NU127 10. Nursing Process: Part One – Flashcards

"Nursing is 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". (ANA, 2010a p6)

1955: Lydia Hall The work of nursing 1967: Yura + Walsh 4 steps of the nursing process. 1973: ANA 5 steps of the nursing process The significant actions taken by registered nurses and forms the foundation of the nurses' decision making (ANA, 2010). 1982: State Board of Nursing started to use the nursing process as a framework for national exams (previously used medical model as organizational framework).

1. Assessing: collecting, validating, and communicating of patient data 2. Diagnosing: analyzing patient data to identify patient strengths and problems 3. Planning: specifying patient outcomes (goals) and related nursing interventions 4. Implementing: carrying out the plan of care 5. Evaluating: measuring extent to which patient achieved outcomes

...Developing a plan of nursing strategies to be integrated within the client-centered health care plan that establishes nursing diagnoses, setting goals to meet identified health care needs, prescribing nursing interventions, and implementing nursing care through the execution of independent nursing strategies and prescribed medical regimen. Evaluating responses to interventions and the effectiveness of the plan of care.

Systematic Dynamic Interpersonal Outcome oriented Universally applicable

Patient: Scientifically based, holistic individualized patient care Continuity of care Clear, efficient, cost-effective plan of action Nurse: Opportunity to work collaboratively with other healthcare workers Satisfaction of making a difference in lives of patients Opportunity to grow professionally

Strategies for collecting subjective data Discuss the focused interview and health history. Describe the mnemonic COLDSPA Describe extraneous variables that influence the quality of data collection Discuss the nursing process, nursing assessment and their relationship. Review steps of the nursing assessment. Discuss Marjorie Gordon's Functional Health Pattern assessment

Initial - everything to get an idea Focused - problem oriented Emergency - focused on concerning data Time-lapsed - if it has changed from the time before

Health perception/health management Nutrition/metabolic Elimination Activity/exercise Sleep/rest Cognitive/perceptual Self-perception/self-concept Role/relationship Sexuality/reproductive pattern Coping-stress tolerance Value belief

Activity/rest Circulation Ego integrity Elimination Food/fluid Hygiene Neurosensory Pain/discomfort Respiration Safety Sexuality Social interactions Teaching/learning Discharge Plan

Immediately give verbal reporting of data whenever a critical change in the patient's health status is assessed. Enter initial database into computer or record in ink on designated forms the same day patient is admitted. Summarize objective and subjective data in concise, comprehensive, and easily retrievable manner. Use good grammar and standard medical abbreviations. Whenever possible, use patient's own words. Avoid nonspecific terms subject to individual interpretation or definition.

Analysis of patient data to identify strengths and health problems that independent nursing interventions can prevent or resolve.

Recognizing significant data - Comparing data to standards Recognizing patterns or clusters Identifying strengths and problems Reaching conclusions

Clarify the exact nature of patient problems and risks that must be addressed to achieve the overall expected outcomes. The nurse needs to understand patient problems and the contributing factors.

No problem Possible problem Actual or potential nursing diagnosis Clinical problem other than nursing diagnosis

Incomplete data Faulty data Omission Including value judgement Making illegally advisable statements Writing needs not responses

Medical: Identify diseases Remains the same as long as disease present MD directs treatment. - e. g. Myocardial Infarction Nursing: Identify unhealthy responses to health + illness. May change day to day Problems treated by nurses (within scope of practice) - e.g. Pain; Fear; altered tissue perfusion.

Actual Risk Possible Wellness Syndrome

Actual Nursing Diagnosis: Describes human response to health conditions/life processes (3 part statement) Risk Nursing Diagnosis: Describes a high probability of developing condition/life process , supported by "risk factors," there are NO defining characteristics or DATA to support an actual diagnosis (2 part statement) Wellness Diagnosis: Describes the readiness to enhance specific health behaviors, focus is on being as healthy as possible. Not related to a disease or problem—NO related factors or risk factors (2 part statement) Syndrome Nursing Diagnosis: Describes a cluster of nursing diagnoses that occur together and are best addressed together with similar interventions (3-part statement)

3-part statement: Part I: the problem; human response Part II: related factors; factors contributing to or the probably cause of the problem (human response) Part III: signs + symptoms

2-part statement: risk for infection related to presence of invasive lines and indwelling catheter Part I: the problem (human response) Part II: the cause of the problem

A 90 yr. old client with left-sided hemiparesis has a red, broken area on skin over coccyx and cannot turn self in bed.

Trial-and-error problem solving Scientific problem solving Intuitive thinking Critical thinking

SMART format: Specific Measurable: will verbalize; will demonstrate Attainable Realistic Timely Example: The patient will sleep 6 hours per night and report a restful night sleep by day 5 of hospitalization.

The client will understand how to change leg dressing. The client will demonstrate dressing change on leg using aseptic technique prior to discharge.

Cognitive: describes increases in patient knowledge or intellectual behaviors - Client will list 2 potential side effects of lorazepam by the end of medication education session 2/25/16 Psychomotor: describes patient's achievement of new skills - Client will demonstrate correct technique for insulin injection prior to discharge (2/25/16) Affective: describes changes in patient values, beliefs, and attitudes - Client will verbalize hopefulness in decision to transition to rehab facility after meeting with substance abuse counselor (2/25/26) **Behavioral: client will eat 50% of meals by day 3 of hospitalization

STG LTG At least one goal/outcome for each diagnosis: dated

Nursing orders Individualized Evidenced-based rationale Nurses perform nursing actions Nurses delegate tasks Nurses Supervise staff Nurses document care + patient responses E.g. Nurse will... weight client each day at 6am before meals and meds

Start all outcomes with "Client will..." Start all Interventions with "Nurse will..." Add a date and time when everything will be done

Ongoing Comparing data to goals Evaluation of progress toward the outcomes Evaluation of the interventions

Terminate the plan of care: Be sure patient's needs will be met at home. Give verbal and written instructions. Discharge the person home.

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.

NANDA-I Nursing Diagnoses Nursing Outcomes Classification (NOC) Nursing Interventions Classification (NIC) NANDA-NOC-NIC Linkages

Nursing care must be documented according to the steps of the nursing process. e.g. The patient was medicated for right leg pain (rated pain 5/10) with advil 800mg po @ 2pm. Now what? REASSESS!

ANSWER: B. Diagnosing Rationale: diagnosing - analyzing patient data to identify strengths and weaknesses

ANSWER: D. Target time Rationale: use SMART format with goal formulation

ANSWER: D. Evaluation Rationale: Evaluation is the process of comparing client responses to the outcome goals to determine whether or to what degree, goals have been met.