are legally inadvisable
I- Tissue Integrity Impaired r/t to infrequent turning aeb 3 cm diameter ankle ulcer
C- Tissue Integrity Impaired r/t immobility secondary to fracture
8. Both parts of a diagnostic statement are the sames
I- Self care deficit : feeding r/t feeding problem aeb unable to bring food to mouth
C- Self Care Deficit: feeding r/t neurological impairment of rt. hand aeb unable to bring food to mouth
Don’t use due to or caused
PLANNING
3- PLANNING3- PLANNING
PLANNING
*Definition:Planning is formulation of the nursing
actions in an organized, individualized and goal directed manner“
Should involve decision making and problem solving.
Should be SNART. (specific,measurable, attainable, realistic and time bound
Types of planning:
1.Initial2.Ongoing3.Discharge
Initial Planning
Developed by the nurse who performs the nursing history and physical assessment
Addresses each problem listed in the prioritized nursing diagnoses.
Identifies appropriate patient goals and related nursing care
Ongoing PlanningCarried out by any nurse who
interacts with patientKeeps the plan up to dateStates nursing diagnoses more clearlyDevelops new diagnoses,Makes outcomes more realistic and
develops new outcomes as neededIdentifies nursing interventions to
accomplish patient goals
Discharge Planning
Carried out by the nurse who worked most closely with patient.
Uses teaching and counseling skills effectively to ensure home-care behaviors are performed competency.
PLANNING PHASES
An informal nursing care plan : is a strategy for action that exists in the nurse’s mind.
For example : the nurse may think “Mrs.Phan is
very tired. I will need to reinforce her teachingafter she is rested.” A formal nursing care plan :is a written or
computerized guide that organize in formation about the client care.
Planning Steps
Prioritizing the nursing diagnoses Identifying long & short term goals
Developing nursing interventionsRecording the nursing care plan in the client’s medical record
Prioritizing Nursing Diagnoses
Five system variables:Five system variables: Physiological Psychological Socio-cultural Developmental Spiritual
Maslow hierarchy + severity of problem + patient input
Review question: Which of the following problems would you treat first ? Severe breathing Diarrhea Itching
Planning steps cont.
2. Establishment of ( goals) OUTCOME and OUTCOME CRITERIA ( What will the patient be able to do? and in what time frame ? = OUTCOME And how will I know it was successful? = OUTCOME CRITERIA
Diagnosis --------------- Ineffective Airway Clearance
r/t Etiology -----------------------Weakness secondary to Stroke EX: Maj. Defining Characteristic (Symptoms)- non productive Ineffective cough Broad Outcome ----------------Effective Airway by 10/4/04 Time frame
aeb Outcome Criteria--------- (symptoms) productive cough
Planning cont.
Purpose of Outcomes and Criteria
Indicators of achievement was the airway effective?
Measuring sticks Did problem ( cough) stay the same,get or , disappear?
Direct Interventions Interventions will be directed toward facilitating a productive
cough
Motivating factors Goal motivates, something to aim for
Diagnosis Ineffective Breathing Patterns
Related to r/t
))EE(( Immobility and chest pain
Secondary to abdominal surgery
As evidenced by
))PP((
))SS(( in respiratory rate from 12 to 22
pulse rate 88 to 104 and irregular
Outcome /goal Effective Breathing
Date: by 10/22/04 respiratory rate to 12 to 16
pulse rate to 80 and regular
Establishing client goal/desired outcomes
Goal(broad):improved nutritional status.
Desired outcome(specificDesired outcome(specific): gain 5 k by April.Purpose of desired goal/outcomes:1- provide direction for planning nursing
intervention.2-serve as criteria for evaluation client progress.3- enable the client and nurse to determine
when the problem has been resolved.4-Help motivate the client and nurse by
providing a sense of achievement.
Long-Term vs. Short-Term Outcomes
Long-term Long-term — requires a longer period to be achieved and may be used as discharge goals.
Short-termShort-term — may be accomplished in a specified period of time
Components of Outcomes
Subject: who is the person expected to achieve the outcome?
Verb: what actions must the person take to achieve the outcome?
Condition: under what circumstances is the person to perform the actions?
Performance criteria: how well is the person to perform the actions?
Target time: by when is the person expected to be able to perform the actions?
Common Errors in Writing Patient Outcomes
Expressing patient outcome as nursing intervention.
Using verbs that are not observable or measurable.
Including more than one patient behavior or manifestation in short-term outcomes.
Writing vague outcomes
Nursing Care Plan
A written guide, organizing client data into a formal statements of strategies to assist the client have optimal health
Nursing care plan design
Date / timeNursing diagnosis
Client’s goal
Nursing intervention
Outcome criteria and evaluation
13-3- 1429 13-3- 1429 A.HA.H
@10:30@10:30
Ineffective Ineffective airway airway clearance R/T clearance R/T accumulated accumulated secretion secretion aeb. aeb. Cyanosis & Cyanosis & abnormal abnormal breathing breathing sound.sound.
Client can Client can be expel be expel the the secreationsecreation
1-Decrease 1-Decrease oxygen oxygen consumption by consumption by *rest*rest
*setting or semi *setting or semi fowler’s fowler’s positionposition
2-increase fluid 2-increase fluid intakeintake
3- B&C 3- B&C exercises .exercises .
Has no secretion Has no secretion aeb no cyanosis & aeb no cyanosis & normal breathing normal breathing sound.sound.
Documenting the Plan of Care
To ensure continuity of care, the plan must be written and shared with all health care personnel caring for the client.
