Nursing Prcess Outline - Kim Baily RN, MSN, PhD Five Steps f the Nursing Prcess Methd f prviding care Purpseful, systematic, and rderly Scpe and Standards f Practice Assessment: Nurse cllects data Diagnsis: Nurse analyzes data in determining diagnses Outcme identificatin: Nurse identifies expected utcmes Planning: Nurse develps a plan f care Implementatin: Nurse implements interventins identified in plan Evaluatin: Nurse evaluates client s prgress What is a prcess? Series f planned actins perfrmed t achieve a gal Methd f planning and prviding care Prmtes rganizatin Each step verlaps with previus and subsequent steps Methd f prblem slving and decisin making Scientifically based understanding f the human bdy Nursing Prcess Characteristics Orderly, step-by-step prcess Client is evaluated Data are cllected and analyzed Plan f care is determined and set int mtin Client is mnitred, evaluated Care plan is revised as needed Nursing Prcess Characteristics Client centered Assists t plan accrding t client needs Client participates Prmtes cllabratin Benefits f the Nursing Prcess Imprved quality f care Cntinuity f care Prmtes client participatin in care Delivery f care is rganized, cntinuus, and systematic Efficient use f time and resurces Expectatins f client and standards f care are met Hlds nurses accuntable and respnsible Step 1: Assessment Key step. Database is cmpiled invlving: Verificatin and validatin f data Organizatin f data Interpretatin f data Dcumentatin f data Objective: bservable, measurable data Subjective: cmmunicated data 1
Step 2: Diagnsis Invlves analysis f data Nursing diagnsis determinatin Questins Critical Thinkers Ask... What actual prblems were identified during assessment? What are pssible causes? Is client at risk fr develping ther prblems? What are the factrs invlved? Did the client indicate a desire t functin at a higher level f wellness? Questins Critical Thinkers Ask... What are the client s strengths? What additinal data might be needed t answer these questins? What are pssible surces f data cllectin? Is cllabratin needed at this time? What data are pertinent t cllect befre cntacting the physician? Actual Nursing Diagnses Client demnstrates signs and symptms An actual prblem exists Risk Nursing Diagnses Prblems client is at risk fr develping Nursing actins may prevent the prblem Wellness Nursing Diagnsis Client desires a higher level f wellness Nursing diagnsis preceded by ptential fr enhanced Cllabrative Prblems Ptential cmplicatins arising during treatment Nurse mnitrs fr nset r change in client Preventin r reductin is initiated Example: PC: Hemrrhage Medical vs. Nursing Diagnses Medical Diagnsis Determined by physician Indicates disease, illness Nursing Diagnsis Determined by the nurse Clinical judgment abut the client Human respnses t disease r treatment Step 3: Planning Determining the care plan Dcumenting the care plan Organizing prpsed curse f actin Priritize nursing diagnses Gals and utcmes are identified, cnstructed, and dcumented Interventins are identified Gals Client centered Fcus n the behavir Describe intended r desired change Expected Outcme Leads t fulfillment f gal Reslutin f the prblem 2
Nursing Interventins Planned actins Prmtes gal attainment Step 4: Implementatin Executing the care plan Interventins are perfrmed Assessment befre, during, and after Reprt and dcument Includes: Putting the care plan int actin Carrying ut planned interventins Assessing, reprting, dcumenting Step 5: Evaluatin Client is evaluated Care plan is evaluated Gal attainment is determined Cgnitive Skills Nurses Use: Decisin making Critical thinking Prblem slving Chapter 2: Assessment Gathering data Organizing Verifying accuracy Dcumenting data Data Cllectin Interview, physical exam, diagnstic exams Cmmunicated and dcumented Begins when client enters health care system Cntinues as lng as there is a need Types f Data Subjective Objective Cmplements, clarifies, supprts Interpretatin f Data Meaning is assigned Cmpared against standards Prevents incnsistencies Data Clustering Determines relatin Finds patterns Dcumenting Assessment Data Prepares a recrd Describes client s health status Prmtes cmmunicatin amng thers invlved in the client s care Chapter 3: Nursing Diagnsis Analysis Prblem identificatin Actual Diagnsis 3
Nursing diagnsis Nursing Prcess The diagnstic label Classificatin list NANDA taxnmy Example f Actual Nursing Diagnsis Risk Nursing Diagnses Pssible develpment f prblems Client is mre at risk than thers Characteristics f Nursing Diagnses Cmplement physician treatments Separate and distinct Structure f Nursing Diagnses Actual nursing diagnsis existing respnse t cnditin prblem exists supprting signs and/r symptms Risk Nursing Diagnses Pssible develpment f prblem Has nt ccurred N signs r symptms NANDA describes Risk Diagnsis as: a clinical judgment made when a client is mre vulnerable t develp the prblem than thers in the same r similar situatins. Cmpnents f Actual Nursing Diagnses PES Prblem Label Nursing diagnsis Etilgy Related t (R/T) r related factr Invlved in develpment f prblem Becmes fcus fr interventins Cause cmpnent Gives directin t prblem statement Signs and Symptms - As evidenced by (AEB) - Defining characteristics Clinical evidence Hw respnse is manifested Same nursing diagnses with different etilgies may require different interventins. Cnstipatin, Perceived Related t: inactivity, insufficient fiber intake Interventin: encurage daily activity t stimulate bwel eliminatin Related t: lng-term laxative use Interventin: instruct client n adverse affects f lng-term laxative use Breast-feeding, Ineffective Related t: inadequate sucking reflex in infant Interventin: assess infant s ability t latch n and suck effectively 4
