Nursing Process NUR101 Fall 2009 Lecture #6 and #7 K. Burger, MSEd, MSN, RN, CNE PPP By: Sharon Niggemeier RN MSN Revised KBurger 8/06 Nursing Process Specific to the nursing profession A framework for critical thinking It’s 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 Develops a clear and care efficient plan of care Client is an active Provides personal participant satisfaction as you see Promotes continuity of client achieve goals care Professional growth as Provides more effective you evaluate communication among effectiveness of your nurses and healthcare interventions professionals 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 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 don’t watch my salt” “ It’s hard to do and I just don’t get it” Nursing Diagnosis Second step of the Nursing Process Interpret & analyze clustered data Identify client’s 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 client’s response to a problem Etiology- what’s causing/contributing to the client’s problem Defining Characteristics- what’s 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 don’t watch my salt” “It’s hard to do and I just don’t get it”. Types of Nursing Diagnoses Actual Imbalanced nutrition; less than body requirements RT chronic diarrhea, nausea, and pain AEB height 5’5” 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 client’s 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 EXAMPLE statements are client Goal: focused. Client will achieve Worded positively therapeutic management Measurable, specific of disease process…. observable, time-limited, Outcome Statement: and realistic AEB B/P readings of Goal = broad statement 110-120 / 70-80 and client Expected outcome = statement of objective criterion for understanding importance measurement of goal of dietary sodium restrictions by day of Utilize NOC as standard discharge. Planning- Types of goals Short term goals Long term goals Cognitive goals Psychomotor goals Affective goals 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” Teach potential Monitor VS q4h complications of Maintain prescribed diet hypertension to instill (2 Gm Na) importance of Teach client amount of maintaining Na sodium restriction, foods restrictions high in sodium, use of Assess for cultural nutrition labels, food factors affecting preparation and sodium dietary regime substitutes Implementing – “Doing” Teach the client- Teach client importance hypertension can’t be of life style changes: cured but it can be (weight reduction, controlled. smoking cessation, Remind the client to increasing activity) continue medication Stress the importance of even though no S/S ongoing follow-up care are present. even though the patient feels well. Evaluation 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.
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