Nursing Process

NUR101 Fall 2008 Lecture #6 and #7 K. Burger, MSEd, MSN, RN, CNE
PPT By: Sharon Niggemeier RN MSN Revised KBurger 8/06 Revised JBorrero 09/08

Nursing Process
Specific to the nursing profession A framework for critical thinking Its purpose is to:
Diagnose and treat human responses to actual or potential health problems

Nursing Process
Organized framework to guide practice Problem solving method - client focused Systematic- sequential steps Goal oriented- outcome criteria Dynamic-always changing, flexible Utilizes critical thinking processes

Scientific Method of problem solving

ID problem Collect data Form hypothesis Plan of action Hypothesis testing Interpret results Evaluate findings

Advantages of Nursing Process

Provides individualized care Client is an active participant Promotes continuity of care Provides more effective communication among nurses and healthcare professionals Develops a clear and efficient plan of care Provides personal satisfaction as you see client achieve goals Professional growth as you evaluate effectiveness of your interventions

5 Steps in the Nursing Process

Assessment Nursing Diagnosis Planning Implementing Evaluating

Assessment
First step of the Nursing Process Gather Information/Collect Data

Primary Source - Client / Family Secondary Source - physical exam, nursing history, team members, lab reports, diagnostic tests.. Subjective -from the client (symptom)
I have a headache

Objective - observable data (sign)

Blood Pressure 130/80

Assessment-collecting data
Nursing Interview (history) Health Assessment -Review of Systems Physical Exam

Inspection Palpation Percussion Auscultation

Assessment-collecting data
Make sure information is complete & accurate Validate prn Interpret and analyze data Compare to standard norms Organize and cluster data

Example of Assessment
Obtain info from nursing assessment, history and physical (H&P) etc... Client diagnosed with hypertension B/P 160/90 2 Gm Na diet and antihypertensive medications were prescribed Client statement I really dont watch my salt Its hard to do and I just dont get it

Nursing Diagnosis
Second step of the Nursing Process Interpret & analyze clustered data

Identify clients problems and strengths

Formulate Nursing Diagnosis (NANDA : North American Nursing Diagnosis Association)-Statement of how the client is RESPONDING to an actual or potential problem that requires nursing intervention

Nsg Dx

vs

MD Dx

Within the scope of Within the scope of nursing practice medical practice Identify responses Focuses on curing to health and illness pathology Can change from Stays the same as day to day long as the disease is present

Formulating a Nursing Diagnosis

Composed of 3 parts: Problem statement- the clients response to a problem Etiology- whats causing/contributing to the clients problem Defining Characteristics- whats the evidence of the problem

Nursing Diagnosis
Problem( Diagnostic Label)-based on your assessment of client(gathered information), pick a problem from the NANDA list... Etiology- determine what the problem is caused by or related to (R/T)... Defining characteristics- then state as evidenced by (AEB) the specific facts the problem is based on...

Example of Nursing Dx
Ineffective therapeutic regimen management R/T difficulty maintaining lifestyle changes and lack of knowledge AEB B/P= 160/90, dietary sodium restrictions not being observed, and client statements of I dont watch my salt Its hard to do and I just dont get it.

Types of Nursing Diagnoses

Actual Imbalanced nutrition; less than body requirements RT chronic diarrhea, nausea, and pain AEB height 55 weight 105 lbs. Risk Risk for falls RT altered gait and generalized weakness Wellness Family coping: potential for growth RT unexpected birth of twins.

Collaborative Problems
Require both nursing interventions and medical interventions EXAMPLE: Client admitted with medical dx of pneumonia Collaborative problem = respiratory insufficiency Nsg interventions: Raise HOB, Encourage C&DB MD interventions: Antibiotics IV, O2 therapy

Planning
Third step of the Nursing Process This is when the nurse organizes a nursing care plan based on the nursing diagnoses. Nurse and client formulate goals to help the client with their problems Expected outcomes are identified Interventions (nursing orders) are selected to aid the client reach these goals.

