NURSING PROCESS - DOC by 1B10IHr7

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									NURSING PROCESS

* The goal of the nursing process is to alleviate, minimize or prevent real or potential problems of health.

* The nursing process is therefore -
       a method by which patient's needs are assessed and analyzed and on which nursing care is planned,
                delivered and evaluated.
       done in an organized sequence of steps

Characteristics of the nursing process
       Systematic                         Purposeful                       Interactional
       Scientific                         Dynamic

The five parts of the nursing process are -
(1) Assessment - systematic collection of data to determine the patient's health status and to identify any
                   actual or potential health problems.
(2) Nursing Diagnosis - identification of actual or potential health problems that are amenable to resolution
                          by means of nursing actions.
(3) Planning - development of goals and a plan of care designed to assist the patient in resolving the nursing
              diagnosis.
(4) Implementation - actualization of the plan of care through nursing interventions or supervision of others
                       to do the same.
(5) Evaluation - determination of the patient's responses to the nursing interventions and the extent to which
                 the goals have been achieved.

Therefore - the nursing process is -
       (1) within the legal scope of nursing
       (2) based on knowledge
       (3) planned
       (4) patient centered
       (5) goal directed
       (6) prioritized
       (7) dynamic

ASSESSMENT
     begins with the nurse's first encounter with the patient
     systematic collection of data
     analysis of data to formulate nursing diagnosis


Source                           Method
Primary
 Patient                         Interview (formal, informal), physical examination, general observations

Secondary
 Family or friends               Interactions
 Patient records                 Written notes of other health care professionals, nurse’s notes, diagnostic reports
                                          (laboratory, x-ray films, etc.), admission records
  Health team members            Interaction with other nurses, physicians, physical therapist, occupational therapist,
                                          social worker, dietitian, respiratory therapist
  Literature                     Consultation of textbooks (nursing, medical, pharmacologic, nutrition) and
                                          journals (nursing, medical)

Information gathering / Interviewing depends on the admission circumstances and the patient
Interviewing skills - listening and questioning
                      observing and interpreting
                      synthesizing
                      incorporating what is learned into a plan of care

Objectives of the Nursing Interview
         Establish a therapeutic relationship with the client.
         Establish the nurse’s sense of caring for the client as an individual.
         Introduce the client to the facility in a manner that is not threatening.
         Gain insight about the client’s concerns.
         Determine the client’s expectations of health care providers and the health care delivery system.
         Obtain cues about parts of the data collection phase that require in-depth investigation (branching).

Types of Interview Techniques
       Problem - seeking technique
       Problem - solving technique
       Direct question technique
       Open-ended question technique

EFFECTIVE DATA COLLECTION TECHNIQUES
      Open-ended questions allow maximum freedom for the patient to respond in his or her own way:
        impose no limitation on how the question may be answered; and can produce considerable
        information, such as, “How do you feel about your new medication?” or “Explain the injection
        techniques to me.”
      Hypothetical questions pose a situation and ask the patient how it might be handled. You can learn
        whether the patient has accurate information and can think about how a similar situation might be
        handled. For example, “What would you do if you noticed a rash on your body?” or “What would you
        do if you felt dizzy?”. These questionsmay be very useful in determining the extent to which the patient
        has learned previously presented material.
      Reflecting or “mirroring” responses are useful techniques in getting at underlying meanings that might
        not be verbalized clearly. The patient might say, “Some days I’d like to throw this need out of the
        window.” A mirror response might be, “You feel angry about the needle?” Now the patient is
        encouraged to verbalize what she or he is actually angry about. This response is nonevaluative and
        nonthreatening.
      Focusing shows the patient that you are attending to what is being said and consists of eye contact
        (within cultural limits), body posture, and verbal responses. The message is, “Tell me more about
        that.”
      Giving broad openings encourages the patient to take the initiative about what is to be talked about:
        “Where would you like to b begin?”.
      Offering general leads encourages the patient to continue: “ … and then?”
      Exploring pursues a topic in more detail: “Would you describe it more fully?”
      Verbalizing the implied give voice to what has been suggested; for instance, the patient says, “It’s no
        use taking this medicine anymore.” You respond, “You’re concerned that it isn’t making a difference
        for you?”
      Encouraging evaluation helps the patient to consider the quality of his or her own experience, such as:
        “how does that seem to you?”

