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organizational framework for the practice of nursing Orderly, systematic Central to all nursing care Encompasses all steps taken by the nurse in caring for a patient
organized sequence of problemsolving steps used to identify and to manage the health problems of clients It is accepted for clinical practice established by the American Nurses Association
Provides an orderly & systematic method for planning & providing care Enhances nursing efficiency by standardizing nursing practice Facilitates documentation of care Provides a unity of language for the nursing profession Is economical Stresses the independent function of nurses Increases care quality through the use of deliberate actions
the legal scope of nursing Based on knowledge-requiring critical thinking Planned-organized and systematic Client-centered Goal-directed Prioritized Dynamic
Being Accountable
Using critical thinking before taking actions Being responsible for your actions Entering the professional role Working at the level of your peers Using the nursing process
Nurses are responsible for a unique dimension of healthcare the diagnosis and treatment of human responses to actual or potential health problems
an apple is cut, others see seeds in the apple. We, as nurses, see apples in the seeds.
Recognize health problems. Anticipate complications. Initiate actions to ensure appropriate and timely treatment.
Critical Thinking
ATTITUDES- curious/open-minded/nonjudgmental.
Critical Thinking
Critical thinking in nursing is an essential component of professional accountability and quality nursing care.
Assessment of Well-Being
According
Nurse collects background info from previous charts Ensure environment is conducive Arrange seating Allow adequate time Nurse introduces self Identifies purpose of interview Ensure confidentiality of information Provide for patient needs before starting
TYPES OF INTERVIEWS
DIRECTED NON-DIRECTED
THINGS THAT IMPAIR COMMUNICATION: PRESENTING QUICK SOLUTIONS UNWARRANTED CHEERFULNESS FALSE REASSURANCE GIVING ADVICE CHANGING THE SUBJECT
ASSESSMENT
Observation
Interview
Types
data-observable and measurable facts (Signs) Subjective data-information that only the client feels and can describe (Symptoms)
CULTURAL DIVERSITY
MUST PROVIDE CARE CONGRUENT WITH A CLIENTS EXPECTATIONS This is not about you ? Respect INDIVIDUALS DIFFERENCES, What is the significance of the problem or illness to the client? What does it mean in the family/community?
Continued
THE NURSING PROCESS HELPS NURSES UNDERSTAND THE STRATEGIES CLIENTS USE IN their attempt at coping: This knowledge will help you FURTHER INDIVIDUALIZE THEIR CARE
Resources
Client Other individuals Previous records Consultations Diagnostics studies Relevant literature
Assessment
Data base assessment comprehensive information you gather on initial contact with the person to assess all aspects of health status. Focus assessment the data you gather to determine the status of a specific condition.
Sources of Data
Primary
source: Client Secondary source: Clients family, reports, test results, information in current and past medical records, and discussions with other health care workers
Disease Prevention
Primary prevention protection from a disease while still in a healthy state. Secondary prevention early detection and treatment of disease. Tertiary prevention prevent complications and to maintain health once the disease process has occurred.
Verifying Data
Essential in critical thinking!!!!! Measurable data Double check personal observations Double check equipment Check with experts and team members Recheck out-liers Compare objective and subjective data Clarify statements
Planning
Establish
2. 3. 4.
Take care of immediate life-threatening issues. Safety issues. Patient-identified issues. Nurse-identified priorities based on the overall picture, the patient as a whole person, and availability of time and resources.
Composite of all patients strengths and health concerns. Moral and ethical issues. Time, resources, and setting. Hierarchy of needs. Interdisciplinary planning.
State what the patient will do or experience at the completion of care. Give direction to the patients overall care. Patient behaviors not nurse behaviors!!
The patient will
DIAGNOSIS
Sort, cluster, analyze information Identify potential problems and strengths Write statement of problem or strength Risk of infection related to compromised nutrition
Look at the first clause of the nursing dx and restate in a statement that describes improvement, control or absence of the problem. Risk for infection r/t surgical procedure. The client will demonstrate no signs or symptoms of infection.
