Nursing Process by MdV1Wi

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									 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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