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The Nursing Process Craven Unit 2 – Ch. 10-14 Cathi Collings MSN & Peggy Korman CNM

The Nursing Process Craven Unit 2 – Ch. 10-14 Cathi Collings MSN & Peggy Korman CNM. 11/27/2014. 1. Chapter 11: Nursing Assessment. Nursing Process. Nursing Assessment Activities. Collection of data Validation of data Organization of data. Preparing for Assessment. Types of assessment

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The Nursing Process Craven Unit 2 – Ch. 10-14 Cathi Collings MSN & Peggy Korman CNM

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  1. The Nursing ProcessCraven Unit 2 – Ch. 10-14Cathi Collings MSN & Peggy Korman CNM 11/27/2014 1 NRS320 Collings2012

  2. Chapter 11: Nursing Assessment NRS320 Collings2012

  3. Nursing Process NRS320 Collings2012

  4. Nursing Assessment Activities • Collection of data • Validation of data • Organization of data NRS320 Collings2012

  5. Preparing for Assessment • Types of assessment • Admission assessment • Focused assessment • Time-lapse assessment • Emergency assessment NRS320 Collings2012

  6. NRS320 Collings2012

  7. NCLEX Question ????? Which of the following is done to evaluate any changes in the patient’s functional health from baseline? a. Focus assessment b. Time-lapse assessment c. Emergency assessment d. Initial assessment NRS320 Collings2012

  8. Preparing for Assessment • Setting and environment • Quiet, private setting • Restricted or secluded • Minimal distractions NRS320 Collings2012

  9. Assessment Skills • Observation • Vision • Smell • Hearing • Touch • Interviewing • Preparatory phase • Introductory phase • Maintenance phase • Concluding phase NRS320 Collings2012

  10. Assessment During an Interview NRS320 Collings2012

  11. Assessment Skills • Physical examination techniques • Inspection • Palpation • Percussion • Auscultation NRS320 Collings2012

  12. Data Collection • Types of data • Subjective • Objective • Sources of data • Primary • Secondary NRS320 Collings2012

  13. Question Tell whether the following statement is true or false: Bowel sound is an example of objective data. NRS320 Collings2012

  14. Validate Data • Comparing cues to normal function • Referring to textbooks, journals, and research reports • Checking consistency for cues • Clarifying the patient’s statements • Seeking consensus with colleagues about inferences NRS320 Collings2012

  15. Organize Data • Functional health approach • Head-to-toe model • Body systems model NRS320 Collings2012

  16. Case Study • P.J. is an 81 year old widowed male. • c/o sore right foot, trouble walking for “few years”, worse in the last month. • Hx: Type 2 DM, HTN, diabetic neuropathy, former smoker • 3 children, all live out of state. • c/o recent poor appetite. • 2 dime sized ulcers on right foot, yellow, black toes. + sensation to bilateral feet. NRS320 Collings2012

  17. Assessment • Denies severe pain, 2/10 at toes. • BP 180/92, HR 88 and regular, RR 20 and unlabored, T 36.7 • S1, S2. • DP/PT pulse 1+ left, not able to doppler or palpate on right. NRS320 Collings2012

  18. Assessment • Bilateral feet cool, R>L • Cap refill R > 3 sec., L = 3 sec. • Scattered expiratory wheezes RUL, RA, SpO2 = 95%. • AAOX3, pleasant, conversant. • c/o hunger, “haven’t eaten yet today” (time is now 6:10pm) • Denies bowel/bladder problems. NRS320 Collings2012

  19. NURSING PROCESS DEFINITION THE ACT OF REVIEWING THE PATIENT’SSITUATION IN ORDER TO OBTAININFORMATION OF PAST HISTORY, PRESENT STATUS AND TO IDENTIFYPATIENT CURRENT PROBLEMS AND NEEDS 11/27/2014 19 NRS320 Collings2012

  20. NURSING PROCESS(ADPIE) ASSESSMENT NURSING DIAGNOSIS PLANNING IMPLEMENTATION OF NURSING ACTIONS EVALUATION 11/27/2014 20 NRS320 Collings2012

  21. 11/27/2014 21 NRS320 Collings2012

  22. ASSESSMENT 11/27/2014 11/27/2014 22 22 ASSESSMENT IS THE DELIBERATE AND SYSTEMATIC COLLECTION OF DATA TO DETERMINE A CLIENT’S CURRENT AND PAST HEALTH STATUS AND FUNCTIONAL STATUS AND TO DETERMINE THE CLIENTS PRESENT AND PAST COPING PATTERNS (Carpenito-Moyet, 2005) NRS320 Collings2012

