Nursing Process - PowerPoint by WNFT9h

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									   Role Components, (Cont.)
• Researcher: goal is to improve quality of nursing
  care, develops questions about procedures and
  medications; collects data daily, values research,
  applies findings to practice
• Mentor: (Webster’s Dictionary), wise and loyal
  adviser; nurse is wise adviser to new nurse or
  employee, loyal by assisting with unit policy and
  procedures, explaining equipment, easing
• Nurse preceptor assignment of new nurse to
  another nurse, assists transition, confident, safe,
  supportive environment, smooth adaptation to
  nurse role, enhances recruitment and retention
   Role Components, (Cont.)
• Collaborator: coordination of patient’s care,
  skillfully schedules and communi-cates pt’s
  needs to departments, meets with
  multidisciplinary personnel to achieve pt’s goal,
  meets with family to plan care management,
  delegates responsibilities to other nurses and
  follows up on delegated tasks
  Role Components, (Cont.)
• Change Agent: daily changes occur in
  present health care delivery system, often
  consequences of nursing input
• Creative, communication skills to
  persuade change as smoothly as possible
• Writes proposals, shares ideas with
  administrators, staff and committee
• Influences public policy, politicians,
  legislators, (staffing, medication issues)
• Professional nursing organizations
        Role Components
• Competent worker, organized care
  provider, knowledgeable caregiver, caring
  person, hard worker
• Advocate: speaks for and acts on behalf
  of another, speaks to doctor, pt’s rights,
  representative, patient is never alone
• Counselor: listens to pt, counsels,
  therapeutic communication, explains,
  defines, reviews options, assists with
  choices that determine health outcome;
  identifies pt’s emotional status
  Role Components, (Cont.)
• Educator: daily: explaining procedures,
  lab results, disease processes, care
  interventions, meeting emotional needs.
  Staff educator: current literature, shares
  know-ledge with co-workers, applies to pt
• Entrepreneur: venturing into health care
  business challenges, filling gaps in health
  care system, expanding scope of nursing
  and health care (aromatherapy, case
  management, counseling services).
  Nurse Practitioner: mng. health clinics,
  adult day care centers
  Role Components, (Cont.)
• Role Model: professional example for
  student nurses and new grads, during
  interaction with pts, team members, co-
  workers, positive, encouraging, supportive
  work environment
• Leader: manages pt care, units, clinics,
  accepts decision making, autonomy,
  responsibility, accountability in providing
  competent care; encourages other nurses
  to also become leaders; interpersonal
  communication is perfected
        Role Socialization
• Internalization of a new personal identity
• Chosen to move to different level in
  education and professional status
• Personal identity meshes with
  professional identity
• Developing internal attitude toward a
• Learning new skills, new way of thinking
• Developing new values toward the nursing
            Adult Learner
• Special expectations/goals for educational
• Principles of adult learning (Lawler, 1991):
  1. requires atmosphere of respect
  2. cooperative, two-way learning environ-
      ment essential
  3. builds on the education of participant
  4. encourages critical contemplative thinking
    Adult Learner, (Cont.)
5. presents situational problems and
    encourages problem-solving
6. adult education is pertinent and     applicable
7. active, give and take process
8. gives power and immeasurable oppor-
    tunity to learner
9. stimulates learner to be self-directed      and
        Adult Learner, (Cont.)
• LVN comes to learning environment with foundation of
  knowledge and experience to be refine and advanced to
  next educational level
• Must have a voice and be involved in learning process
• Interact with staff/faculty, examine/analyze clinical
  situations, find solutions to clinical and patient problems
• Experience provides confidence, comfort, independence in
  clinical environment
• Seek feedback to improve critical thinking skills and
• Opportunity to blossom and reach full potential
• Value past education, meet challenges of accepting new
  ideas and nursing techniques
• Time of tremendous growth and change!!
       Resocialization Tool
• Throwe and Fought, 1987
• Assessment tool/table using Erickson’s
  developmental stages to identify changes during
  role transition
• pp 34-40, Transitioning from LPN/VN to RN,
  Duncan, DePew.
            Role Transition
• Change in role requirements, expecta-tions, work