Planning Begin by prioritizing client problems

Prioritize list of clients nursing diagnoses using Maslow Rank as high, intermediate or low Client specific Priorities can change

Planning Developing a goal and outcome statement

Goal and outcome statements are client focused. Worded positively Measurable, specific observable, time-limited, and realistic Goal = broad statement Expected outcome = objective criterion for measurement of goal Utilize NOC as standard
EXAMPLE

Goal: Client will achieve therapeutic management of disease process. Outcome Statement: AEB B/P readings of 110-120 / 70-80 and client statement of understanding importance of dietary sodium restrictions by day of discharge.

Planning- Types of goals

Short term goals Long term goals Cognitive goals Psychomotor goals Affective goals

Goals are patient-centered and SMART

Specific Measurable Attainable Relevant Time Bound
Pt will walk 50 ft. Pt will eat 75% of meal Pt will be OOB 2-4hrs Pt will maintain HR<100 Pt will state pain level is acceptable 6 (0-10)

Planning-select interventions
Interventions are selected and written. The nurse uses clinical judgment and professional knowledge to select appropriate interventions that will aid the client in reaching their goal. Interventions should be examined for feasibility and acceptability to the client Interventions should be written clearly and specifically.

Interventions 3 types
Independent ( Nurse initiated )- any action the nurse can initiate without direct supervision Dependent ( Physician initiated )-nursing actions requiring MD orders Collaborative- nursing actions performed jointly with other health care team members

Implemention
The fourth step in the Nursing Process This is the Doing step Carrying out nursing interventions (orders) selected during the planning step This includes monitoring, teaching, further assessing, reviewing NCP, incorporating physicians orders and monitoring cost effectiveness of interventions Utilize NIC as standard

Implementing- Doing
Monitor VS q4h Maintain prescribed diet (2 Gm Na) Teach client amount of sodium restriction, foods high in sodium, use of nutrition labels, food preparation and sodium substitutes
Teach potential complications of hypertension to instill importance of maintaining Na restrictions Assess for cultural factors affecting dietary regime

Implementing Doing
Teach the clienthypertension cant be cured but it can be controlled. Remind the client to continue medication even though no S/S are present. Teach client importance of life style changes: (weight reduction, smoking cessation, increasing activity) Stress the importance of ongoing follow-up care even though the patient feels well.

Evaluation- To determine effectiveness of NCP

Final step of the Nursing Process but also done concurrently throughout client care A comparison of client behavior and/or response to the established outcome criteria Continuous review of the nursing care plan Examines if nursing interventions are working Determines changes needed to help client reach stated goals.

Evaluation
Outcome criteria met? Problem resolved! Outcome criteria not fully met? Continue plan of care- ongoing. Outcome criteria unobtainable- review each previous step of NCP and determine if modification of the NCP is needed. Were the nsg interventions appropriate/effective?

Evaluation
Factors that impede goal attainment:
Incomplete database Unrealistic client outcomes Nonspecific nsg interventions Inadequate time for clients to achieve outcomes.

Checkpoint
Identify which stage of the nursing process is being described below: The nurse writes nursing interventions A goal is agreed upon The nurse performs a physical assessment A revision is made to the NCP The nurse administers antibiotic medication A statement is written that outlines the clients response to a potential health problem

S and O Data Quiz

RR 22/min, even unlabored I can only walk 3 blocks before my legs start to hurt Pain rated 3 on a scale of 0-10 Skin pink, warm and dry Urine output 300mL/8 hr My wife doesnt come to visit very often Dressing clean, dry and intact.

NCLEX Time
The nurse records the following subjective data in the clients medical record: A.Breath sounds clear to auscultation B.Amber urine in sufficient quantities C.Pain intensity 8 out of 10 D.Skin warm and dry

NCLEX Time
When interviewing a client, the nurse uses the following open-ended style sentence: A.Do you have any concerns right now? B.Is your family worried about you being in the hospital? C.How many times do you get up to go to the bathroom at night? D.What do you mean when you say, I dont feel quite right?

NCLEX Time
In order for an actual nursing diagnosis to be valid it must have one or more supporting: A.Laboratory results B.Diagnostic data C.Defining characteristics D.Medical diagnoses

NCLEX Time
Nursing diagnoses are aimed at identifying client problems that are treatable by _______. A.The physician B.The nurse C.Invasive techniques D.Complementary strategies