Nursing process

1. Nursing process

3. The Nursing Process *An organized sequence of problem-solving steps used to identify and to manage the health problems of clients. • Orderly, systematic • Central to all nursing care • Encompasses all steps taken by the nurse in caring for a patient

4. *Benefits of Nursing Process: • Provides an orderly & systematic method for planning & providing care • Enhances nursing efficiency by standardizing nursing practice • Facilitates documentation of care • Provides a unity of language for nursing profession • Is economical • Stresses the independent function of nurses • Increases care quality by using deliberate actions

5. Steps of nursing process • Assessment • Nursing Diagnosis • Planning • Implementation • Evaluation

6. Characteristics of the nursing process • Within the legal scope of nursing • Based on knowledge-requiring critical thinking • Planned-organized and systematic • Client-centered • Goal-directed • Prioritized • Dynamic • Continuity of care

7. Characteristics of nursing process-continued • Prevention of duplication • Individualized care • Standards of care • Increased client participation

8. Important • Nurses are responsible for a unique dimension of healthcare “the diagnosis and treatment of human responses to actual or potential health problems”. • Critical thinking in nursing is an essential component of professional accountability and quality nursing care. • Critical thinking is careful, deliberate, and goal directed. • Nurse should be understanding the reason behind knowledge. • Nurse is curious, open-minded, non-judgmental….

9. ASSESSMENT • Observation • Interview: • Types of questions • Environment (physical and emotional) and spiritual considerations • Examination

10. *Types of Data to Collect: • Objective data-observable and measurable facts (Signs) • Subjective data-information that only the client feels and can describe (Symptoms) *Sources of Data: • Primary source: Client • Secondary source: Client’s family, reports, test results, information in current and past medical records, and discussions with other health care workers

11. * Assessment: • Data base assessment – comprehensive information you gather on initial contact with the person to assess all aspects of health status. • Focus assessment– the data you gather to determine the status of a specific condition.

12. * Nursing Diagnosis: Health issue that can be prevented, reduced, resolved, or enhanced through independent nursing measuresby: • Sorting, clustering, analyzing information • Identifying potential problems and strengths • Writing statement of problem or strength • Prioritizing the problems • Not a medical diagnosis * Nursing Diagnosis: Judgment or conclusion about the risk for—or actual—need/problem of the patient (NANDA format)

13. Diagnostic Statements: • Name of the health-related issue or problem as identified in the NANDA list • Etiology (its cause) • Signs and Symptoms • The name of the nursing diagnosis is linked to the etiology with the phrase “related to,” and the signs and symptoms are identified with the phrase “as manifested (or evidenced) by” • Problem: (Potential complication of seizure disorder related to medication incompliance) (No AEB) • Problem: (Risk of infection related to compromised nutrition state) (No AEB) • Strength: (Potential for effective breastfeeding related to knowledge level and support system)

14. *Planning: • The process of prioritizing nursing diagnoses and collaborative problems, identifying measurable goals or outcomes, selecting appropriate interventions, and documenting the plan of care. • The nurse consults with the client while developing and revising the plan. • The nurse shares the plan of care with nursing team members, the client, and client’s family. • The plan is a permanent part of the record. *Setting Priorities: • Determine problems that require immediate action • Maslow’s Hierarchy of Human Needs

15. Nurse Identified Priorities • Composite of all patient’s strengths and health concerns. • Moral and ethical issues. • Time, resources, and setting. • Hierarchy of needs. • Interdisciplinary planning. • Identifying Client-centered outcomes • State what the patient will do or experience at the completion of care. • Give direction to the patient’s overall care. • Patient behaviors not nurse behaviors!!

16. *Outcome: -Components of Outcomes • Subject: who is the person expected to achieve the outcome? • Verb: what actions must the person take to achieve the outcome? • Condition: under what circumstances is the person to perform the actions? • Performance criteria: how well is the person to perform the actions? • Target time: by when is the person expected to be able to perform the actions?

17. *Steps for deriving outcomes from Nursing Diagnosis: • Look at the first clause of the nursing dx and restate in a statement that describes improvement, control or absence of the problem. • Risk for infection R/T surgical procedure. • The client will demonstrate no signs or symptoms of infection.

18. *Short-Term Goals: • Outcomes achievable in a few days or 1 week • Developed form the problem portion of the diagnostic statement • Client-centered • Measurable • Realistic • Accompanied by a target date *Long-Term Goals: • Desirable outcomes that take weeks or months to accomplish for client’s with chronic health problems

19. *Selecting Nursing Interventions: • Planning the measures that the client and nurse will use to accomplish identified goals involves critical thinking. • Nursing interventions are directed at eliminating the etiologies. *Selecting an intervention: • The nurse selects strategies based on the knowledge that certain nursing actions produce desired effects. • Nursing interventions must be safe, within the legal scope of nursing practice, and compatible with medical orders.

20. *Nursing Interventions: • Monitor health status. • Minimize risks. • Resolve or control a problem. • Assist with ADLs. • Promote optimum health and independence. • Either: • Direct interventions: actions performed through interaction with clients. • Indirect interventions: actions performed away from the client, on behalf of a client or group of clients.