• Requires internal change in thinking about or
  viewing new role
• May think performing same responsibilities but
  now more knowledgeable
• Using critical thinking skills and nursing judgment
• Not an overnight change
     Role Transition, (Cont.)
• Phases (Nicholson and West, 1998) stages
  relating to life transitions
• Preparation: psychological preparedness for
  transition, psychological desire to make the
  change, examines personal qualities and decides
  whether possesses mental, emotional abilities
  needed to become RN, closely watching RN’s for
  comparison of own abilities
    Role Transitions, (Cont.)
• Encounter: first few days/weeks after initial
  decision, necessary contacts for college
  enrollment, financial arrangements, personal
  schedule revisions, feeling of loss and
• Adjustment: focus, establishes new set of
  priorities, previous co-worker relationships
  change during school and after RN, feels pulled
  between two worlds, LVN vs RN roles
• Stabilization: LVN takes on values of RN role,
  adjustments/changes as needed, enjoys
  successes of new role, viewing transition as a
  challenging opportunity, will help
  emotionally/mentally, prepares for growth
           Role Conflict
• Person’s role has two or more conflicting,
  incompatible expectations
• Dilemma in trying to assume both roles
  Intrapersonal: guilt over not spending
  enough time with significant others,
  struggling to meet school and social
  Interpersonal: physician requests
  procedure contrary to facility policy,
  conflict between doctor’s/employer’s
     Avoidance of Conflicts
• Prioritizing tasks
• Using effective communication skills
• Appropriately delegating responsibilities
         Change Process
• Response to pressures during various life
  experiences that cause modifications in
• Change can occur because of an external
  or internal force
  External: brought about by situation outside
  Ourselves or something we cannot control
  Internal: arises within ourselves, stems from
  Personal desire for something different
  Usually adapt more easily to internal because
            Change Theory
• Kurt Lewin, 1951, based on restraining and
  driving forces
  Restraining: issues in life/society that resist
  change (fears, perceived threats, values,
  Driving: motivators to change (desire for different
  clinical arena)
     Change Theory, (Cont.)
• Phases:
  Unfreezing: uncomfortable, restless, senses
  change about to occur, less uneasiness if change
  desired, struggle between restraining/driving
  forces to change status quo (decision to return to
  Change Theory, (Cont.)
Moving: change accepted and goals set
to determine direction, involvement of
others, easier if their input valued (goals,
plans to accomplish degree)
Refreezing: equilibrium established,
change is status quo, benefits of change
emphasized (adaptation to student life)
Once graduated, change process
reoccurs as adaptation to new work
environment takes place!
                Chapter 3
• LVN and RN knowledge and roles
• Compare and contrast roles, responsibil-ities,
  knowledge levels, similarities and differences
• Definitions of LVN/PN and RN based on data,
  research, councils
        National Nursing
Organizations’ Definitions of
          Nursing Roles
• Chornick, Yocom, Jacobson, 1993, job analysis
   study to establish entry-level practices for RNs
 • National Council Licensure Examination for RNs
   (NCLEX-RN) designed from study
 • Emphasizes:
   Knowledge: facts
   Comprehension: understanding of facts
   Application: putting facts to use
   Analysis: (not in LPN exam) ability to break down
   facts, give rationale for using and applying facts,
   higher level of cognitive/critical thinking to make a
Definitions Of Nursing Roles,
 • National Council of State Boards of Nursing,
 • NCLEX-PN/RN Testing Content Comparison
 • p 54, Transitioning from LPN/VN to RN, Duncan,
Definitions Of Nursing Roles,
 • National League of Nursing, 1989, 1990
 • Established roles and responsibilities for practical
   and associate degree nursing programs
 • LPN/VN roles: provider of care supervised by
   RN, member of the discipline
 • RN roles: provider of care, manager of care,
   member of the profession
Definitions Of Nursing Roles,
 • K. Claytor, 1993
 • LPN and RN Roles and Responsibilities
   Comparison table
 • pp 56-57, Transiioning from LPN/VN to RN,
   Duncan, DePew.
 • Differences between two roles are the
   professional changes that you will experience
   during next few semesters of your educational
Definitions Of Nursing Roles,
 • 2000, Council of Associate Degree Nursing
   Competencies Task Force, National League of
   Nursing, and National Organization of Associate
