Unit 2

Nursing ProcessReporting

Client Teaching

Key WordsKey WordsActual nursing diagnosisAnalysisAssessmentAssessment modelAssumptionsBiasComprehensive assessment

Critical pathwaysData clusteringDefining characteristicsDelegationDependent nursing interventionsDischarge planningEtiologyEvaluation

Assessment

Diagnosis

Planning & Outcome Identification

Evaluation

Implementation

NursingNursing

ProcessProcess

North American Nursing Diagnosis Association (NANDA)

NANDA-International is recognized as the leader in development and classification of nursing diagnoses

[http://www.nanda.org/html/about.html]

Nursing Process

AssessmentFirst step in the nursing process

Involves several stepsData collectionConfirm the data is accurateOrganize the dataInterpret the data

Nursing Process - Assessment

Three types:

1. Comprehensive – provides baseline client data2. Focused – limited in scope, targets a particular

need or health care concern3. Ongoing – systematic monitoring & observation

related to specific problems

Nursing Process - Assessment

Two methods of Assessment1. Subjective – client’s perspective

Examples: Report of fainting, complaint of dizziness, nausea, headache

2. Objective – observable & measurableExamples: Vomiting, unsteady gait, pale skin, rapid breathing

Nursing Process: Data Collection

Data collection occurs in 3 phases:

1. Before you see the client2. When you see the client3. After you see the client

Nursing ProcessOrganizing the Data

Assessment models

Maslow’s Hierarchy of Needs

Body Systems Model

Human response model

Neuman's System’s Model

Identification of Patterns

Distinguish between relevant and irrelevant data

Determine whether and when there are gaps in the data and

Identify patterns of cause & effect

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.

Focuses on the client’s responses to actual or potential health problems

Focuses on the illness, injury, or disease process

Changes as the client's response and/or health changes

Remains constant until a cure is effected

Nursing DiagnosisMedical Diagnosis

Identifies situations the nurse is licensed and qualified to treat

Identifies conditions the MD is licensed & qualified to treat

Strep ThroatBody Temperature, Risk for Altered

AmputationBody Image Disturbance

Cerebrovascular accident (CVA)

Activity Intolerance

AppendectomyPain

Medical DiagnosisNursing Diagnosis

Chronic obstructive pulmonary disease

Breathing Pattern, Ineffective

Development of the Nursing Diagnosis

Two-part Statement1. Problem statement – describes the client’s

response to an actual or potential health problem (diagnostic label)

2. Etiology – cause of the problem3. 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 Statement1. Problem statement 2. Link3. Etiology neuromuscular impairment.

Ineffective breathing pattern

R/T (related to)

Example:

Nursing ProcessThree-part-statement

1. Problem statement – describes the client’s response to an actual or potential health problem (diagnostic label)

2. Etiology – cause of the problem3. The diagnostic label & etiology are linked by

the terminology Related to (R/T)4. Defining characteristics

Development of the Nursing Diagnosis

Three-part Statement1. Problem statement 2. Link3. Etiology 4. Defining

characteristics (signs & symptoms)

neuromuscular impairment.

Ineffective breathing patternR/T (related to)

Example:

as evidenced by C-6 spinal cord injury, poor chest expansion

Nursing Diagnosis

Decreased cardiac output, related to alterations in rate, rhythm, electrical conduction, as evidenced by diminished peripheral pulses.

Decreased cardiac output, related to alterations in rate, rhythm, electrical conduction

Activity intolerance related to prolonged bed rest/immobility as evidenced by fatigue and weakness

Activity intolerance related to prolonged bed rest/immobility

Three-Part StatementTwo-Part Statement

Types of Nursing Diagnoses

Actual nursing diagnosis – a problem exists. Composed of the problem statement, related factors and signs & symptoms

Risk nursing diagnosis – indicates the problem doesn’t exist but has special risk factors

Wellness nursing diagnosis – indicates the client’s desire to attain a higher level of wellness in some area of function.