21. *Evaluation: • The way nurses determine whether a client has reached a goal. • It is the analysis of the client’s response, evaluation helps to determine the effectiveness of nursing care. • Ongoing part of the nursing process • Monitoring the patient’s response to drug therapy • Identifying the variables affecting outcome achievement • Deciding whether to continue, modify, or terminate the plan -Determining Outcome Achievement: • Must be aware of outcomes set for the client. • Must be sure patient is ready for evaluation. • Is patient able to meet outcome criteria? • Is it: (Completely met? ,Partially met?, Not met at all?) • Record in progress in notes. • Update care plan.

22. *Identifying Variable Affecting Outcome Achievement • Maintain individuality of care plan: • Is the plan realistic for the client? • Is the plan appropriate at the time for this particular client? • Were changes made in the plan when needed? • How does the client feel about the plan? *Predict, Prevent, and Manage: • Focus on early intervention • Based on research • Predict and anticipate problems • Look for risk factors

23. *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) • 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”

24. Functional Health Pattern(NANDA) • Health Perception-Health management pattern • Nutritional-Metabolic Pattern • Elimination Pattern • Activity-Exercise Pattern • Sexuality-Reproduction Pattern • Sleep-Rest Pattern • Sensory-Perceptual Pattern • Cognitive Pattern • Role-Relationship Pattern • Self-Perception-Self- Concept Pattern • Coping-Stress Tolerance Pattern • Value-Belief Pattern

25. Health Perception-Health Management Pattern • Energy Field Disturbance. • Altered Growth and Development. • Altered Health Maintenance. • Ineffective Management of Therapeutic Regimen: Individual. • Health Seeking Behaviors • Effective Management of Therapeutic Regimen • Risk for Injury • Risk for diagnoses • Risk for Suffocation • Risk for Poisoning • Risk for Trauma • Risk for Peri-operative Positioning Injury

26. Nutritional-Metabolic Pattern • Decreased Adaptive Capacity: Intracranial. • Ineffective Thermo regulation. • Fluid Volume Deficit • Fluid Volume Excess • Altered Nutrition: Less than body requirements • Altered Nutrition: More than body requirements • Ineffective Breastfeeding • Interrupted Breastfeeding • Ineffective Infant Feeding Pattern Impaired Swallowing • Altered Protection • Impaired Tissue Integrity • Altered Oral Mucous Membrane • Impaired Skin Integrity.

27. Elimination Pattern • Altered Bowel Elimination Constipation • Colonic constipation • Perceived constipation • Diarrhea • Bowel Incontinence • Altered Urinary Elimination Patterns of Urinary Retention • Total Incontinence • Functional Incontinence • Reflex Incontinence • Urge Incontinence • Stress Incontinence • Risk for constipation • Risk for altered urinary elimination

28. Activity- Exercise Pattern • Activity Intolerance • Impaired Gas Exchange in effective Airway Clearance • Ineffective Breathing Pattern • Decreased Adaptive Intracranial Capacity • Decreased Cardiac Output • Disuse syndrome • Diversional Activity Deficit • Impaired Home Maintenance Management • Impaired Physical Mobility • Dysfunctional Ventilatory Weaning Response • Inability to Sustain Spontaneous Ventilation • Self-Care Deficit: (Feeding, Bathing/Hygiene, Dressing/Grooming, • Toileting) • Altered Tissue Perfusion: (Specify type: Cardiac, Cerebral, and Cardiopulmonary. Renal, Gastrointestinal, Peripheral) • Disorganized Infant Behavior • Risk for Disorganized Infant Behavior • Risk for Peripheral Neurovascular Dysfunction • Risk for altered respiratory function

29. Sexuality-Reproduction Pattern Risk- Diagnoses Risk for altered sexuality pattern Actual Diagnoses Sexual Dysfunction, Altered Sexuality Patterns

30. Sleep-Rest Pattern Wellness Diagnoses: Opportunity to enhance sleep Risk Diagnoses: Risk for sleep pattern disturbance Actual Diagnosis: Sleeps Pattern Disturbance

31. Sensory-Perceptual Pattern Wellness Diagnosis: Opportunity to enhance comfort level Risk Diagnoses: Risk for pain, Risk for Aspiration Actual Diagnoses: Pain, Chronic Pain and Dysreflexia.

32. Cognitive Pattern *Actual diagnosis • Acute confusion • Chronic Confusion • Decisional Conflict • Impaired Environmental Interpretation Syndrome • Knowledge Deficit (Specify) • Altered Thought Processes • Impaired Memory *Wellness Diagnosis: Opportunity to enhance cognition *Risk Diagnoses: Risk for altered thought processes

33. Role-Relationship Pattern *Actual Diagnoses • Impaired Verbal Communication • Altered Family Processes: Alcoholism • Anticipatory Grieving • Dysfunctional Grieving? • Altered Parenting • Parental Role Conflict • Altered Role Performance • Impaired Social Interaction: Social Isolation *Risk Diagnoses Risk for dysfunctional grieving, High risk for Loneliness. Risk for Altered Parent/Infant/Child Attachment