   Degree Nursing wrote Educational Competencies
   for Graduates of Associate Degree Nursing
 • Defines competency expectations of ADN
   programs, main functions, expected abilities,
   skills, expertise of an ADN graduate, delineates
   core components and competencies as
   professional behaviors, communication,
   assessment, clinical decision making, caring
   interventions, teaching and learning,
   collaboration, and nursing care
    Professional Behaviors
• Nurse adheres to standards of
  professional practice
• Nurse is accountable for own actions and
• Nurse practices nursing within legal,
  ethical, and regulatory framework
  including concern for others as
  demonstrated by caring, valuing the
  profession of nursing, and participating in
  ongoing professional development
Professional Behaviors, (Cont.)
• Evaluates personal learning needs and
  assumes responsibility for continued
  education and personal development
• Has opportunities to contribute to
  profession by gathering research data,
  facilitating change in organizational
  structure and analyzing and evaluating
  quality control measures
• Research done individually or as a team
  by distributing, collecting, and analyzing
  surveys or conducting interviews
• Interactive process, exchange of information,
  verbally, non-verbally, writing, information
• Therapeutic communication: verbal/non-verbal
  between nurse and patient, assesses pt’s ability
  to cope with change, develop more satisfying
  interpersonal relationships, and ability to
  integrate new knowledge and skills
    Communication, (Cont.)
• Ability to assess and analyze verbal and non-
  verbal communication between pts, families,
  health care members
• Assists pts with coping and solving problems
• Coordinates communication and activities with
  pts, families, health care members
• Collection, analysis, synthesis of relvevent data,
  appraising pt’s health status
• Holistic view of pt, physical, develop-mental,
  emotional, psychosocial, cultural, spiritual and
  functional status and how influences and affects
• In-depth assessment utilizing nursing process
  steps of goal setting, planning, interventions to
  address patient’s needs
    Clinical Decision Making
• Performance of accurate assessments, use of
  multiple methods to access information, analysis
  and integration of knowledge and information to
  formulate clinical judgments
• Performs more comprehensive, in-depth
  assessment obtained from multiple sources and
  applies critical thinking to determine best patient
  care approach
       Caring Interventions
• Nursing behaviors and actions that assist clients
  in meeting their needs
• Based on knowledge and understanding of
  natural sciences, behavioral sciences, nursing
  theory, research, and past nursing experiences
• Nurturing, protective, compassionate, person-
    Teaching And Learning
• Encompasses health education to
  promote and facilitate informed decision
  making, achieve positive outcomes,
  support self-care activities
• Transmission of information, evaluation of
  response to teaching, modification of
  teaching based on responses
• Learning involves assimilation of
  information to expand knowledge and
  change behavior by assessing needs of pt
  and developing individual-ized client
  teaching plan
Teaching And Learning, (Cont.)
• Outcomes set for client, RN evaluates progress
  toward learning
• Modifies plan according to progress in knowledge
  and observed changed behaviors
• Depth of teaching increases as nurse obtains
  more education
• Initiates shared planning, decision making,
  problem solving, goal setting, assumption of
  responsibilities by those who work together
  cooperatively with open, professional
          Managing Care
• Efficient, effective use of human, physical,
  financial and technological resources to
  meet client needs and support
  organizational outcomes
• Initiates and completes nursing
  assessment, client interview, and history
• Initiates, evaluates and revises written
  nursing care plans
• Initiates discharge planning according to
  physical, psychosocial, and financial
     Managing Care, (Cont.)
• Completes client care assignments, orients,
  supervises, evaluates staff performance
• In charge of patient care, coordinates care for a
  group of patients
• Includes safety and cost-effective factors in
  patient care plans
• Leads individualized client conferences
• The rationale for performing a procedure in a
  certain way is based on knowledge and
  critical thinking skills gained through the
  educational experience of the Registered
Transition to
Registered Nursing
   Nursing Process: Overview, Assessment and
   Nursing Diagnosis