Planning & Outcome Identification

Planning is formulation of the actual nursing actions

Three types of planning:Initial planning – developing the preliminary plan of careOngoing planning – updates of care based on reassessmentDischarge planning – anticipation & planning of client needs after discharge

Planning PhasePrioritizing the nursing diagnosesIdentifying long & short term goalsDeveloping nursing interventionsRecording the nursing care plan in the client’s medical record

Prioritizing Nursing Diagnoses

Maslow’s hierarchy of needs

Physiological Needs

Safety & Security Needs

Love & Belonging Needs

Self-Esteem Needs

Self-

Actualization

Needs

Physiological Needs

Prioritizing Nursing Diagnoses

Betty Neuman's System Theory

Five system variables:

PhysiologicalPsychologicalSocioculturalDevelopmentalSpiritual

Protected by the lines of defense & resistance to keep the system stable

Basic structure &

Energy Resources

Identification of OutcomesProvides guidelines for individualized nursing interventions

Establishes goals & evaluation criteria to measure effectiveness of the nursing care plan

Short-term goals – 1 weekLong-term goals – weeks to months

Goals

Verbalizes comfortVerbalizes the presence of pain

Identifies factors that influence the pain experience

Long termShort term

Nursing Interventions

An action performed by the nurse that helps the client achieve the results specified by the goals and expected outcomes.

Refer directly to the nursing diagnoses.

Nursing InterventionsIndependent nursing interventions – nursing actions that are initiated by the nurse.

Interdependent nursing interventions –actions that are implemented by the nurse in conjunction with other health care professionals

Dependant nursing interventions – requires a physician order

InterventionsSpecific order – written in the medical record

or nursing care plan by a physician or nurse

Standing order – a standardized intervention

Protocol - a series of standing orders or procedures that should be followed under certain specific conditions.

Nursing Care Plan

A written guide, organizing client data into a formal statements of strategies to assist the client to optimal health

Implementation4th step in the nursing process

Involves putting the nursing care plan into action.

Nursing activities (interventions) to meet the goals set with the client begin.

Documentation Data to be recorded:

Client’s condition prior to the interventionIntervention performedClient’s response to the interventionClient outcomes

ReportingActivities completed & those yet to be completed

Current problems

Abnormal findings or changes in the client assessmentTreatment results

Diagnostic tests completed with results (if available) or tests scheduled

Evaluation5th step in the nursing process

Determines if client goals are met or not

Determination of continued or cessation of plan

Critical ThinkingThe rational examination of ideas, inferences, assumptions, principles, arguments, conclusions, issues, statements, beliefs and actions.

Making a decision is the end point of using critical thinking.

Decision MakingRecognizing and defining a problem

Gathering relevant information

Generating possible conclusions

Testing possible conclusions

Evaluating Conclusions

Decision Making & The Nursing Process

Recognizing and defining a problemGathering relevant informationGenerating possible conclusionsTesting possible conclusionsEvaluating Conclusions

AssessmentAssessmentDiagnosisPlanning & outcome identificationImplementationEvaluation

Class ActivityUse the steps in nursing process to

Describe how one would decide to purchase a new carDescribe how one would select a restaurantDescribe how one would plan a weddingDescribe how one would select a petDescribe how one would select a health insuranceDescribe how one would select a career

Documentation

Chapter 10

Documentation Defined

The interactions between and among health professionals, clients, their families, and health care organizationsThe administration of tests, procedures, treatments, and client education; andThe results of, or client’s response to, diagnostic tests and interventions (Eggland & Heinemann, 1994)

Effective Documentation

Follow the nursing processEntries are made chronologically

Date & timeObservationInterventionEvaluation

Use of healthcare facility approved vocabulary and abbreviations.SignatureAccurate

Methods of Documentation

Narrative charting: describes the client’s status, interventions and treatments in a story form.

Source-oriented charting: narrative charting by individual disciplines on separate records.

Methods of DocumentationProblem-oriented charting: problem-oriented medical record (POMR)

SOAP charting: Subjective, Objective, Assessment, Plan

SOAPIE/SOAPIER charting:Subjective, Objective, Assessment, Plan, Implementation, Evaluation/Revision

PIE charting: problem, intervention and evaluation

FOCUS charting: uses a columnar format to chart data, action and response (DAR)

Charting by Exception (CBE): documentation of deviations for the baseline or established norms

Computerized documentation: electronic medical record

Methods of Documentation

Forms

Kardex – a summary worksheet reference of basic client care information that traditionally is not part of the medical record.