  23. DATA COLLECTION 11/27/2014 11/27/2014 23 23 • SUBJECTIVE DATA • “THE PATIENT STATES” • “I feel …” • OBJECTIVE DATA • MEASURABLE DATA • TEMPERATURE • PULSE • RESPIRATIONS • What you see NRS320 Collings2012

  24. ASSESSMENT DATA WHERE DOES THE NURSE OBTAIN ALL OF THE INFORMATION NEEDED TO DEVELOP A CARE PLAN FOR THE PATIENT? PATIENT FAMILY INFORMATION SYSTEMS (PT. CHART) REPORT (NURSE TO NURSE) Physical Assessment 11/27/2014 24 NRS320 Collings2012

  25. What next? • Organize data - by system, problem, etc. • Identify Subjective & Objective data • Identify abnormal findings, links between information • E.g. c/o pain, hx of injury, current condition of wound, treatments used, pain scale rating • Nursing student, mother of 2 toddlers, PT work all fit in “roles” or ‘stressors’ w/ coping strategies, statements [“I am too busy to be sick”] NRS320 Collings2012

  26. ASSESSMENT DATA SUBJECTIVE Nurses report (second hand assessment information) Patient statements “In quotes” Family statements “In quotes” OBJECTIVE X-Ray shows ……. Lab results are …… What you see History from chart 11/27/2014 26 NRS320 Collings2012

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  28. NURSING DIAGNOSIS 11/27/2014 11/27/2014 28 28 • NURSING DIAGNOSIS CLASSIFIES HEALTH PROBLEMS WITHIN THE DOMAIN OF NURSING • DOMAIN • A REALM OR RANGE OF PERSONAL KNOWLEDGE AND RESPONSIBILITY NRS320 Collings2012

  29. NURSING DIAGNOSIS • A NURSING DIAGNOSIS IS A CLINICAL JUDGMENT ABOUT INDIVIDUALS, FAMILIES, OR COMMUNITIES AND THEIR RESPONSE TO ACTUAL AND/OR POTENTIAL HEALTH PROBLEMS OR LIFE PROCESSES • (NANDA International, 2007) NRS320 Collings2012

  30. Nursing Diagnosis • Provides the basis for selecting nursing interventions to achieve outcomes for which the nurse is accountable • Both a label for the description and the action of describing the patient’s problems NRS320 Collings2012

  31. Purpose of the Nursing Diagnosis • Purpose: ID problems, synthesize info from assessment by: • Analyzing data • ID patient strengths • ID normal [baseline] functional level and • Indicators of actual or potential dysfunction Formulate a diagnostic statement NRS320 Collings2012

  32. Your judgment • The Nursing Diagnosis is where you share your decisions about what the patient’s PRIORITY Problems are; what are the causes [Etiology- R/T]; and what are the Symptoms [AEB] • When you begin, use plain English • Then find the NANDA diagnosis and language NRS320 Collings2012

  33. How to Choose a Nsg. Dx • Identify patterns [in data] • Validate the diagnosis • Formulate the statement using nursing language, within domain of nursing NRS320 Collings2012

  34. Nursing Diagnosis • Language provides means of communication between nurses • Taxonomy: classification system [NANDA] • Problem, etiology • Leads naturally to planning, goal setting and evaluation NRS320 Collings2012

  35. The Rules • N.D. is different than medical diagnosis • Medical DX describes disease/pathology • Nursing DX describes patient response • Actual, risk, or wellness • Areas that nurses treat independently • Collaborative Problems: M.D. and RN involved – not in independent nursing • RN can ID problem, communicate, Treat w/ M.D NRS320 Collings2012

  36. Sample data collection • HR 80 B/P 140/78, sPO2 95% on RA, temp 103F [oral] • Pt c/o dizziness • Skin is intact, flushed, warm/hot, dry to touch • Pt reports he was working outside, mowing lawn for 3 hours; “had a couple of beers” • Outside temp 97, humidity 17% • Pt is 22 year old male • Caucasian, appears stated age, Ht/Wt//BMI WNL NRS320 Collings2012

  37. Example Data Set Cont. • Slept well last nt; ate usual food in a.m.; none since 8 a.m. Hx of Rt rotator cuff repair last year, immunizations up to date; describes self as ‘healthy’. No previous similar problems NRS320 Collings2012

