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What is nursing?

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"The protection, promotion, and optimization of health and abilities, prevention of illness and injury, alleviation of suffering through the diagnosis and treatment of human response, and advocacy in the care of individuals, families, communities, and populations". (2010).

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Master' Degree

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independent practioner role; prescribe treatments; cannot prescribe narcotics

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Doctoral programs

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advanced care nursing

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LPN

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licesend practical nurse; don't have the ability to make a care plan

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Associates Degree vs BSN

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BSN can provide patient care and work in community agencies such as schools and you can also be involved in research

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Practical and Vocational Nurse

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Nurse Aids and CNAs

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Regulation of Nursing Practice

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Nurse Practice Act and ANA standards

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Practice Act

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State Boards of Nursing - Defines the practice of nursing - Establishes criteria for RN/LPN/ARNP - Determines scope of practice Activities that nurses may perform Enforce rules that govern nursing

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ANA Standards of Practice

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"Provide a means by which a profession clearly describes the focus of its activities, the recipients of service, and the responsibilities for which its practitioners are accountable" - make the NCLEX

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Scope of practice

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by state boaard of nursing; example FL state board decided that nurse practioniers cannot prescribe narcotics

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The Nursing Process definition

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"a systematic problem-solving approach toward giving individualized nursing care"

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What is the nursing process used for nurses to do?

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to use as a PROBLEM-SOLVING process in all settings, with clients of all ages, to identify and treat human responses to potential or actual health problems incorporating each client's unique aspects

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The Nursing Process by the ANA

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in 2004; Nursing scope and standards of practice Describes nursing process as foundational for decision making and competent nursing care

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State of Florida Nurse Practice Act Definition of Professional Nursing:

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"Practice of professional nursing" means the performance of those acts requiring substantial specialized knowledge, judgment, and nursing skill based upon applied principles of psychological, biological, physical, and social sciences which shall include, but not be limited to: 1. The observation, assessment, nursing diagnosis, planning, intervention, and evaluation of care; health teaching and counseling of the ill, injured, or infirm; and the promotion of wellness, maintenance of health, and prevention of illness of others. 2. The administration of medications and treatments as prescribed or authorized by a duly licensed practitioner authorized by the laws of this state to prescribe such medications and treatments. 3. The supervision and teaching of other personnel in the theory and performance of any of the above acts.

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Why is the state board important?

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? It will tell us the nursing process; if you don't do it appropriately you can be held accountable in the court of law

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How do you know if a nurse is doing their job?

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Look at and see if the nurse is doing the nursing process; infection is a big way to see if the nurses are doing their job Ex: have a LPN and allow them to a dressing change correctly you as a BSN nurse are held accountable

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Components of the Nursing Process

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Assessment Diagnosis Planning Intervention Implementation Evaluation

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What is the MAIN component used in every section of the nursing process?

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Critical thinking skills are interwoven-cognitive processes used in complex thinking operations such as problem solving and decision making

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Nurses vs. Doctors

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Doctors only look at the physical aspect but the nurses look at the whole picture

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Assessment

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the systematic gathering of information related to the physical, mental, spiritual, socioeconomic, and cultural status of an individual, group, or community

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Assesments steps

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- Appraisal of the patient's current health state, deficits and strengths - Collection of objective and subjective data - Consideration of physical, psychological, emotional, sociocultural, and spiritual - Becomes reference point for all other assessments - Provides foundation for nursing diagnosis

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If you have a good assessment...

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the entire process; will be thorough

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ANA Competencies for Assessment

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The RN will: Collect comprehensive data Include the patient, family, and significant others as the patient requests Identify barriers to appropriate adaptation Prioritize data based on real and anticipated events Use evidence-based tools for data collection Synthesize data to identify patterns or variances Accurately document the data to share with other health care providers

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Can I delegate Assessments?

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NOOOO; Assistants can bring you the data but you must assess the data; they just take it sometimes and do not know what to do with it; do something with the data (You are responsible for showing them how to do it correctly); You are responsible and accountable for the data collection/assessment

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The ANA's Code of Ethics for Nurses, Provision 4 (2001), states:

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"The nurse . . . determines the appropriate delegation of tasks consistent with the nurse's obligation to provide optimum patient care."

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Nursing Assistive Personnel

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CNA, Patient Care Tech can collect data for the nurse but the nurse must determine what is to be delegated and remains accountable and responsible.

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NCSBN Model Nursing Practice Act (2007) RN:

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Extensive data collection, initial & ongoing Address anticipated & emerging changes in client status Recognize alterations to the patient's status Synthesize all aspects of the client condition Plan & evaluate nursing interventions Communicate/consult with other health care members

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NCSBN Model Nursing Practice Act (2007) LPN

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Provide a FOCUSED assessment Appraisal of the patient status or situation which contributes to the assessment by the RN Support ongoing data collection Communicate significant findings to the RN

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TJC - JCAHO about assessment

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The RN must assess patient needs for all nursing care within 24 hours of inpatient admission" Assessment must be written, comprehensive, and used to identify and assign priorities for care. Each agency designates timeframes for reassessment

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Sources of Data

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1. Subjective-Info from client, family (How you are feeling; when did it start; pain; level of mobility; do not have any facts behind this ) 2. Objective-Gathered through physical assessment, lab/diagnostic tests (something you can validate) 3. Primary-subjective & objective data from client 4. Secondary-"secondhand" from chart/family member If there is no one if the room what do you do? use the chart and notes

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Initial Assessment

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Why is client seeking care? Collect data - Full and comprehensive one

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Ongoing asssessment

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performed as needed, dynamic - change in presentation

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Comprehensive Assessment

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Full Body Observation Physical Assessment Nursing Interview

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Focused Assessment

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Obtain data about an actual, potential, or possible problem that has been identified or suspected, not on overall health status Ex: guy comes in with stomach bug; you will focus on an GI exam

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As Needed Assessment

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in depth focused assessment, stemming from specific client needs When you do your comprehensive assessment and see something you want the client to do; you adjustment your findings to the clients needs

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How is data used?

