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Historical development of the nursing process

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*1955—nursing process term used by Hall *1960s—specific steps delineated *1967—Yura and Walsh published first comprehensive book on nursing process *1973—ANA Congress for Nursing Practice developed Standard of Practice *1982—state board examinations for professional nursing uses nursing process as organizing concept

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The five steps of the nursing process

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Assessing, diagnosing, planning, implementing, evaluating

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Assessment

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An RN uses a systematic, dynamic way to collect and analyze data about a client, the first step in delivering nursing care.

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Diagnosing

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The nursing diagnosis is the nurse's clinical judgment about the client's response to actual or potential health conditions or needs.

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Planning

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includes goals and creating plan of care to meet those goals

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Implementing

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carry out plan of care

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Evaluating

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measuring extent of outcomes (how patient achieved them)

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characteristics of the nursing process

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-systematic -dynamic -interpersonal -outcome oriented -universally applicable

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systematic

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part of an ordered sequence of activities

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dynamic

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steps overlap, each flows into the next

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interpersonal

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human being is always at the heart of nursing

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outcome oriented

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nurse and patient work as unit, identity outcomes (individualized)

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universally applicable

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a framework for all nursing activities

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Patient benefits of the nursing process

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-scientifically based, holistic individualized patient care -allows pt to work with nurse to achieve continuity of care -clear, efficient cost-effective care

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nurse benefits of the nursing process

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-opportunity to work collaboratively with other healthcare workers -grow professionally as a nurse -satisfaction of making a making a difference in lives of patients

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Benefits of the nursing process

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-Health Care Organizations required to submit data elements to regional and national data banks -Nursing data elements documented by using NANDA, NOC, NIC -Approved by American Nurses Association

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NANDA

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North American Drug Association

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NOC

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Nurse-sensitive outcome association

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NIC

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Nursing Intervention Classification

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American Nurses association

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-Provides a broad base of nursing knowledge at point-of-care -Supports aggregation of data -Development of knowledge: quality/cost of care

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History of Nursing Dx

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-Until the 1980's most state laws PROHIBITED nurses from diagnosing. -1980: ANA published the 'Social Policy Statement" which defined nursing as... "The diagnosis and treatment of human responses to actual and potential heath problems" -1985 NANDA (North American Nursing Dx Association) formed

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Purpose of the diagnosing step

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-Identify how an individual, group, or community responds to actual or potential health and life processes. 2. Identify factors that contribute to, or cause, health problems. 3. Identify resources or strengths upon which the individual, group, or community can draw to prevent or resolve problems.

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Nursing concerns and responsibilites

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-Recognizing signs and symptoms of common health problems and those that may indicate the need for more expert diagnosis -Predicting problems in those at risk and taking steps to manage risks and prevent complications -Identifying human responses and promoting optimum function, independence, and quality of life -Initiating actions and referrals in a timely way to ensure appropriate, qualified treatment

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types of diagnoses

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-nursing diagnosis -medical diagnosis -collaborative problems

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Nursing diagnosis

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describes patient problems nurses can treat independently (scope of practice)

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medical diagnosis

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describes problems for which the physician directs the primary treatment

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collaborative problems

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managed by using physician-prescribed and nursing-prescribed interventions

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Four steps of data interpretation and analysis

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1. Recognizing significant data *comparing data to standards 2. recognize patterns of clusters of data 3. identifying strengths and problems 4. reach conclusions

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reaching conclusions: no problem

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requires no nursing response. just reinforce the patient's healthy habits

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reaching conclusions: possible problem

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-nurse collects more data to identify if they have problem or not

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reaching conclusions: actual or potential nursing diagnosis

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actually have problem, so start nursing diagnosis

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reaching conclusions: clinical problem other than nursing diagnosis

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not nursing related, pulls in other professional

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types of nursing diagnoses: actual

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the actual problem

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types of nursing diagnoses: risk

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makes patient more vulnerable to problems