GENERALLY INEFFECTIVE DATA COLLECTION TECHNIQUES

           Closed-ended questions (such as “why?” – which allow little or no freedom in choosing a response,
            such as “Do you take your medicine?” (Patient responds “No”) or “How long have you been taking
            insulin?” (Patient responds, “3 years. Typically there are only one or two possible answers to the
            question. The interviewer remains in close control over the interview because of the rigid structures.
            Although the closed-ended question may be useful in an emergency institution (When it is necessary to
            gather information in a short time), it is important to provide an opportunity for asking the patient to
            explain the answer to these questions in great detail.
           Leading questions typically suggest the desired response, such as, “The infection seems to be getting
            better, don’t you agree?” and thereby reduces the rage of responses because the interviewees most
            commonly agrees with any leading statement. Highly emotional questions (“Where did you learn that
            injection technique?”) also suggests the desired response and may be heard as challenging. Provoking
            the interviewee to attach or become defensive, thereby blocking communication.
           Probing is a persistent questioning, a demand for more information than is given willingly. “Now tell
            me about ….” This creates an uneasy feeling in the patient and may be interrupted as an invasion of
            privacy, resulting in a defensive response or withholding. “right” from “wrong”.
           Agreeing / disagreeing implies that the patient is “right” or “wrong” rather than promoting the
            patient’s idea as separate from your own. This can block exploration of an issue. “I agree, that would
            be the thing to do.” Or “You didn’t mean to do that, did you?”

STRATEGIES FOR EFFECTIVE COMMUNICATION
       Silence is helpful for making observations and provides the client with time to organize thoughts and
         present complete information to the interviewer.
       Attentive listening demonstrates interest in the client's needs, concerns, and problems. Listening can
         be facilitated by maintaining eye contact, remaining relaxed, and using appropriate touch techniques.
       Conveying acceptance demonstrates the interviewer's willingness to listen to the client's beliefs, values,
         and practices without being judgmental.
       Related questions are planned. When asking these questions, the nurse uses words and word patterns
         in the client's normal sociocultural context.
       Paraphrasing provides an opportunity for the interviewer to validate information from the client
         without changing the meaning of the statement. Paraphrasing is the interviewer's formulation of what
         the client has said in more specific words.
       Clarifying facilitates correct communication of information. It is achieved by asking the client to
         restate the information or by providing an example.
       Focusing eliminates vagueness in communication, limits the areas of discussion, and helps the
         interviewer direct attention to the pertinent aspects of a client's message.
       Stating observations provides the client with feedback about how the interviewer observes behavior,
         actions, facial expression, or activities.
       Offering information allows the interviewer to clarify treatments, initiate health teaching, and identify
         and correct misconceptions.
       Summarizing condenses the data into an organized review. It validates data because the client has the
         opportunity to confirm that they are correct. Summarizing indicates the end to a particular part of the
         interview.

The way in which you approach the initial meeting, affects the nurse patient relationship.
The information gathered is both subjective and objective
Subjective - what is "said" by the client that is their own perception
             cannot be validated by the nurse
Objective - information obtained by the nurse through interview, physical assessment, lab results, etc.

NURSING DIAGNOSIS
     a statement that describes the client's actual or potential response to a health problem that the nurse is
             licensed and competent to treat.
     done on an ongoing basis after assessment / determination of actual or potential problem
     (note box / pg. )       North American Nursing Diagnosis Association (PANDA) Accepted
                               Nursing Diagnosis)
Nursing diagnosis are NOT -
       medical diagnoses / medical treatments / diagnostic studies
       equipment used to implement medical therapy
       the problems that the nurse experiences while caring for the patient

Characteristics and the etiology of the problem must be identified

Structure of the Nursing Diagnosis         (1) pattern of functioning or health problem
                                           (2) the factors that influence or are related to the functioning

PES format
       P = problem       E = etiology / related factors     S = defining characteristics or cluster of signs / symptoms