   West Coast University
   Week 3

• History of the Nursing Process and Nursing
• Discuss characteristics of Nursing Process and
  Nursing Diagnosis
• Describe Assessment
• Formulate a Nursing Diagnosis

This is Nursing

This is Brian on Nursing

    History of Nursing Diagnosis
•    1950’s
      – Introduction only – mainly used in relationship to the care plan
      – only sporadically in the literature
•    1970’s
      – 1st National Conference for classification of Nursing Diagnosis and
        formed the North American Nursing Diagnosis Association (NANDA)
      – ANA published standards of practice & a social policy statements

History of Nursing Diagnosis
• 1970’s – continued
   – ANA published standards of practice & a social policy
       • Defined nursing as diagnosis and treatment of human response
         to actual or potential health problems
• 1990’s
   – 9th Conference of NANDA was held and Taxonomy II was

       • 2011
          Latin American Biennial Symposia will be held in Sao Paulo
          Brazil, June 3-4, 2011
       Students who want to join Nanda

     Globalization of Nursing
• Nursing Diagnosis is
  recognized globally
   – Provides common
     language for nursing to
     talk to each other,
     identifies problems, gives
     nursing greater
     accountability, and
     professional autonomy
   – Captures nursing’s
     contributions to health,
     enables cross-country
     comparisons of nursing
     and promotes the
     development of nursing

• Pre-1955: No clearly identifiable boundaries
  defined for nursing practice
• 1955: Term nursing process coined by Lydia Hall
• 1973: ANA published Standards of Clinical
  Nursing Practice


• 1973: Classification of nursing
  diagnoses began: North American Nursing
  Diagnosis Association (NANDA)
• 1980: ANA published A Social Policy Statement
• 1982: NCLEX exams were revised
  to include concepts
• 1994: JCAHO initiated requirements for
  accredited hospitals to use the nursing process
• Current: Ongoing use of the five-step process
• In 2006 NANDA had their 13 Conference

Basic Characteristics of the Nursing
 • Method of providing care
 • Purposeful, systematic, and orderly
 • Method of problem solving and decision making
 • Scientifically based—understanding of the
   human body
 • Philosophically based—understanding of
   philosophical views

Nursing Process Characteristics
 •   Method for organization
 •   Promotes wellness
 •   Restores wellness
 •   Maintains present state of health


Nursing Process Characteristics
 • Promotes quality care
 • Promotes coordinated, ongoing care
 • Serves as a guide to avoid omissions or
 • Provides a framework for nursing


Nursing Process Characteristics
 • Client centered
 • Assists to plan
   according to client
 • Client participates
 • Promotes
   collaboration with
   other disciplines
 • Universally applicable

            Nursing Skills
• Interpersonal
• Technical
• Intellectual

          Critical Thinking
• Purposeful thought process
• Strategy used in search for meaning
• Deliberate questions are asked

            Problem Solving
•   Gather data
•   Identify problem
•   Interpret data
•   Plan to resolve
•   Implement plan
•   Evaluate results

           Decision Making
• Based on scientific theories
• Results from nurse’s ability to think critically
• Perceptual and intellectual skills used

Maslow’s Hierarchy of Needs

Benefits of the Nursing Process
• Improved quality of care
• Continuity of care
• Promotes client participation in care
• Delivery of care is organized, continuous,
  and systematic
• Efficient use of time and resources
• Expectations of client and standards of
  care are met
• Holds nurses accountable and responsible

Five Steps of the Nursing Process
 •   Assessment
 •   Diagnosis
 •   Planning and outcome identification
 •   Implementation
 •   Evaluation

Scope and Standards of Practice
I.   Assessment: Nurse collects data
II.  Diagnosis: Nurse analyzes data in
     determining diagnoses
III. Outcome identification: Nurse identifies
     expected outcomes
IV. Planning: Nurse develops a plan of care
V. Implementation: Nurse implements
     interventions identified in plan
VI. Evaluation: Nurse evaluates client’s progress
          From American Nurses Association. (1991). Standards of
             clinical nursing practice. Washington DC: Author.