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types of nursing diagnoses: possible

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describe suspected problem, but we need to get more data to either validate problem or rule it out

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types of nursing diagnoses: wellness

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good diagnosis

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types of nursing diagnoses: syndrome

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cluster of actual or at risk diagnoses

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actual nursing diagnosis (3 parts)

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-diagnostic label -related factors (etiology) -defining characteristics (signs and symptoms)

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risk nursing diagnosis (2 parts)

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-diagnostic label -risk factors

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wellness diagnosis (1 part)

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diagnostic label

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three components of a diagnosis

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-problem -etiology -defining characteristics

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problem

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identifies whats actually unhealthy about pt clear + concise

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etiology

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cause/contributing factors

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defining characteristics

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subjective + objective data that helps support diagnosis

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High priority nursing diagnosis

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greatest threat to patient well-being

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medium priority nursing diagnosis

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nonthreatening diagnoses

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low priority nursing diagnosis

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diagnosis not specifically related to current health problems

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Maslow's Hierarchy of Human Needs

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-physiologic needs -safety needs -love and belonging needs -self-esteem needs -self-actualization needs

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benefits of nursing diagnoses 2

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-Individualizing patient care -Defining domain of nursing to healthcare administrators, legislators, and providers -Seeking funding for nursing and reimbursement for nursing services

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sources of error when writing nursing diagnoses

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-Writing diagnoses in terms of needs, not responses -Making legally inadvisable statements -Identifying as a problem what is not necessarily unhealthful -Identifying as a problem signs and symptoms -Reversing the clauses -Identifying as a patient problem what cannot be changed

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Sources of error cont

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-Identifying environmental factors rather than patient factors as the problem -Having both clauses say the same thing -Including value judgments in nursing diagnosis -Including medical diagnosis in diagnostic statement

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common sources of error in nursing diagnoses

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-Premature diagnoses based on incomplete database -Erroneous diagnoses resulting from inaccurate or faulty database -Routine diagnoses resulting from failure to tailor data to patient -Errors of omission

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goals of outcome identification and planning step

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-est. priorities -identify and write expected patient outcomes -select evidence-based nursing interventions -communicate plan of care

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a formal plan of care allows nurse to:

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-Individualize care that maximizes outcome achievement -Set priorities -Facilitate communication among nursing personnel and colleagues -Promote continuity of high-quality, cost-effective care -Coordinate care -Evaluate patient response to nursing care -Create a record used for evaluation, research, reimbursement, and legal reasons -Promote nurse's professional development

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planning outcome focused care

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-purpose of outcomes: promotes *outcomes are the measuring sticks of the plan of care *outcomes direct interventions *outcomes are focused solely on pt *focus on client/or a part of their care *motivators for pt

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initial planning

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-Developed by the nurse who performs the nursing history and physical assessment -Addresses each problem listed in the prioritized nursing diagnoses -Identifies appropriate patient goals and related nursing care

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Ongoing planning

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-Carried out by any nurse who interacts with pt -Keeps the plan up to date -States nursing diagnoses more clearly -Develops new diagnoses -Makes outcomes more realistic and develops new outcomes as needed -Identifies nursing interventions to accomplish patient goals

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discharge planning

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-Carried out by the nurse who worked most closely with the patient -Begins when the patient is admitted for treatment -Uses teaching and counseling skills effectively to ensure home care behaviors are performed competently

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cognitive outcome

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describes increases in patient knowledge or intellectual behaviors

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psychomotor outcome

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describes patient's achievement of new skills

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affective outcome

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describes changes in patient values, beliefs, and attitudes

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determining outcomes

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if all else fails, the outcomes should be the reverse, or the resolution, of the problem statement (the first part of diagnosis) *outcomes state the benefits of nursing care that you expect to see

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short term outcomes

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-describe the early expected benefits of nursing intervention -accomplished in specific period of time

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long term outcome

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-Describe the benefits expected to be seen at a certain point after the plan has been implemented -Requires a longer period to be achieved and may be used as discharge goals

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The focus of the outcome is..

