Nursing Process and Concept Mapping

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Nursing Process Review Steps
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1. Assessment 2. Nursing Diagnosis 3. Planning 4. Nursing Intervention 5. Evaluation
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Assessment
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– Collection of data that is then used to identify client needs – Data collection tool vary according to institution and unit – Not a linear process, as you assess you are listening, making observations, and mentally grouping data into meaningful patterns – Relationship – Subjective and objective – Not the only time you assess the patient, always re-assessing its an ongoing process
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Nursing Diagnosis and components
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-Assignment of nursing diagnosis(es) to clustered data – Nursing diagnosis provides basis for selecting nursing interventions to achieve outcomes for which the nurse is accountable – Five components: 1. Label (name of nursing dx) 2. Definition 3. Set of defining characteristics- S$S- data- how you build your case 4. Group of related risk factors 5. Risk Factors – NANDA: North American Nursing Diagnosis Administration- has all N dx, what we will use to ID our patients problems
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History of Nursing Diagnosis
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– First introduced in 1950 – In 1953, Fry proposed the formulation of nursing diagnosis – In 1973, first national conference held – In 1980 and 1995 the American Nurses Association (ANA) included diagnosis as a separate activity in its publication Nursing: a Social Policy Statement – In 1982, North American Nursing Diagnosis Association (NANDA) was founded – Nurses take care of people in human response to illness/condition, we are not licensed to diagnosis – we look at what is the effect on the person when they get labeled with a diagnosis – Note 60s civil war and women’s rights –> women started to speak up –> true profession –> ND
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Planning
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– Goals are set and nursing care is planned: 1. Client organized 2. Prioritized 3. Document plan
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Intervention and types
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– Plan of care is carried out 1. Independent: a. Counseling: informal- coaching through anxiety of surgery vs. formal- teaching about DM, education people importance of incentive spirometer, counseling teenagers about safe sex b. Providing comfort measures c. Teaching d. Offering emotional support e. Managing the environment- in hospital safety for falls, if patient wants mom in the room or not (re-assessing situations) f. Assessing 2. Dependent: activities carried out under a physician’s orders- Dr. order an IV antibiotics and you implement that order, things doing as a nurse under physicians order
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Evaluation
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– Planned outcomes are measured against actual outcomes – Met? – Partially met? – Unmet? and then revise accordingly
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Nursing History
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– Types of Assessments – Types of Data – Sources of data – active listening and processing – types of interviews – Review of Functional Health Patterns – Documenting the data
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Nursing Diagnosis- Types
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– Focus on client’s problem(s) – Establishes a link between assessment and planning interventions 1. Problem Focused 2. Risk Focused 3. Health Promotion
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Problem Focused Nursing Diagnsois
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– describes a clinical judgement concerning an undesirable human response examples: infection, nausea, vomiting secondary to medications, acute pain, knowledge deficit, ineffective airway clearance – Requires: Defining characteristics and related factors
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Risk focused Nursing Diagnosis
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– describes a clinical judgement concerning the vulnerability for developing an undesirable human response – examples: risk for falls, risk for DVT, risk for HAI- usually easiest to do – Requires risk factors
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Health Promotion Nursing Diagnosis
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– Describes a clinical judgement concerning a patient’s motivation and desire to increase well-being and actualize human health potential – not many in med/surg. unless want to quit smoking – depression- if depression is keeping them from care and asked and they want to change – requires defining characteristics (can also use related factors)
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Steps in Diagnostic Process
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1. Review the Assessment Data 2. Cluster the data 3. Select possible nursing diagnosis- these must match the client’s reason for seeking care, goals for health, and preferences 4. Differentiate Among Possible Diagnoses – Does cluster match one of the dx better than others – If data insufficient, gather more with a focus (re-assess, talk to patient gather more information figure out what you don’t know) – Review defining characteristics – May need to keep both dx, until situation becomes clearer 5. Identify Appropriate Diagnoses: using clinical judgement and prioritization 6. Determine Related Factors: etiological (casual) factors which give direction to nursing care 7. Validate Nursing Diagnoses with the Client
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Should you use patient or client?
