The Nursing Process

1. The Nursing Process • Module G

2. HOW OBERVANT ARE YOU???? • Looking, Listening, Feeling, Smelling ---- • Do the above in order too ---- • Assess, Diagnosis, Plan, Implement, and Evaluate

3. THE NURSING PROCESS – 5 STEPS • 1. Assessment • 2. Diagnosis • 3. Planning • 4. Implementation • 5. Evaluation • Each step is dependent on the accuracy of the step preceding it.

4. Assessment-Data Collection is a Primary Tool • Puzzle Pieces • Gathering Info about pt • Data collection requires us to examine the data • Does it fit the picture? • Formal vs Informal • Pt is our primary source for this data • What are secondary sources?

5. Focus vs Data Base Assessment • Focus Ass’t – is performed to gather detailed information about a specific condition. • Baseline Data - is gathered on initial contact with pt to gather info about all aspects of health status

6. Two Types of Data • S – Subjective - What the patient tells you • Subjective = Statements • “I’m itching” • O – Objective – Detectable by an observer or can be tested • O = Objective • What are some examples?

7. Nursing Diagnosis Process • Data Validation \ • > Interpretation of • Data Clustering / Data • \/ • Identification of • Client needs • \/ • Formulation of • Nursing Diagnosis

8. Organizing Data • Your assessment tool will assist you with this • Clustering into categories helps you get a better picture • Maslow’s Heiarchary of Needs helps you too

9. Steps in Data Analysis • 1. Do you see a pattern or trend • 2. Compare your data to Standards (Norms) i.e., B/P 168/102 (Normal 110/70) – Rales heard in lung fields ( Normal – clear lung sounds) • 3. Make a reasonable conclusion

10. Four Methods Nurses use to:Collect Data • 1. Interview • 2. Nursing Health History • 3. Physical Examination – Head • 4. Diagnostic and Laboratory Results

11. What’s Next ???? • Once data collection & analysis is complete we next DIAGNOSE using NANDA. You are looking for the Diagnostic label (NANDA) that addresses the problem. • Problem – is an unmet need or anything that interferes with a persons ability to meet their needs. • Related factors – Etiology : Follows the Diagnostic label & directs interventions • Ex: Impaired skin integrity R/T immobility

12. Three Types of Diagnoses • Actual • “Risk for” • Wellness

13. Legalities in Stating Nursing Diagnoses • Don’t write the diagnostic statement in such a way that it may be legally incriminating. • High risk for injury R/T Lack of side rails or High Risk for injury R/T Disorientation • Don’t state the Nsg Dx using medical terminology; focus on the person’s response to the medical problems • Mastectomy R/T Cancer vs. Body Image disturbance R/T effects of surgical procedure. • Don’t use 2 problems @ the same time.

14. Planning • Setting • Establish: • 1. Realistic patient-centered goals • 2. Measurable goal criteria • Address: 7 guidelines when writing goals and outcomes • 1. Patient centered 2. Singular • 3. Observable 4. Measurable • 5. Time Limited 6. Mutual • 7. Realistic • Two Types of Goals: Short vs. Long Term

15. Planning – Determining Nursing Interventions • Types: Nurse Initiated, Physician initiated, Collaborative • Elements: • Requires decision making • Scientific rationale based • Psychomotor & IPR skills • Clinical functioning • Address: Who, What, When, Where, How

16. Components of a Goal • Subject • Behavior • Condition (Time) • Criteria – List • Each is a separate outcome • Each is specific & concrete • Each is measurable, seen, heard, felt, observable • Must R/T goal • Realistic

17. Implementation • The actual process of putting the PLAN into action, a team effort including: • 1. Reporting • 2. Performing the care • 3. Setting Priorities • 4. Documentation • 5. Assessing & reassessing • 6. Adhere to polices

18. Evaluation • To judge or appraise • Determine if expected outcomnes were met • A constant on-going process for determining if patient goal(s) are being met or if patient needs are changing • 3 Goal Possibilities: • Met, Partially Met, Not Met

19. Nursing Process is Dependent On: • Knowledge – • What to • Why • Skills – • How to • Caring – • Willing to • Able to

20. Critical Thinking? Who needs it? • Critical Thinkers look beyond the obvious = Sound Judgment • Sound Judgments = Safe Care • Safe Care = Accountability because we critically think.

21. Questions often asked by critical thinkers • What if? Do I have enough data (facts)? • How can I? How could I have missed that? What did I assume & why? • What did I learn about?*Critical Thinkers are always learning.

22. Critical Thinking • Confidence • Contextual perspective • Creativity • Flexibility • Inquisitiveness • Intellectual integrity • Intuition • Open=Minded • Persistence • Reflection • = Habits of the Mind