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the patient

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outcome should

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-be measurable -be mutually formulated with the client -include a date and time -be realistic

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parts of a measurable outcome

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subject, verb, conditions, performance criteria, target time

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subject

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patient

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verb

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the action that patient performs (verbalizing, etc)

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conditions

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specify particular circumstance by which outcome will be achieved

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performance criteria

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describe in measurable terms, the expected patient behavior

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target time

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specifies when patient is going to reach goal (expected time)

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SMART outcomes

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Specific, measurable, attainable, realistic, time-bound/timely

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problems related to outcome identification and planning

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-Failure to involve patient -Insufficient data collection -Nursing diagnoses developed from inaccurate or insufficient data -Outcomes stated too broadly -Outcomes derived from poorly developed nursing diagnoses -Failure to write nursing order clearly -Nursing orders that do not solve problems -Failure to update the plan of care

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common errors in writing patient outcomes

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-Expressing patient outcome as nursing intervention -Using verbs that are not observable or measurable -Including more than one patient behavior or manifestation in short-term outcomes -Writing vague outcomes

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determining nursing interventions (ask yourself 3 questions)

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1. What can be done to prevent or minimize the cause(s) of this problem? 2. If nothing can be done about the cause(s), what can be done about the problem? 3. How can I tailor my interventions to meet the outcome I have listed?

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nurse-initiated interventions

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actions performed by a nurse without a physician's order

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physician-initiated interventions

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actions initiated by a physician in response to a medical diagnosis but carried out by a nurse under doctor's orders

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collaborative interventions

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treatments initiated by other providers and carried out by a nurse

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actions performed in nurse-initiated interventions (Alfaro, 2002)

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-Monitor health status. -Reduce risks. -Resolve, prevent, or manage a problem. -Facilitate independence or assist with ADLs. -Promote optimum sense of physical, psychological, and spiritual well-being.

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nursing orders (interventions) are generated from

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-second part of 3-part nursing diagnosis -"related factors" or "cause" suggest nursing interventions -they may also come from problem statement

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Patient variables influencing outcome achievement

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-Developmental stage -Psychosocial background

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Nurse variables influencing outcome achievement

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-Resources -Current standards of care -Research findings -Ethical and legal guides to practice

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common reasons for noncompliance

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-Lack of family support -Lack of understanding about the benefits -Low value attached to outcomes -Adverse physical or emotional effects of treatment -Inability to afford treatment

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evaluating step

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-Allows achievement of outcomes -Directs nurse-patient interactions -Measures patient outcome achievement -Identifies factors to achieve outcomes -Modifies the plan of care, if necessary

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action based on outcome achievement

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-Terminate plan of care when expected outcome is achieved. -Modify plan of care if there are difficulties achieving outcomes. -Continue plan of care if more time is needed to achieve outcomes.

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how to evaluate cognitive outcomes

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asking patient to repeat info or apply new knowledge

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how to evaluate psychomotor outcomes

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demonstrating new skills (actually do it)

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how to evaluate affective outcomes

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observing patient behavior and conversation

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how to evaluate physiologic outcomes

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using physical assessment skill to collect and compare data

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if outcomes are met

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-terminate the plan of care *be sure patient's needs will be met at home *give verbal and written instructions *discharge the person home

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evaluative statements

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-Decide how well outcome was met (met, partially met, or not met). -List patient data or behaviors that support this decision.

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variables affecting outcome achievement

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-Patient *For example, a patient gives up and refuses treatment -Nurse *For example, a nurse is suffering from burn-out -Healthcare system *For example, inadequate staffing

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revisions in the plan of care

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-Delete or modify the nursing diagnosis. -Make the outcome statement more realistic. -Increase the complexity of the outcome statement. -Adjust time criteria in outcome statement. -Change nursing interventions.

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