Fundamentals of Nursing II

NURSING PROCESS

DR NAIEMA GABER

Learning objectives

Define nursing process.

Detect the importance and purposes of NP

Identify the components of NP

Determine the characteristics of NP

Discuss the five steps of nursing process

Document following the standard criteria

PREPARED BY:MS/NAWAL GAMEL ABDULGHANI

Unit1:the Nursing process &critical thinking

Definition of Nursing Process

An organized sequence of problem-solving steps used to identify and to manage the health problems of clients.

A systemic, rational method of providing individualized nursing care.

Medical vs. Nursing Assessments:

Medical assessmentsFocus on the client’s disease.

Nursing assessmentsFocus on the client’s response to disease.

The Purposes of Nursing Process:

To Identify the client’s health status & actual or potential health care problems.

To establish nursing plan to meet the identified health needs.

Characteristics of nursing process

1.Open, flexible2. Humanistic and individualized.3.Cyclical and ongoing4.Client centered.5. Goal directed.6.Emphasizes feedback and validation

Why do we learn Nursing Process ?

To practice universal standards of care to meet client’s health needs

Practice and improve critical thinking skills

Benefits of Nursing Process

Provides a systematic method for providing care.

Increases care quality

Enhances nursing efficiency by standardizing nursing practice.

Facilitates documentation of care.

Provides a unity of language for the nursing profession.

Is economical.Emphasize the independent function of nurses.

Using the nursing processUsing critical thinking before taking actions

Being responsible for your actionsEntering the professional role on the practical areas.

Working at the level of peers

Being Accountable

Recognize health problems. Anticipate complications. Initiate actions to ensure appropriate

and timely treatment.

Begin to think CRITICALLY !!!!!!

What Are Your Responsibilities?

Evaluation

Implementation

Planning

Diagnosis

Assessment

DIGNOSISi.D problemFormulate

nursing diagnosis

Assessment:Assessment: the

first step in NP

it is the process of gathering, verifying and communicating data about a client”.

It describes client’s health problems or response for nursing therapy given.

It starts by wards give additional meaning to the diagnosis as altered, impaired, decreased, ineffective, acute, chronic….

Types of Nursing Assessments

Comprehensive initial Comprehensive initial ( provide baseline client data shortly after admission)

Focused- limited Focused- limited in the scope targets a particular need or health care concern.

Ongoing – systematic Ongoing – systematic monitoring & observation related to specific problem.

1-Data collection

2-Confirm the data is accurate

Assessment Steps

3-Organize the data

4-Interpret the data

1--Data Data collectioncollection::

Data collection : it is the process of gathering information about a client’s health status.

Type of data collection:Objective data(signs)

Observable and measurable data that can be seen, heard, or felt by someone other than the person experiencing them

E.g., elevated temperature, skin moisture, vomiting

Subjective data(symptoms) Information perceived only by the affected personE.g., pain experience, feeling dizzy, feeling anxious

2-Confirm that data is accurate

Sources of Data

4-OtherHealthcareprofessional

s

3-Patient record

2-Family and

significant others

1-Patient5-Nursing and

OtherHealthcareliterature

33--Organizing DataOrganizing Data

Assessment models:Assessment models:Wellness Models Maslow’s Hierarchy of NeedsBody Systems ModelNeman’s System model.

44 - -Validating DataValidating Data

Is the act of “double-checking” or verifying data to confirm that they are accurate.

How to differentiate the(cues) and (inferences)??

CuesCues = signs and = signs and symptomssymptoms

InferenceInference = = what you think,a judgment about the cues

Swollen finger

Misshapen

Reddened

Painful

Broken finger

DocumentinDocumenting Datag Data

Enter initial database into computer or record in ink on designated forms the same day patient is admitted.

Summarize objective and subjective data in concise, comprehensive, and easily retrievable manner.

Use correct grammar and standard medical abbreviations.

Whenever possible, use patient’s own words. Avoid non-specific terms, individual

interpretation or definition.

2- Nursing diagnosis2- Nursing diagnosis

DIAGNOSIS

National American Nursing National American Nursing Diagnosis Association-------Diagnosis Association-------NANDA

1973 First national First national conference of nursing diagnosis

1985 named NANDAnamed NANDA

1990 1990 ANA endorsed it as official diagnosis taxonom.…Is incorporated in ANA standards of practice

Meets every two years

Local chapters 148 diagnoses +16 Carpenito

1953 term first usedterm first used

Nursing Diagnosis

A clinical judgment about individual, family, or community responses to actual or potential health problems/ life processes.