CONSTRUCTION OF A NURSING DIAGNOSIS
Diagnosis are written as either actual (alteration in) or Potential for
       actual = the problem already exists
       potential for = the problem has a possibility of surfacing

Status Classification of Patient Problems / Needs
* Active:                         A problem / need that is currently present and manifested by signs and symptoms.
                                  In recording the problem / need, you use a three part PES statement. Altered
                                  Urinary Patterns related to neuromuscular impairment evidenced by dribbling,
                                  250 cc residual urine.
* High Risk or Potential:         A problem / need that you believe could develop, but since it has not yet occurred,
                                  there are no signs or symptoms, only "risk factors.": The problem / need would be
                                  written as a two-part statement. Impaired Physical Mobility, high risk for, related
                                  to neuromuscular impairment.
* Resolved:                       A problem / need which no longer requires intervention. Since the problem no
                                  longer exists, no diagnostic statement is needed.

COMMON ERRORS IN CREATING AND WRITING THE PATIENT DIAGNOSTIC STATEMENT
Identifying an incorrect nursing diagnosis or misstatement of problem / needs can lead to incorrect goals /
outcomes and inappropriate nursing interventions. This can result in inappropriate / inadequate treatment of the
patient that may not resolve the problem and that may, on occasion, place the nurse at risk for legal liability.
* Using the Medical Diagnosis: Self-Care Deficit, related to stroke
  Correct: Self-Care Deficit, related to neuromuscular impairment
* Relating the Problem to an Unchanged Situation: High risk for injury related to blindness
  Correct: High risk for injury related to unfamiliarity with surroundings
* Confusing the Etiology of Sign / Symptoms for the Problem: Postoperative lung congestion related to bedrest
  Correct: Airway Clearance, ineffective, related to general weakness and immobility
* Use of a Procedure Instead of the "Human Response". : Catheterization related to urinary retention
  Correct: Urinary Retention related to perineal swelling
* Lack of Specificity: Constipation related to nutritional intake
  Correct: Constipation related to inadequate dietary bulk and fluid intake
* Combining Two Nursing Diagnoses: Anxiety and Fear related to separation from parents
  Correct: Fear related to separation from parents or Anxiety, moderate, related to change in environment and
  unmet needs
* Use of Judgmental / Value-Laden language: Pain, chronic, related to secondary / monetary gain
  Correct: Pain, chronic related to recurrent muscle spasms. Note: The patient's complaint is valid, but the issue
  of secondary gain may require additional assessment to choose appropriate interventions
* Making Assumptions: Parenting, altered, high risk for, related to inexperience (new mother)
  Correct: Knowledge Deficit: Child care issue related to lack of previous experience, unfamiliarity with resources.
  Author note: The label "Knowledge Deficit" can have negative connotations for the patient and may result in
  defensive responses. The authors support the use of substitute label, "Learning Needed."
* Writing a Legally Inadvisable Statement: Skin Ingegrity, impaired related to not being turned q2h.
  Correct: Skin Integrity, impaired, related to pressure and altered circulation. Note: If a patient complication
  occurs as a result of poor care / failure to meet standards of care, an incident report would be completed and
  document what happened.

PLANNING

Involves the following -
        (1) assignment of priorities to the nursing diagnosis
        (2) the specification of immediate, intermediate, and long term goals of nursing action
        (3) the identification of specific nursing interventions appropriate for attaining the goals
        (4) the identification of interdependent interventions
        (5) the specification of expected outcomes
        (6) the documentation of the nursing diagnoses, goals, nursing interventions and expected outcomes on the
            nursing care plan.

Establishing Expected Outcomes
        stated in terms of the patient's behaviors
        must be realistic and measurable

Measurable -
identify                         hold                             exercise
describe                         demonstrate                      communicate
perform                          share                            enough
relate                           express                          walk
state                            has an increase in               stand
list                             has a decrease in                sit
verbalize                        has an absence of                discuss

Nonmeasurable -
know                             think
understand                       accept
appreciate                       feel