Questions Critical Thinkers Ask...
 • What actual problems were identified during
 • What are possible causes?
 • Is client at risk for developing other problems?
 • What are the factors involved?
 • Did the client indicate a desire to function at a
   higher level of wellness?


Questions Critical Thinkers Ask...
 • What are the client’s strengths?
 • What additional data might be needed to answer
   these questions?
 • What are possible sources of data collection?
 • Is collaboration needed at this time?
 • What data are pertinent to collect before
   contacting the physician?

•   Gathering data
•   Organizing
•   Verifying accuracy
•   Documenting data

Characteristics of Assessment
•   Systematic, ongoing, and continuous
•   Process of collecting data
•   Identification of problems
•   Data yield information regarding health status

            Types of Data
• Subjective
• Objective
• Complements, clarifies, supports

             Baseline Data
• Initial data becomes foundation
• Accurate data collection is critical
• Used for comparison of future data

             Data Collection
•   Interview, physical exam, diagnostic exams
•   Communicated and documented
•   Begins when client enters health care system
•   Continues as long as there is a need

     Validating & Clarifying Data
• Subjective Data: “I feel like my heart is racing”
• Objective Data: Pulse 150 beats per minute,
  regular, strong

            Sources of Data
•   Client
•   Family or significant other
•   Nursing records
•   Medical records
•   Consultations
•   Health care team members
•   Diagnostic results
•   Relevant literature

       Data Collection Tools
•   Organization
•   Documentation
•   Nursing models
•   Holistic

     Methods of Data Collection
• Observation
• Interview
• Physical assessment

      Promoting Data Collection
• Use communication techniques
  –   paraphrasing
  –   clarifying
  –   focusing
  –   summarizing
  –   open-ended questions

           Data Clustering
• Determines relation
• Finds patterns

• Analysis
• Problem identification
• Nursing diagnosis

Nursing vs. Medical Diagnoses
  Nursing Diagnosis
    •   Determined by the nurse
    •   Clinical judgment about the client
    •   Human responses to disease or treatment
    •   May change

  Medical Diagnosis
    • Determined by physician
    • Indicates disease, illness
    • Doesn’t change

Definition: Nursing Diagnosis
• A clinical judgment about individual, family, or
  community responses to actual or potential
  health problems/life processes. Nursing
  diagnosis provides the basis for selecting
  interventions to achieve outcomes for which the
  nursing is accountable

     Types Nursing Diagnosis
•   Actual
•   Risk
•   Possible
•   Syndrome
•   Wellness
•   Collaborative

    Making a Nursing Diagnosis
•   Know diagnoses
     – Collect valid & pertinent data, cluster data, differentiate nursing
       diagnosis from collaborative problems, prioritize
•   Defining the characteristics
     – Major & Minor
•   Related factors
     –   Pathophysiological
     –   Treatment
     –   Situational
     –   Maturational

                     Actual ND
• Represents a problem that has been validated by the
  presence of major defining characteristics.
• Has four parts
   –   Label
   –   Definition
   –   Defining characteristics
   –   Related factors

                     Risk ND
• Clinical judgment that an individual, family or community is
  vulnerable to develop the problem than others in the same
  or similar situation

                Possible ND
• Describes a suspected problem requiring additional data.
  This is where data is not complete or an evaluation has not
  been completed
• Not a NANDA ND because it is not classified, yet viable for
  the clinical nurse for further clarification of a problem

