Nursing Process

1. Nursing Process Ch 11

2. What Is It? • Framework = method = formula • Systematic approach • Dynamic • Interpersonal • Patient-centered • Goal-oriented

3. Steps (Parts) • Assessing • Diagnosing • Planning • Implementing • Evaluating

4. Quote . . . • Nurses are responsible for a unique dimension of healthcare – “ the diagnosis and treatment of human responses to actual or potential health problems”

5. Evolution • In 1960s nursing recognized as distinct entity • 1973 the ANA Congress developed Standards of Practice • Ongoing reassessments and revisions

6. Trends • Initially plans of care were long and handwritten • Today’s care plans are • Standardized • Computerized • Focus on similarities between illnesses, etc

7. Problem Solving • Combination of • Trial-and-error • Scientific process • Intuition

8. Purpose • Provide patient care that is • Scientific • Holistic • Creative

9. Critical Thinking • Ability to • identify a problem • analyze it • develop a response • follow through • Based on • experience • Knowledge • Intuition

10. Critical Thinking, cont’d. • “…active, organized, cognitive process used to carefully examine one’s thinking and the thinking of others.” • Involves use of MIND • Form conclusions • Make decisions • Draw inferences • reflect

11. C. T. Characteristics • Independent thinker • Fair-minded • Intellectually humble • Intellectually courageous • Good faith & integrity • Curious & persevering • Disciplined • Creative • Confident

13. Assessing Ch 12

14. 4 Types • Initial • Shortly after contact with patient • Most facilities have specific time-frames • Establishes database for development of plan

15. Focused • Gathers data about specific problem • May be part of initial assessment, but more often is not • Emergency • Identifies life-threatening problems • Time-Lapse • Compares current to previous data

16. Data Collection • Consider • time • needs of patient • developmental stage • physical surroundings • past and present coping patterns

17. Data Characteristics • Complete • Factual • Accurate • Relevant

18. Data Sources • Subjective • Patient • Primary source • Usually BEST source • Family & significant others • When patient is a child or impaired adult • Spouses • Consider confidentiality when including friends

19. Data Sources, cont’d • Objective • Observed data (What is not spoken) • Findings from physical exam • Results from diagnostic or lab tests • Information from pertinent nursing or medical literature

20. Objective Sources cont’d. • Patient record • H & P • Laboratory • Consultations • X-ray, CT, PT/OT, other ancillary departments

21. Data Collection • Demographics • Medical history • Habits • Meds, allergies • Environmental/familial factors • Potential for injury • Ability to participate in plan of care

22. Data Collection • Physical assessment • Usually by Review of Systems • Overview of symptoms • Diet • Each body system

23. Interview • Planned • Consider schedule of tests • Patient preferences • Family or visitor presence

24. Interview Phases • Preparatory • Introduction • Working • Termination

25. Interview Phases • Preparatory • Nurse collects background info from previous charts • Ensure environment is conducive • Arrange seating • 3 – 4 ft apart • Interviewer at 45° angle to patient • Allow adequate time

26. Phases cont’d. • Introduction • Nurse introduces self • Identifies purpose of interview • Ensure confidentiality of information • Provide for patient needs before starting

27. Phases cont’d. • Working • Nurse gathers info for subjective data • Excellent communication skills are needed • Active listening • Eye contact • Open-ended questions

28. Phases cont’d. • Termination • Inform patient when nearing end of interview • Ensure patient knows what will happen with info • Offer patient chance to add anything

29. Data Validation • Verifies understanding of information • Comparison with another source • patient or family member • record • health team member

30. Data Documentation • Clear and concise • Appropriate terminology • Usually on a designated form • Physical assessment • Usually by Review of Systems • Overview of symptoms • Diet • Each body system

31. Documentation • Record in permanent record ASAP • Use patient’s own words in subjective data – enclose in “ ___” (quotation marks) • Avoid generalizations – be specific • Don’t make summative statements – describe - e.g. patient is being ornery should be patient resists instruction or patient states “Don’t talk to me, I don’t care about that”