Consists of:1. Prioritized nursing diagnostic statements.2. Outcomes.3. Interventions.
Types of Institutional Plans of Care
Kardex plans of careComputerized plans of careCase management plans of care
Clinical pathways, care maps
Student plans of careConcept map care plan
Guidelines for writing nursing care plans
Date and sign the plan Use category heading. Use standardized /approved medical or English symbols
and key word. Be specific. Refer to procedure book or other source information. Tailor the plan to the unique characteristics of the client by
ensuring that the client choice. Ensure that the nursing plan incorporates preventive and
health maintenance aspect as well as restorative one. Ensure that plan contain intervention for ongoing
assessment of the client Include collaborative and coordination activities in the
plan Include plan for the client’s discharge and home care need.
4- IMPLEMENTAION4- IMPLEMENTAION
IMPLEMENTAION
Interventions or implementation
Categoriesa. Dependent‑implementing M.D. orders-- give Vioxx
medication per order
b. Interdependent‑in cooperation with other health team members----follow P.T. plan for exercise
c. Independent‑ performed without M.D. order----turn patient
q.2. hrs
* 4th steps in the nursing process.
"Specific nursing activities /actions that a nurse must perform to prevent complications , provide comfort(physical, psychological and spiritual) and promote, maintain and restore
health."
Process of implementation or intrvetion
Reassessing the client.Determining the nurse’s need for assistance.Implementing the nursing interventions.Supervising the delegated care.Documenting nursing activities.
interventions
Diagnosis
Altered Skin Integrity
Broad Outcome
Pt. will experience wound healing
Etiology
R/t immobilitysecondary to fracture
INTERVENTIONS
Defining Characteristics
3cm diameterankle wound
Outcome Criteria
diameter to 2cm
interventionsCharacteristics a. consistentb. scientific basis c. law, professional standards, agency accrediting bodies
Intervention Rationale Teach client to rotate Repeated use of the same insulin injection sites site may cause fibrosis,
and decreased insulin absorption
interventionsINDIVIDUALIZED Donna‑‑17 year old, immobilized by skeletal traction for a FX. Lt. leg due to a motorcycle accident
Betsy‑‑84 year old nursing home resident, slightly dehydrated , confused and confined to bed from a hip fracture
Dx Risk for skin breakdown r/t immobility secondary to ...........................
DonnaDonna BetsyBetsyBed trapeze specialized, air mattress
Position cue to turn turn q. 2 hours
Nutrition protein, zinc etc.tube feeding, fluids
Criteria for choosing nursing intervention
The plan must be:1. Safe and appropriate for the individual's age,
health, and condition.2. Congruent with client’s values, beliefs, and
culture.3. Congruent with other therapies.4. Based on nursing knowledge and experiences.5. Within establish standards of care as
determined by state laws, professional association and the policies of the institution.
interventions
Guidelines for Writinga. date and signb. list specific activities
Incorrect Correct Teach colostomy care 1. demonstrate steps us
applying colostomy pouch
2. identify equipment needed with colostomy care
3. provide printed instructions and discuss content
4. Have client do return demonstration
EVALUATION
Evaluation
5th step in the nursing process.Importance of the evaluation:Determines if client goals are met or not.Determines of continued or cessation of
plan.Determining outcome achievement.Identifying the variables affecting outcome achievement.Deciding whether to continue, modify, or terminate the plan
Determining Outcome Achievement
Must be aware of outcomes set for the client. Must be sure patient is ready for evaluation. Is patient able to meet outcome criteria? Is it: Completely met? Partially met? Not met at all? Record in progress in notes. Update care plan.
EvaluationEvaluation
Process to determine how well the plan worked:
1 .Gathering data2 .Compare data with outcome criteria
3 .Make judgmenta. outcome achievedb. outcome not achievedc. partially achieved
If not----‑check interventions
human responsesoutcomes
related factors
Identifying Variable Affecting Outcome Achievement
Maintain individuality of care plan: 1. Is the plan realistic for the client? 2. Is the plan appropriate at the time for
this particular client? 3. Were changes made in the plan when
needed? 4. How does the client feel about the plan?
Predict, Prevent, and Manage
Focus on early intervention Based on research Predict and anticipate problems Look for risk factors
The interactions between and among health professionals, clients, their families, and health care organizations
The administration of tests, procedures, treatments, and client education; and
The results of, or client’s response to, diagnostic tests and interventions
Documentation Defined
Communication with other healthcare professionals
Record of diagnostic and therapeutic ordersCare planningQuality of care reviewingResearchDecision analysisEducationLegal and historical documentationReimbursement
Effective Documentation
Follow the nursing process Date & time, Observation, Intervention & Evaluation Use of healthcare facility approved
vocabulary and abbreviations. Signature Accurate
Methods of Documentation
Narrative charting: describes the client’sstatus, interventions and treatments in astory form. Source-oriented charting: narrative charting
by individual disciplines on separate records. Problem-oriented charting: problem- oriented medical record (POMR)
Methods of Documentationcont.
PIE charting: problem, intervention and evaluationFOCUS charting: uses a columnar format
tochart data, action and response (DAR)Computerized documentation: electronic medical record
Formats for Nursing Documentation
Initial nursing assessmentKardex and patient care summaryPlan of nursing careCritical collaborative pathwaysProgress notesFlow sheetsDischarge and transfer summaryHome healthcare documentationLong term care documentation
Types of Flow Sheets
Graphic record24-hour fluid balance recordMedication record24-hour patient care records and acuity
charting forms