slide 1 1 nursing process: foundation for practice npn 105 joyce smith rn, bsn

Nursing Process: Foundation for Practice

NPN 105

Joyce Smith RN, BSN

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

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

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

Assessment: Phase One of the Nursing Process

• Purpose: • Establish a baseline of information on the client

and develop a data base• Determine client’s normal function• Determine client’s risk for dysfunction• Determine presence or absence of dysfunction• Determine client’s strengths • Provide data for diagnostic phase

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 patient’s responses to health problems or potential health problems

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, patient’s behavior, diagnostic and

laboratory data, medical records

Approaches for Data Collection

• Gordon’s 11 Functional Health Patterns• Uses a series of questions which assist in

formulating a nursing diagnosis

• Problem focused assessment• Focuses on the patient’s problem and develop

you plan of care around the problem

Gordon’s 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

Types of Nursing Assessments

• Initial assessment

• Focused assessment

• Emergency assessment

• Time-lapsed assessment

Types of Data

• Subjective Data• Information perceived only the affected person• Cannot be perceived or verified by another

person• Examples: feeling nervous, nauseated, chilly

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 (>101 F),

moist skin, refusal to eat, vital signs

Characteristics of Data

• Complete

• Factual and accurate

• Relevant

Components of Data Collection

• Interview• Orientation phase• Working phase• Termination

Sources of Data

• Primary• patient

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

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

Interpreting Assessment Data

• Data interpretation and validation

• Data clustering

• Data documentation

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

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

Health Problem

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

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

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

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

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

Nursing Diagnosis

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

Nursing Diagnosis

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

NANDA

• NANDA: North American Nursing Diagnosis Association

• Established in 1973 to identify standards and classify health problems treated by nurses

NANDA

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

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

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

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

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 patient’s

responses change

Nursing Diagnosis

• Medical Diagnosis• Myocardial infarction

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

Differentiating Nursing Diagnosis versus Medical Diagnosis

Nursing Diagnosis Medical Diagnosis

- focus on unhealthy responses to health and illness.

- identify diseases

- describe problems treated by nurses within the scope of

independent nursing practice.

- describe problems for which the physician directs the primary

treatment .

- may change from day to day as the patient’s responses change

- remains the same for as long as the disease is present

Myocardial infarction (heart attack) is a medical diagnosis.

Examples of nursing diagnoses for a person with myocardial infarction include Fear, Altered Health Maintenance, Knowledge Deficit, Pain, and Altered Tissue Perfusion.

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

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

Nursing Diagnosis

• Types of diagnoses• Actual • Risk • Wellness

Types of Nursing Diagnoses

1- Actual Nursing Diagnoses

Describe a human response to a health problem that is being manifested. They are written as three- part statements: diagnostic label, related factors, defining characteristics.

Example – Acute pain related to surgical trauma and inflammation, as evidenced by grimacing and verbal reports of pain.

2- Risk nursing diagnosis

As defined by NANDA, ’’describes human responses to health conditions that may develop in a vulnerable individual, family, or community. It is supported by risk factors that contribute to increased vulnerability’’.

Risk nursing diagnoses are two – part statements because they do not include defining characteristics (diagnostic label, risk factors).

Example - Risk for infection related to surgery and immunosuppression.

Risk for aspiration related to reduced level of consciousness

Risk for Impaired Skin Integrity related to inability to turn self from side to side in bed.

3- Wellness nursing diagnosis

Is a diagnostic statement that describe the human response to levels of wellness in an individual, family, or community that have a potential for enhancement to a higher state (NANDA, 2005).

Wellness nursing diagnosis are one part statement includes diagnostic label.

Example

– Readiness for enhanced spiritual well being

- Readiness for Enhanced Self-Esteem.

Q- Which One is accurate nursing diagnosis?

1- Readiness for Enhanced Family Coping

2- Family coping potential due to desire for better health

What a Nursing Diagnosis is Not

• A nursing diagnosis is NOT a medical diagnosis

• A nursing diagnosis is NOT a statement of patient need

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

Nursing Planning

The third step of the nursing process includes the formulation of guidelines that establish the proposed course of nursing action in the resolution of nursing diagnoses and the development of the client’s plan of care.

The planning of nursing care occurs in three phases: initial, ongoing, and discharge. Each type of planning contributes to the coordination of the client’s comprehensive plan of care.

Initial planning involves development of beginning of care by the nurse who performs the admission assessment and gathers the comprehensive admission assessment data. Initial planning is important in addressing each prioritized problem, identifying appropriate client goals, and correlating nursing care to hasten resolution of the client’s problems.

Ongoing planning entails continuous updating of the client’s plan of care. Every nurse who cares for the client is involved in ongoing planning.

- Discharge planning involves critical anticipation and planning for the client’s needs after discharge.

The four critical elements of planning include:

• Establishing priorities

• Setting goals and developing expected outcomes (outcome identification)

• Planning nursing interventions (with collaboration and consultation as needed)

• Documenting

The client’s basic needs, safety, and desires, as well as anticipation of future diagnoses must be considered. One of the most common methods of selecting priorities is the consideration of Maslow’s hierarchy of needs, which requires that a life-threatening diagnosis be given more urgency than a non life threatening diagnosis.

The client must participate in the identification of priorities so that the nature of the problem, as well as the client’s values, are reflected in the selected course of action.

3rd Component of the Nursing Process- Implementing:

• The provider carries out the plan of care

During Implementing, the care provider:

• Carries Out The Plan Of Nursing Care or Setting your plans in motion and delegating responsibilities for each step.

• Continues Data Collection And Modifies The Plan Of Care As Needed

• Documents Care

ImplementingConsists of doing and documenting the activities that are the specific nursing actions needed to carry out the interventions or nursing orders. The first three nursing process phases-assessing, diagnosing, and planning-provide the basis for the nursing actions performed during the implementing step. In turn, the implementing phase, provide the actual nursing activities and client responses that are examined in the final phase, the evaluating phase.

Process of Implementing

• Reassessing the client

• Determining the nurse’s need for assistance

• Implementing the nursing interventions

• Supervising the delegated care

• Documenting nursing activities

Documenting Nursing Activities, the nurse complete the implementing phase by recording the interventions and client responses in the nursing process notes. The nurse may record routine or recurring activities such as mouth care in the client record at the end of shift, while some actions recorded in special worksheets according to agency policy. Immediate recording helps safeguard the client to prevent double actions.

During Evaluating, the care provider:• Measures The Clients Achievement Of

Desired Goals/Outcomes

• Identifies Factors That Contribute To The Client’s Success Or Failure

• Modifies The Plan Of Care, If Indicated

Process of Evaluating Client Responses

Collecting data related to the desired outcomes

Comparing the data with outcomes

Relating nursing activities to outcomes

Drawing conclusions about problem status

Continuing, modifying, or terminating the nursing care plan.

When determining whether a goal has been achieved, the nurse can draw one of the three possible conclusions: The goal was met, that is the client response is

the same as the desired outcomes.The goal was partially met, that is either a short

term goal was achieved but the long term was not, or the desired outcome was only partially attained.

The goal was not met.

• Thank you….

67