Realistic Guidelines - Establishing Client Goals / Outcomes from Nursing Diagnosis
1. Be realistic in establishing goals. Be sure to consider the following
        * Growth and development
        * Behavioral patterns of the individual
        * Physical health state
        * Available human and material resources
        * Other planned therapies for the client
        * The time frame in which the client may be expected to achieve an expected outcome
2. Whenever possible, set goals mutually with the client
IMPLEMENTATION
     refers to the carrying out of the proposed plan of care / actually doing what is stated
     nurse assumes responsibility but can delegate to other members of the health care team

Action strategies for providing nursing care

Strategy                                 Definition                               Examples of activities

Monitoring                       Collecting data on an ongoing            Vital signs, intake and output, cardiac
                                  Basis                                    monitoring, assessing level of
                                                                           Consciousness, skin turgor, urine
                                                                           Tests
Compensating (partially          Performing or assisting patient to       Assisting patient with comfort measures,
 Or wholly)                       perform necessary activities that       ADL, carrying out prescriptive activities
                                  patient is unable to or has diff-        (medication, treatments)
                                  culty performing
Teaching                         Helping patients learn what they         Health education, methods of disease pre-
                                  can do to maintain or restore op-        vention, teaching skills such as dressing
                                  timal health                             changes, injections, taking vital signs
Supporting                       Helping patients cope with changes       Use of empathy skills to help patient
                                  in life-style, environment, or new         explore feelings, assistance with
                                  experiences                                problem solving, facilitation of coping
                                                                             skills
Motivating                       Providing an environment that facil-     Encouragement to carry out difficult or
                                   itates achieving optimal health         painful actions, health maintenance
                                                                           activities

IF IT IS NOT DOCUMENTED - IT WAS NOT DONE!
Recordings are made concisely, precisely and objectively.
Recordings -
       relate to the nursing diagnoses
       describe the nursing interventions and the patient's responses to the intervention
       include any additional pertinent data

EVALUATION
     measure or indicator of the progress of the patient toward meeting the stated goals

To evaluate the degree of success in achieving a goal the nurse should -
       (1)examine the goal statement to identify the exact desired client behavior or response
       (2) assess the client for the presence of that behavior or response
       (3) compare the established outcome criteria with the behavior or response
       (4) judge the degree of agreement between outcome criteria and the behavior or response
       (5) if there is no agreement (or only partial agreement) between the outcome criteria and the
                behavior or response, what is/are the barriers? Why did they not agree?


Once the questions have been answered, the nursing process starts again with a new assessment, nursing diagnosis,
plan, implementation and evaluation.
NURSING PROCESS (Griffin Hospital)

Assessment
       1. Complete Patient Admission Interview
       2. Acquire additional information from observation, physical assessment, old chart,
          admitting sheet, physician, or any source possible.
       3. Write Nursing Diagnoses
          (Patient Problems)
          Problem - related to - Etiology - as evidenced by signs and symptoms
       4. Nursing Diagnosis (Patient Problem) is not medical diagnosis, diagnostic test,
          medical treatment, equipment, nursing management problem.

Planning
       1. Prioritize Nursing Diagnosis (Problems)
       2. Write GOAL (Expected Outcome for each Nursing Diagnosis)
          Goals should be:
            Realistic - measurable and specific
               Who will do what, by when, how many times
            Patient centered - "The patient will ...."
            (Expected outcome)

Implementation (Intervention)
      1. Write Nursing orders for:
               a. Nursing treatments (specific measures)
               b. Nursing observations and assessments
               c. Patient teaching / counseling
         Each nursing order answers questions - What ; When ; How ; Who
      2. Start Patient / Family Teaching Plan
               a. KNOWLEDGE
                  include       1. What patient needs to know
                                2. When it will be taught
                                   When feedback will be obtained
                                3. How it will be taught (eg: lecture, handout)
                                4. Who will teach (if not the nurse)
               b. SKILLS
                  include       1. What patient needs to be able to do
                                2. When patient will demonstrate skill
                                3. How it will be taught (eg: demonstration, filmstrip)
                                4. Who will teach (if not nurse)
               c. CONSULTS
                  include those patients referred to (eg: Home Care, Social Services)

Evaluation
        1. Document all progress toward expected outcomes
        2. Document all teaching and feedback
        3. Discharge note should include:
                a. Patient's condition
                b. Patient's understanding of all teaching: ability to do skills
                c. Plans for follow-up care

								
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