Components of Outcomes
Subject: who is the person expected to achieve the outcome? Verb: what actions must the person take to achieve the outcome? Condition: under what circumstances is the person to perform the actions? Performance criteria: how well is the person to perform the actions? Target time: by when is the person expected to be able to perform the actions?
Nursing Interventions
1. 2. 3. 4. 5.
Road maps directing the best ways to provide nursing care. Evidence based nursing. Monitor health status. Minimize risks. Resolve or control a problem. Assist with ADLs. Promote optimum health and independence.
Interventions
Nursing Diagnosis
Health
issue that can be prevented, reduced, resolved, or enhanced through independent nursing measures
1.
2.
3.
To ensure continuity of care, the plan must be written and shared with all health care personnel caring for the client. Consists of: Prioritized nursing diagnostic statements. Outcomes. Interventions.
Documentation
Clear and concise Appropriate terminology
Usually on a designated form Usually by Review of Systems Overview of symptoms Diet Each body system
Physical assessment
Documentation
Use patients own words in subjective data enclose in ___ (quotation marks) Avoid generalizations be specific Dont make summative statements describe - e.g. patient is being ornery should be patient resists instruction or patient states Dont talk to me, I dont care about that
Evaluation
1. 2.
3.
Determining outcome achievement Identifying the variables affecting outcome achievement Deciding whether to continue, modify, or terminate the plan
Must be aware of outcomes set for the client. Must be sure patient is ready for evaluation. Is patient able to meet outcome criteria? Is it: Completely met? Partially met? Not met at all? Record in progress in notes. Update care plan.
Maintain individuality of care plan: 1. Is the plan realistic for the client? 2. Is the plan appropriate at the time for this particular client? 3. Were changes made in the plan when needed? 4. How does the client feel about the plan?
Focus on early intervention Based on research Predict and anticipate problems Look for risk factors
Diagnostic Statements
Name
of the health-related issue or problem as identified in the NANDA list Etiology (its cause) Signs and Symptoms The name of the nursing diagnosis is linked to the etiology with the phrase related to, and the signs and symptoms are identified with the phrase as manifested (or evidenced) by
medical diagnoses or medical treatment measures with the risk for unique complications Documenting the complications for which clients are at risk Making pertinent assessments to detect complications
Continued
Reporting trends that suggest development of complications Managing the emerging problem with nurse- and physician-prescribed measures Evaluating the outcomes
or conclusion about the risk for or actualneed/problem of the patient NANDA format
Planning
The
process of prioritizing nursing diagnoses and collaborative problems, identifying measurable goals or outcomes, selecting appropriate interventions, and documenting the plan of care. The nurse consults with the client while developing and revising the plan.
Setting Priorities
Determine
Short-Term Goals
Outcomes
1 week Developed form the problem portion of the diagnostic statement Client-centered Measurable Realistic Accompanied by a target date
Long-Term Goals
Desirable
outcomes that take weeks or months to accomplish for clients with chronic health problems
Time
frame
the measures that the client and nurse will use to accomplish identified goals involves critical thinking. Nursing interventions are directed at eliminating the etiologies.
Selecting an intervention
The nurse selects strategies based on the knowledge that certain nursing actions produce desired effects. Nursing interventions must be safe, within the legal scope of nursing practice, and compatible with medical orders.
nurse shares the plan of care with nursing team members, the client, and clients family. The plan is a permanent part of the record.
Evaluation
The
way nurses determine whether a client has reached a goal. It is the analysis of the clients response, evaluation helps to determine the effectiveness of nursing care.
part of the nursing process Determining the status of the goals and outcomes of care Monitoring the patients response to drug therapy
Documentation
Clear and concise Appropriate terminology
Usually on a designated form Usually by Review of Systems Overview of symptoms Diet Each body system
Physical assessment