  38. Example – Nsg. Dx • Pt with temp 103 F, dry, flushed skin, c/o dizziness, tachycardia • Open to interpretation [judgment] • Fever? Infection? Something else…. • “Fever” doesn’t tell us much • Interventions? Antipyretic? Antibiotics? • “Hyperthermia r/t environmental stressors and overexertion AEB dry, flushed skin, temp 103F and “dizziness” tells us what is going on and what we think caused the problem… NRS320 Collings2012

  39. N.D. • …. And leads us to goals and interventions Hyperthermia r/t environmental stressors and overexertion AEB dry, flushed skin, temp 103F and “dizziness” Environment and overexertion are things to educate pt about, control if possible NRS320 Collings2012

  40. N.D. and goals • R/T …overexertion AEB dry, flushed skin, temp 103F and “dizziness” • Clues toward goals and interventions • Pt will.. have temp WNL, …report absence of dizzy feeling, ..demonstrate understanding of risks of overexertion in heat.. increase fluid intake at work [by …] NRS320 Collings2012

  41. N.D. and Interventions • Etiology [R/T] leads us to appropriate interventions • NO antipyretics, antibiotics – wrong etiology for this ‘fever’ • Hydrate, change environment, cool pt, educate re: risks and need for H2O NRS320 Collings2012

  42. Nsg. Dx resources • Care plan Book • NANDA List [Craven p 209-210] Start with plain English THEN find NANDA DX With use, language will come more easily • PRACTICE! NRS320 Collings2012

  43. Sample ASSESSMENT DATA 2 SUBJECTIVE Family states that pt. developed increasing confusion prior to falling Family states that pt. complained of severe headache Family states that patient continues to be in pain. Pt c/o pain; points to face = >6/10 or ‘severe’ pain Pt is 88 y.o male OBJECTIVE VITAL SIGNS Bp 182/90, P-110 irreg. R-22, T-99.0, Pulse Ox. 93% Pain 8/10 Blood Sugar 113 HEAD TO TOE ASSESSMENT Neuro A & O X1 [person] VS as noted Heart sounds clear -rhythm irregular BS clear + Bowel sounds x4 0 edema Rt. Extremities flaccid Rt. Leg externally rotated 11/27/2014 43 NRS320 Collings2012

  44. Significant ASSESSMENT DATA SUBJECTIVE Family states that pt. developed increasing confusion prior to falling Family states that pt. complained of severe headache Family states that patient continues to be in pain. Pt c/o pain; points to face = >6/10 or ‘severe’ pain Pt is 88 yo male OBJECTIVE VITAL SIGNS Bp 182/90, P-110 irreg. R-22, T-99.0, Pulse Ox. 93% Pain 8/10 Blood Sugar 113 HEAD TO TOE ASSESSMENT NeuroA & O X1 [person] VS as noted Heart sounds clear -rhythmirregular BS clear + Bowel sounds x4 0 edema Rt. Extremities flaccid Rt. Leg externally rotated 11/27/2014 44 NRS320 Collings2012

  45. Additional Findings from chart FRACTURED Rt. HIP [x-ray] CONFUSION HYPERTENSION X 15 years INSULIN DEPENDENT DIABETES [25 yrs] HISTORY OF FALLS [ 3 last year] IRREGULAR HEART BEAT [a fib] 11/27/2014 45 NRS320 Collings2012

  46. Priorities • ABC’s • Safety • Pain • Pretty universal priorities – apply to most all situations • Actual Diagnoses before Risk Dx NRS320 Collings2012

  47. POTENITIAL NURSING DIAGNOSES SAFETY [Risk for injury] R/T confusion, history of falls, impaired mobility SKIN INTEGRITY [risk for or actual impaired] R/T Pressure/ischemia 2* to immobility, delicate skin /age, tissue trauma PAIN [acute] R/T Tissue damage, swelling 2* to FRACTURED HIP 11/27/2014 47 NRS320 Collings2012

  48. Other Possible N.DX • Risk for impaired tissue/cerebral perfusion R/T irregular heartbeat [potential clots] • Risk for powerlessness R/T dependent status after injury • Risk for delayed surgical recovery R/T altered immune and healing response 2* to IDDM, age NRS320 Collings2012

  49. BUILDING A NURSING DIAGNOSIS 1. PROBLEM 2. ETIOLOGY 3. SYMPTOMS 11/27/2014 49 NRS320 Collings2012

  50. PES Diagnosis [for actual problems] • Acute Pain R/T tissue trauma AEB c/o pain >6/10, fractured Rt hip • Tells us [etiology] Tissue Trauma [which we see (symptom) as a fracture on X-ray] is causing PAIN (Problem) We also know because the pt says he is in pain (Symptom) NRS320 Collings2012

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