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PATIENT
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STEPS for Nursing DX
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– Assess patient health status: patient, family, health care resources, use critical thinking –> – Validate data with other source –> – Is additional data needed? (If yes go back to assess, reassess) –> – Interpret and analyze meaning of data —> – Data clustering: groups s/s and classify and organize –> – Look for defining characteristics and related factors –> – Identify patients needs –> – Formulate nursing dx and collaborative problems
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Relationship between a Diagnostic Label and Related Factors and Etiology
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Problem is related to Etiology: Problem: Patient’s health problem is reduced PA stays in tense position Etiology: discomfort in perineum- increases with movement *Nurses use critical thinking to see clusters of data and consider context of the health problem* – Mobility and functional problem –> Discomfort reduces mobility, rates discomfort 7/10, winces when moves (using functional health problems, and your knowledge tells you discomfort reduces mobility) –> Diagnostic Label: Impaired Physical Mobility Etiology: Acute incisional Pain
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3- Part Nursing Diagnosis Format
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1. Problem: Impaired Physical Mobility (identify nursing dx) 2. Etiology/Related Factors: r/t Incisional Pain 3. Symptoms/Defining Characteristics: AEB (as evidence by) patient unable to turn self in bed; requires 2 assist to stand and pivot to chair
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Related Factors Definition and Types
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– are associated with the patient’s actual or potential response to a health problem – NANDA 1-4 categories 1. Pathophysiological- biological or psychological 2. Treatment- related 3. Situational- environmental or personal (anxious because crazy brother has showed up and asked a lot of questions) 4. Maturational (unique to older adults or pediatric) – Assess- ask and observe – Clustering Cues- the patient responds that pain is 7/10 scale note that patient is lying stiff in bed – Etiology.Related to swelling from incisional trauma – Nursing dx= Acute Pain related to trauma of incision
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Types of Planning
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– Initial Planning – Ongoing planning – Discharge planning – Collaborative Planning – Consultation: ID appropriate person, provide factual information, allow independent judgement, discuss recommended solutions, decide who should implement care – Care Plan conferences
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Important Steps in Planning
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Establishing Priorities: useful tool for thinking about priorities is Maslow’s hierarchy of needs- what’s most threatening – Health care setting influences prioritization – Client’s perception of need – Client’s self care ability AND – Establishing Outcomes: desired end results that must be realistic, measurable, acceptable to the client, and include a time-frame
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Outcome Measures
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– Morbidity – Client satisfaction – ADLs – Mortality – Cognitive function – Length of stay – Effectiveness and Efficiency – Infection rate – Nursing sensitive client outcomes: pressure ulcers, client falls, client satisfaction with pain management, client satisfaction with overall care and nursing care, and infection rate * Nursing Outcome Classification System: NOC
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Intervening and types
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– Implementation of planned nursing activities – Skills include: teaching, collaborating, managing, coordinating, monitoring, assisting, supporting, protection, and sustaining – Types of Interventions 1. Direct Care 2. Indirect Care 3. Nurse-initiated and Physician-initiated
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Elements of an Intervention
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– Who – Where – When – Why – How – Example: 2 hour repositioning for prevention of pressure ulcers: who = patient, where- in bed, when- every two hours, why- prevent pressure ulcers, how- with assistance + goal- ambulate to door – Nursing Intervention Classification (NIC) System
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Concept Mapping
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– Originated by Joseph Novak at Cornell University in the 1970’s – Research to understand the ways children think while learning – Can be used to understand nurses thinking about treatment of patients – = a visual representation of patient problems and interventions that show their relationship with one another – purpose= to better synthesize relevant data about a patient – Connections between concepts instead of just concepts or patient conditions – Difference between knowing how to use skills and knowing when to use skills (usually one problem is influenced by something else)
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Concept Mapping: Diagram
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– a visual description of the nursing process for a particular patient – Draw out problems, assessment data, interventions, and evaluation of that data
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Advantages to Concept Mapping
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– Facilitates the critical thinking process – Allows the learner to synthesize large amounts of material into a coherent diagram – Allows the student to see inter-relationships among data and problems – Enables problems to be prioritized – Expedites learning and allows for long term retention of material – Versatile- allows for student creativity – Method of communication between student and instructor
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Developing a Concept Map what goes in middle and around?
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– The reason for the patient admission or major problem is located in the center of the map – Major problems are then identified and placed around the center of the page like spokes on a wheel
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Developing a Map: Step Number 1
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– In the center of the diagram, write out the reason for admission, medical diagnosis, co-morbidities, or anything that is causing a problem for this patient Example- Knee Replacement, Hypertension, Asthma
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Developing a Map: Step Number 2 a and b
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(a) – Research the admitting diagnosis, co-morbities or any problems that are currently affecting the patient – Identify potential problems that the patient may encounter (b)- develop a basic skeletal diagram of health problems
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Developing a Map: Step 3
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– Identify and list key assessments to be completed based on your research of the reason for seeking care – problems should radiate out from the center box like spokes on a wheel
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Developing a Map: Step 4
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– Review Gordon’s Functional health Patterns to identify if all areas of concern or problems have been identified in the map – BIO-PSYCHO-SOCIAL
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Developing a Map: Step 5
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– Analyze and categorize specific patient data and identify key ongoing assessments: – subjective/objective – abnormal assessment findings – treatments – medications -IV fluids – Abnormal diagnostic and laboratory tests – Pertinent Medical history – Patient’s emotional state – Pain
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Developing a Map: Step 6
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– Identify outcomes for each problem that has been identified – Needs to be measurable
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Developing a Map: Step 7
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– Draw lines between inter-related problems – Think about which problems may impact each other and draw lines to demonstrate relationships
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Developing a Map: Step 8
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– Label the problems with a nursing diagnostic label developed by the NANDA – Analyze the relationship between the problem and the data to identify and appropriate diagnosis
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Developing a Map: Step 9
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– Number the problems on the diagram and prioritize them – Highest priority = #1 and next is 2 – ABC’s- Gordon’s Functional Health Patterns- Maslow’s Hierarchy of Needs
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Developing a Map: Step 10
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– Throughout the clinical day evaluate the interventions and plan of care to determine whether or not the outcome was achieved
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Pre-conference map
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Steps 1, 2, 3
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Clinical Setting REvision
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Steps 4, 5, 6, 7
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Post- Clinical Map
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Steps 8, 9, 10
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Evaluating Client Outcomes
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– What are the client’s responses to interventions in relation to expected outcomes? Are the responses desirable or undesirable? – Are the interventions effective in meeting expected outcomes? If not, why are the interventions ineffective? Is it necessary to revise outcomes or interventions? – Is the nursing diagnosis still active? Is it necessary to revise it or to add new nursing diagnoses?
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Factors Affecting Outcomes Attainment
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1. Facilitators – Realistic outcomes – Frequent monitoring – Maintaining continuity of care – Collaboration – Client participation 2. Barriers – Lack of critical thinking – Lack of knowledge about client care, diseases, and tx – Fragment nursing care – Lack of communication – Lack of involvement of client
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Factors Affecting outcomes-
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– Experience and expertise of nurse – Patient acuity – Availability of resources – Interruptions from care providers – Nurse-patient relationship – Ward organization – Priority-setting strategies and frameworks – Philosophies and models of care

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