Flowsheets – columnar format makes documenting dates and times of particular assessments easier to track.

Review of Medical Record Forms

After reviewing the different healthcare organization’s document, discuss the method of documentation for each (flow chart, computerized, FOCUS charting, etc.)

Reporting

Based on the nursing process a verbal report of the client’s health status, needs, treatments, outcomes and responses is communicated to other members of the health care team.

Client TeachingTeaching-learning process is a planned interaction that supports behavioral change that is not a result of maturation or coincidence.

Formal teaching – planned and goal directed

Informal teaching – initiated at any time a learning need is identified

Client Teaching

Learning – a process whereby an individual integrates information that results in a behavioral change.

Learning DomainsCognitive – intellectual understanding (learning the technique for giving a clean catch urine specimen)

Affective – related to attitudes, beliefs and emotions (recognizing the value of diet)

Psychomotor – motor skills (learning to perform blood sugar testing)

Adult Leaner: Basic Assumptions

Personality develops from dependence to independence

Learning readiness is affected by developmental stage and sociocultural factors

Previous learning experiences can be used as a foundation

Opportunities to use the new knowledge reinforces the new knowledge

Learning Principles

RelevanceMotivationReadinessMaturation

ReinforcementParticipationOrganizationRepetition

Learning Styles

Visual learner –processing information sight

Auditory learner –processing listening

Kinesthetic learner-experiencing the information through touching, feeling & doing

Barriers to the Teaching-Learning Process

Physiological

Psychological

Environmental

Sociocultural

Teaching MethodsDiscussions

Formal lecture

Question and answer sessions

Role play

Games/computer activities

Class Activity

Assignment: Break into 3 groups (Children, adolescents, older adults). Present to the class the:

MOST significant factors that influence learning for your assigned developmental stageTypes of learning needsStrategies to enhance learning at each stage

VITAL SIGNS

Temperature

Pulse

Respirations

Blood Pressure

The “Signs of Life”

Temperature [T]

Routes:OralRectalAxillarySkinTympanic membrane

Temperature [T] –ReadingsVariationsNormal ReadingRoute

37ºC or 98.6ºFOral

37.5ºC or 99.6ºFRectal

>38ºC or 100.4ºF Pyrexia

37ºC or 98.6ºFTympanic

<36ºC or 96.8ºF Hypothermia

36.5ºC or 97.6ºF

Axillary

Pulse [P]

Terms to knowPulse rateBradycardiaTachycardiaPulse rhythmPulse amplitudePulse deficit

Pulse [P]

TemporalCarotidApical Femoral Dorsalis pedis

BrachialUlnarRadialPoplitealPosterior Tibial

Pulse Points

Pulse - Readings

<60 Bradycardia

60-100 beats/minute

[P]

>100 Tachycardia

VariationsNormal Reading

Vital Sign

Respirations [R]

Terms to Know:EupneaBradypneaHypoventilationTachypneaHyperventilationDyspnea

Respirations - Readings

<60 Bradycardia

16-20 respirations/

minute

[R]

>100 Tachycardia

VariationsNormal Reading

Vital Sign

Blood Pressure (B/P)Measures the force exerted by the blood against the walls of the blood vessels. Dependent upon the Cardiac output –volume of blood per minute pumped by the left ventricle; Peripheral Resistance – pressure within a vessel that resists the flow of blood.

Blood Pressure - Terms

Arterial pressureDiastolic blood pressureSystolic blood pressurePulse pressureOrthostatic hypotension

Blood Pressure - Readings

<90/60 Hypotension

90/60 –140/90

[B/P or BP]

>140/90 Hypertension

VariationsNormal Reading

Vital Sign

Unit 3: Health Promotions

Chapter 15: Wellness Concepts

Key Terms

HealthWellness

Health Promotion

Class discussion:What is a eudaemonistic approach to health?What is the Healthy People 2000? 2010?What are the leading cases of death associated with lifestyle factors that can be controlled?

The EndNext class topics for review:Prevention as InterventionBasic NutritionDiet TherapyNutritional SupportExcretion/EliminationNursing Process & Client NutritionRest & Sleep & the Nursing ProcessAssignment: Keypoints to teaching body mechanics due Sept. 16, 2003