A nursing diagnosis provides the basis for selection of nursing interventions to achieve outcomes for which the nurse is accountable.

Steps of Nursing DIAGNOSISSteps of Nursing DIAGNOSIS

Sort, cluster, analyze informationIdentify potential problems and strengths

Write statement of problem or strength

Example: Example: Risk of infection related Risk of infection related to compromised nutritionto compromised nutrition

Medical DiagnosisNursing diagnosis•Identifies conditions theMD is licensed &qualifiedto treat

•Identifies situations thenurse is licensed andqualified to treat

•Focuses on the illness,injury, or disease process

•Focuses on the client’sresponses to actual orpotential health problems

•Remains constant until acure is effected

•Doesn’t remain constant until a cure is effected

Types of Nursing Diagnoses

1-Actual nursing diagnosis – a problem exists.Composed of the problem statement, related factorsand signs & symptoms2- Risk nursing diagnosis – indicates the problemdoesn’t exist but has special risk factors3-Wellness nursing diagnosis – indicates the client’sdesire to attain a higher level of wellness in somearea of function.4-possible nursing diagnosis.5- syndrome nursing diagnosis

Components of the Nursing Diagnosis

A-Two-part StatementA-Two-part Statement1. Problem statement – describes the client’s

response to an actual or potential health problem (diagnostic label)

2. Etiology – cause of the problem The diagnostic label & etiology are linked

by the terminology Related to (R/T)Example:Ineffective breathing pattern R/T

neuromuscular impairment.

Development of the Nursing Diagnosis

Two-part Statement: Example:

1. Problem statement: Ineffective breathing pattern

2. Link: R/T (related to)

3. Etiology: neuromuscular impairment.

Components of the Nursing Diagnosiscont.

B- Three-part-statementB- Three-part-statement1. Problem statement – describes the

client’s response to an actual or potential health problem (diagnostic label)

2. Etiology – cause of the problem The diagnostic label & etiology are linked

bythe terminology Related to (R/T)3. Defining characteristics

Development of the Nursing Diagnosis

Three-part StatementExample:

1. Problem statement Ineffective breathing pattern

2. LinkR/T (related to) R/T (related to)

3. Etiology neuromuscular impairment.

4. Defining characteristics

(signs & symptoms)

as evidenced by spinal cord injury, poor chest expansion

Development of the Nursing Diagnosis

Two-part Statement = (Risk)Three-part Statement = (actual)

Decreased cardiac output,

related to alterations in rate, rhythm, electrical conduction,

Decreased cardiac output,

related to alterations in

rate, rhythm, electrical

conduction as evidenced

by diminished peripheral

pulses.

Activity intolerance related to

prolonged bed rest/immobility

Activity intolerance related to

prolonged bed rest/immobility as

evidenced by fatigue and

Weakness

ACTUAL DIAGNOSISAn actual diagnosis represents a state that has been clinically

validated by identifiable major defining characteristics. Consists of a label, related factors & defining characteristics.

Three Part Statement P E SP =

Problem ( Precise qualifier / modifiers) Altered High Risk Ineffective

Decreased Deficit Excess Dysfunctional

DisturbanceChronic Less than More than

Anticipatory

Diagnostic Label = Problem + modifier = Chronic Pain

Actual dx.

E = Related FactorsRelated factors are etiological or other contributing

factors that have influenced the health status change.

Etiology sometimes = Causes or factors of risk Chronic pain r/t Altered Tissue perfusion

………. secondary to DiabetesPathophysiologic Alteration in skin Integrity r/t ) caused by(Compromised immune system Inadequate circulationInadequate peripheral circulation

Treatment-relatedMedicationsDiagnostic studies Anxiety r/t )caused by( lack of knowledgeSurgery of how to dress his woundTreatments

SituationalEnvironmental Home Risk for Injury r/t unsteady gaitCommunityInstitutionPersonalLife experiencesRoles

Maturational Nutrition Imbalance : Less than Body Requirements r/t

Age related to inadequate sucking

Etiological Factors

Actual diagnosis.

S = Defining characteristicsS= signs / symptoms

Clinical cues--subjective and objective signs or symptoms that point to the nursing diagnosis

• Are separated into major and minor designations.• Major defined as critical indicators present 80-100 of the time.

•Minor are supporting and present 50-79%

Major defining characteristics must be present for

diagnosis to be valid

Actual diagnosis

P E

Diagnostic Label Related factorimpaired Skin Integrity related to prolonged immobility

SDefining characteristics

as evidenced by a 2 cm sacral lesion

A real problem exists !!!!!!!!A real problem exists !!!!!!!!