34. Self-Perception-Self-Concept Pattern *Actual Diagnoses • Anxiety fatigue - Fear - Hopelessness- Powerlessness- Personal Identity. • Disturbance - Body Image • Disturbance- self Esteem • Disturbance. Risk Diagnoses • Risk for hopelessness • Risk for body image disturbance • Risk for low self esteem

35. Coping-Stress Tolerance Pattern *Actual Diagnoses • Impaired Adjustment • Ineffective Individual Coping • Ineffective Family Coping: Disabling • Ineffective Family Coping: Compromised • Ineffective Community Coping: Post-Trauma Response, • Rape-Trauma Syndrome Relocation and Stress Syndrome. *Risk Diagnoses • Risk for ineffective coping (individual, family, or community) • Risk for self-harm • Risk for self- abuse. • Risk for Self-Mutilation • Risk for suicide • Risk for Violence; Self- directed or directed at others

36. Value-Belief Pattern *Actual Diagnosis Spiritual disturbance (distress of the human spirit). *Risk diagnosis Risk for spiritual distress *Wellness Diagnosis Potential for enhanced spiritual Well- Being

37. **PRACTICAL STEPS • Perform assessment • Look at the NANDA list • Look for the defining characteristics or symptoms from your assessment • Look for the related factors - things that cause the symptoms • Make the sentence read: NANDA Diagnosis…RT…AEB…

38. Develop SMART patient goals or the "patient will" statements • Specific & Individualized • Measurable • Attainable • Reasonable Timed, and a date

39. Write nursing interventions • Write rationale that match the intent of the interventions and goals • Evaluate the outcome or result of goal interventions. • More specifically...as you begin to write the care plan, refer to your assessment findings. What is the priority problem? Are there clues to the need for patient teaching? What symptoms is the patient experiencing?

40. Often it helps to look at the NANDA list first, and see if there is one particular diagnosis that seems to fit the situation. Then look up that diagnosis in the Nursing Diagnosis book. Look at their definition, to see if it fits your patient. Then look for the defining characteristics or evidence: These are the signs and symptoms you have seen in the patient. They will be the "as evidenced by" or AEB of the diagnosis statement.

41. Next, look for the related factors:These are the "related to" or R/T part of the statement. Remember, avoid using the medical diagnosis as a "related to" part. However, it may be used as a "secondary to" statement. Then change it around to make the sentence read: NANDA Diagnosis…RT…AEB… 

42. For example, if my patient has sores on his legs, and he also has Diabetes Mellitus, you might use the statement: Decreased blood flow and nutrients to tissues of the lower extremities, secondary to Diabetes Mellitus AEB a 2 cm skin lesion on the left great toe, and a 4 cm lesion on the inner aspect of the right ankle."

43. Nursing diagnoses that are in the "risk for" categories do not need the AEB portion of the statement, since there is no actual evidence. However, you should avoid using too many "risk for" diagnosis. One or two, out of eight to ten, is acceptable. • Assessment abnormalities should always be reflected in the nursing diagnosis, and subjective and objective data. If the assessment data is not there, you have no evidence. • Gradually, with practice, you will find that nursing diagnoses are easier and easier to develop.

44. *GOALS or OUTCOMES: • Next you'll want to develop patient goals or the "patient will" statements. These must be specific, measurable, attainable, realistic, timed, and dated. Collaborate with the patient, to gain cooperation with the planned goals. They should also be measurable, and include a time frame, and a date. Goals should conform to the nursing diagnosis. Make them specific to your patient's problem.

45. They should be individualized to your patient, not just "canned" from the book. • They should be attainable for your patient. • Then look in the Nursing Diagnosis book for nursing interventions that could be used to assist the patient to attain the goal (s), you have established. • Next, find the rationale that match the intent of the interventions and goals. • And finally, evaluate the outcome of the interventions. These statements should match the wording used in the goal column, and be followed by the statement as to whether the goal was "met, partially met, or not met.

46. Nursing Care Plan 1 *Nursing Diagnosis: ALTERED THOUGHT PROCESSES *Definition:A state in which an individual experiences a disruption in cognitive operations and activities

47. *Possible Etiologies (related to) • Withdrawal into the self • Underdeveloped ego; punitive superego • Impaired cognition fostering negative perception of self or the environment

48. *Defining Characteristics (evidenced by) • Inaccurate interpretation of environment • Delusional thinking • Hypovigilance • Altered attention span-distractibility • Egocentricity • Impaired ability to make decisions, problem-solve, reason • Negative ruminations

49. *Goals/objectives **Short-Term Goal • Patient will recognize and verbalize when interpretations of the environment are inaccurate within 1 week. **Long-Term Goal • Patient will experience no delusional or distorted thinking by discharge.

50. *Interventions with Selected Rationales • Convey your acceptance of patient’s need for the false belief, while letting him or her know that you don’t share the delusion. A positive response would convey to the patient that you accept the delusion as reality. • Do not argue to deny the belief. Use REASONABLE DOUBT as a therapeutic technique: “I find that hard to believe.” An arguing with the patient or denying the belief serves no useful purpose; delusional ideas are not eliminated by this approach, and the development of a trusting relationship may be impeded.