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By other disciplines (collaboration); such as Social workers, psycholgists, physical therapy, To plan for nursing care To ensure clients receive The proper care By qualified individuals At the time it is needed

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Maslows Hierarchy of needs

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see chart

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What is the most confusing process?

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The nursing diagonosis The most confusing process; determine the diagnosis If this is off it will mess you up for the rest of the process What the patient is at risk for or what the patient is actually facing

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The nursing diagnosis does what?

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Analyze your assessment data Using critical thinking skills to identify patterns in the data and draw conclusions about the client's health status Includes strengths, problems, and factors contributing to the problems

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Fry - 1953,

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" The nursing diagnosis identifies the client's need for nursing rather than medical care."

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1960's nursing schools

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began teaching nursing diagnosis as part of the nursing process

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1973

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The First Conference on Nursing Diagnosis ANA Standards of Practice included nursing diagnosis as an expectation for nurses

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1980s

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Most state nurse practice acts began to designate nursing diagnosis as an exclusive responsibility of registered professional nurses

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ANA standards for nursing practice DIAGNOSIS

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The Registered Nurse will: Derive the diagnosis based on the assessment Validate the diagnosis in a manner that facilitates development of expected outcomes and measures **** Identify actual or potential risks the patient as well as identify potential barriers to health Use a standardize classification system, when available in naming diagnosis

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NANDA definition of Nursing Diagnosis

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"a clinical judgment about individual, family, or community responses to actual or potential health problems/life processes. Nursing diagnosis provides the basis for selection of nursing interventions to achieve outcomes for which the nurse is accountable" (2007).

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A health problem is any condition that

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requires intervention in order to promote wellness or to prevent or resolve disease/illness Decide how to treat it: independently, or collaboratively, with MD/ARNP

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Collaborative Problems

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Physiological complications of diseases, medical treatments, or diagnostic studies - human response problem Clients with certain diseases or treatments are at risk for developing the same complications - potential problem Always a potential problem Treatment of pain - collaborative problem

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An example of how a nurse would treat pain without consulting a doctor

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breathing techniques, aromatherapy, moving the pillows etc.

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Medical Diagnosis

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Describes a disease, illness, or injury RN's can't legally diagnose (ARNP's can & do)

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Nursing Diagnosis

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A statement of client health status that nurses can identify, prevent, or treat independently

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In nursing diagnosis the nurse wants to

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Treat or prevent a problem; relieve symptoms Examples: Ineffective tissue perfusion

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In a medical diagnosis the goal is to identify

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appropriate pathology and determine treatment, monitor for improvement or worsening of condition. Order appropriate diagnostic testing. Example - Acute Myocardial Infarction

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Types of Nursing Diagnosis

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actual - happening risk possible syndrome wellness

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Risk Diagnosis

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having palpitations but show signs and symptoms for ineffective tissue profusion

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Possible Diagnosis

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similar to a risk (don't really use it)

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Syndrome Diagnosis

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a collection of things going on with a patient (rarely use) tailored more to a specific disease process

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Wellness Diagnosis

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optimize your health status (get healthier and more fit)

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Cues are...

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signs something is NOT right!

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Gap in data

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when there is things that are not making sense; example ask a person if he smokes and he says no; but he has a cigar in his pocket; you ask him about it; you need to teach him about the problems associated with tobacco

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inferences in diagnostic reasoning

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Make inferences - what are the strengths or weakness in their ability to care for themselves; discharge abilities; may have to get social work to find outside care

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Diagnostic Reasoning steps

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1. Analyze & Interpret Data Identify significant data Groups of related cluster cues Identify data gaps and inconsistencies 2. Draw conclusions about health status Make inferences Identify problem etiologies 3. Verify problems with the patient 4. Prioritize problems

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Self Knowledge

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What beliefs, values, and experiences affect your thinking and may be misleading? Are there stereotypes or biases that influence your thinking? Are you relying heavily on past experience? Have you relied heavily on the medical diagnosis, the care setting, or what others have said about the patient?

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Taxonomy

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System for classification based on the characteristics the items have in common.

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Examples of Taxonomy

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DSM-IV for psychiatric conditions ICD-10 for disease classification

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NANDA

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North American Nursing Diagnosis Association International Description of health problems treated by nurses - think of nursing diagnosis

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Your independent Nursing Diagnosis

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you to tailor and plan the patient intervention ; the human response to a potential or actual problem

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Diagnostic Statements problem part

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Describes client's health status or human response to problem and identifies a response that needs to be changed

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Diagnostic Statements problem connecting phrase

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Related to, as evidenced by

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Diagnostic Statements problem etiology

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Contains the factors that cause, contribute to, or create a risk for the problem May include label, defining characteristics, related factors, or other factors

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