               Syndrome ND
• Clustering of predictable actual or high-risk NDs related to
  events or situations
• Complex clinical situation, use with care and stated as a
  one-part statement
• There should be a clustering of other NDs

                 Wellness ND
• Clinical judgment about an individual, family or community
  transition from a specific level of wellness to a higher level
• Stated as a one-part

      Collaborative Problems
• Physiologic complications that nurses monitor to detect
  onset or changes in status. Nurses manage collaborative
  problems with PCP-prescribed (dependent nursing
  functions) and Nursing-prescribed (independent nursing
  functions) to minimize complications

Cultural, Ethical & Spiritual ND
•   Cultural Needs
     – Where is the cultural component?
     – Belief system, knowledge, food, environment, powerlessness
•   Ethical Issues
     – What do you do with issues that are illegal, or different from your
       belief system?
•   Spiritual Concerns
     – Does, or how does the patient utilize spirituality in there health care?

                     Components of a
                     Nursing Diagnosis
       • Stated as one, two or three parts

       Type of Diagnosis                        Parts needed
Actual                     3 – Label, Factors, S/S

Risk                       2 – Label, Factors

Possible                   2 – Label, Factors

Syndrome                   1 – Label

Wellness                   1 – Label

Collaborative              Need the stem: Potential Complications (PC)

Formulating Nursing Diagnosis

     Diagnostic Label

                               Related to

    Contributing Factors
      (Etiology – RT)

    Signs & Symptoms       As evidenced by/secondary to

Example of Actual Nursing Diagnoses
   • Hyperthermia
     – Client’s temperature is 104.6°F.
   • Impaired Gas Exchange
     – Client’s oxygen saturation in arterial blood is 92%.


Example of Actual Nursing Diagnoses
   • Pain
      – Client states pain level “8” on scale of one to ten.
   • Anxiety
      – Client states he is experiencing anxiety.
   • Self-care deficit
      – Client is unable to perform ADLs.

      Components of Actual
       Nursing Diagnoses
• Problem
• Etiology
• Defining characteristics

• Label
• Nursing diagnosis

•   Related to (R/T) or related factor
•   Involved in development of problem
•   Becomes focus for interventions
•   Cause component
•   Gives direction to problem statement

    Defining Characteristics
• As evidenced by (AEB)
• Clinical evidence
• How response is manifested


            Scenario One:
The nurse is caring for a client who was involved in a motor
vehicle accident and sustained superficial skin trauma. The
client’s epidermal layer of skin on the right knee, forearm,
and hand is excoriated, reddened, and bleeding as the
result of sliding across a cement pavement.

• Impaired Skin Integrity
• R/T: mechanical factors, shearing forces
• AEB: disruption of skin surface, destruction of
  skin, layers, traumatized skin excoriated,
  reddened, bleeding

          Scenario Two
The client you are caring for has been medically
diagnosed with a right cerebral vascular accident
(stroke). He experiences partial paralysis on the
left side of his body. He is unable to turn over
while in bed without assistance and has
demonstrated decreased muscle strength and
control in the left extremities.

• Impaired Physical Mobility
• R/T: neuromuscular impairment
• AEB: inability to purposefully move within the
  environment, decreased muscle strength, control,
  left-sided partial paralysis

        Components of Risk
        Nursing Diagnoses
•   Potential problem
•   Risk factor
•   No evidence
•   Problem does not exist

Risk Nursing Diagnoses Examples
  • Cancer patient, Risk for Infection
     – Risk Factors (R/T): inadequate secondary defenses,
  • Client with surgical incision, Risk for Infection
     – Risk Factors (R/T): inadequate primary defenses,
       invasive procedure


Risk Nursing Diagnoses Examples
  • Client who is semi-conscious, vomiting,
    Risk for Aspiration
     – Risk Factors (R/T): reduced level of
       consciousness, vomiting
  • Neonate unable to maintain his body
    temperature, parent does not keep the child
    covered, Risk for Hypothermia
     – Risk Factors (R/T): extremes of age,
       inadequate clothing


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