Related t: inexperience, knwledge deficit Interventin: determine mther s desire and mtivatin t breastfeed Cmpnents f Risk Nursing Diagnses Ptential prblem Risk factr N evidence Prblem des nt exist Risk Nursing Diagnses Examples Cancer patient, Risk fr Infectin Risk Factrs (R/T): inadequate secndary defenses, immunsuppressin Client with surgical incisin, Risk fr Infectin Risk Factrs (R/T): inadequate primary defenses, invasive prcedure Wellness Nursing Diagnsis Indicatin f desire t attain higher level f wellness Example: Ptential fr Enhanced Nutritin Chapter 4: Steps Invlved in Planning Determine pririty prblems Establish gals and expected utcmes Write gals and expected utcmes Plan interventins with scientific ratinale Cmmunicate and dcument the plan Gal Definitin General statement Indicates intent r desired change Expected Outcme Definitin Stated in mre specific terms Same cmpnents as gal Gal and Expected Outcmes Example Bdy image disturbance Gal: Client will demnstrate acceptance f amputatin and an ability t adjust t lifestyle change within six mnths. Expected utcmes: Lks at and tuches area f missing bdy part Participates in wund/stump care Plans fr prsthesis Returns t frmer scial invlvement Characteristics f Gals and Expected Outcmes Measurable: includes time frame Client centered: fcus n the client s actin Specific Realistic Shrt-Term Gal Identifies behavir Achieved within hurs r days Lng-Term Gal Identifies desired behavir Achieved within weeks t mnths 5
Overall greater expectatins Discharge Planning Invlves lng-term gals Referral Cntinued recvery Expected Outcmes Measurable steps May identify mre than ne Prgress tward gal achievement Cmpnents f Gals and Expected Outcmes Subject Client centered Behavir Will verbalize Will ambulate Will reprt Will eat Will demnstrate Time frame Realistic Criteria f Perfrmance Level f behavir May include a time limit r descriptin Hw far, hw lng, hw much Criteria f Perfrmance Examples Understanding f medicatin regime Length f the hall Decrease in pain level f fur r less Seventy-five percent f meal Decreased bld pressure within frty-eight hurs Gal Applicatin Client (subject) will ambulate (behavir) assisted by physical therapy (PT) t nurse s statin and return t rm twice (criteria f perfrmance) daily (time frame). Gal Applicatin Mr. Jhnsn (subject) will verbalize (behavir) understanding f medicatin regime (criteria f perfrmance) prir t discharge (time frame). Gal Applicatin Ms. James (subject) will lse (behavir) tw and a half punds (criteria f perfrmance) within three weeks (time frame) by using prescribed American Heart Assciatin Diet plan (cnditins) 6
Interventins Selectin Guidelines Guided by regulating rganizatins Legal realm f practice Client values Cnsequences f actin Classificatin f Nursing Interventins Independent Initiated by the nurse N additinal directin required N physician rder required Dependent Require an rder Example Nursing diagnsis: Activity intlerance R/T: bed rest, generalized weakness AEB: verbalizatin f verwhelming lack f energy, dyspnea n exertin while perfrming activities f daily living Gal: Client will verbalize imprved level f energy when carrying ut activities f daily living within ne week. Nursing Interventins Assess ability t perfrm activities f daily living. Evaluate adequacy f nutritin and sleep. Schedule perids f uninterrupted time fr client t rest thrughut the day. Assist client with activities f daily living as necessary. Prmte and encurage ADL independence withut causing exhaustin. Evaluatin Purpse T estimate effectiveness f care T estimate quality f care T estimate client respnses T determine if the care plan is wrking T determine hw well the care plan is wrking Characteristics f Evaluatin Onging Cntinues as lng as care is prvided Client respnses are cmpared Fcuses n relatinship Success f plan is judged Evaluative Questins Were the expected utcmes achieved? Is the plan apprpriate? Shuld the plan be mdified r terminated? Were gals specific, measurable and realistic? Were nursing diagnses relevant? Was assessment thrugh and accurate? Did the client and family participate in pririty prblem identificatin and gal setting? Care Plan Mdificatin Prgress Favrable May indicate apprpriate interventins Expect revisins r mdificatins 7
Lack f Prgress Plan needs revisin r mdificatin Nursing prcess steps reactivated Reassess plan Reassess client Cmpare findings Discntinue When gal is achieved Prtin f plan Cntinue with reassessment 8