RISK DIAGNOSIS

Is a clinical judgment that an individual, family or community is more vulnerable to develop the problem than others in the same or similar situation. .

Two part statement.----- --P ) problem(

No defining characteristics

No signs or symptoms becauseNo problem yetNo problem yet

E ) related risk factor(

Risk nursing diagnosis

P EDiagnostic label Etiological risk factors

Risk for Injury related to lack of awareness of

hazards

Factors present a risk situation for a problem to occur

SYNDROME DIAGNOSIS

Comprise a cluster of actual or risk nursing diagnoses that

are predicted to be present because of a certain event or situation.Nursing Diagnoses Associated with

Disuse SyndromeRisk for ConstipationRisk for Altered Respiratory FunctionRisk for InfectionRisk for ThrombosisRisk for Activity IntoleranceRisk for InjuryRisk for Altered Thought Processes

Common Errors In Diagnostic Statements

1. Don’t use medical terms when writing a diagnosis

I‑ Self‑Care Deficit Hygiene r/t Stroke

C- Self-care Deficit: Hygiene r/t weakness secondary to Stroke

2. Don’t write a diagnosis for an unchangeable situation

I‑ Anxiety r/t impending death aeb stating” I am afraid to die”

C- Anxiety r/t fear of dying

Common errors

3. Use of procedure / treatment instead of a human response

I- Cauterization r/t urinary retention

C- Risk for Infection Transmission r/t device with contaminated drainage: urinary

4. Don’t write diagnoses that are too general

I- Constipation r/t nutritional intake aeb small hard stools

C- Constipation r/t dietary roughage and fluid intake

Common errors

5 .Don’t combine two problems at the same time

I- Pain and Fear r/t to upcoming abdominal

surgery C- Pain r/t tissue trauma secondary to abdominal

surgery aeb “ Pain ranked 4/5”

.

6. Don’t use judgmental/value laden language or make assumptions

I- Spiritual Distress r/t atheism aeb statement “ I don’t believe in God”

C- Spiritual Distress r/t to feelings of rejection aeb “ I don’t think God cares about me”

7. Don’t make statements that are legally inadvisable

I- Tissue Integrity Impaired r/t to infrequent turning aeb 3 cm diameter ankle ulcer

C- Tissue Integrity Impaired r/t immobility secondary to fracture

8. Both parts of a diagnostic statement are the sames

I- Self care deficit : feeding r/t feeding problem aeb unable to bring food to mouth

C- Self Care Deficit: feeding r/t neurological impairment of rt. hand aeb unable to bring food to mouth

Don’t use due to or caused

PLANNING

3- PLANNING3- PLANNING

PLANNING

*Definition:Planning is formulation of the nursing

actions in an organized, individualized and goal directed manner“

Should involve decision making and problem solving.

Should be SNART. (specific,measurable, attainable, realistic and time bound

Types of planning:

1.Initial2.Ongoing3.Discharge

Initial Planning

Developed by the nurse who performs the nursing history and physical assessment

Addresses each problem listed in the prioritized nursing diagnoses.

Identifies appropriate patient goals and related nursing care

Ongoing PlanningCarried out by any nurse who

interacts with patientKeeps the plan up to dateStates nursing diagnoses more clearlyDevelops new diagnoses,Makes outcomes more realistic and

develops new outcomes as neededIdentifies nursing interventions to

accomplish patient goals

Discharge Planning

Carried out by the nurse who worked most closely with patient.

Uses teaching and counseling skills effectively to ensure home-care behaviors are performed competency.

PLANNING PHASES

An informal nursing care plan : is a strategy for action that exists in the nurse’s mind.

For example : the nurse may think “Mrs.Phan is

very tired. I will need to reinforce her teachingafter she is rested.” A formal nursing care plan :is a written or

computerized guide that organize in formation about the client care.

Planning Steps

Prioritizing the nursing diagnoses Identifying long & short term goals

Developing nursing interventionsRecording the nursing care plan in the client’s medical record

Prioritizing Nursing Diagnoses

Five system variables:Five system variables: Physiological Psychological Socio-cultural Developmental Spiritual

Maslow hierarchy + severity of problem + patient input

Review question: Which of the following problems would you treat first ? Severe breathing Diarrhea Itching

Planning steps cont.

2. Establishment of ( goals) OUTCOME and OUTCOME CRITERIA ( What will the patient be able to do? and in what time frame ? = OUTCOME And how will I know it was successful? = OUTCOME CRITERIA

Diagnosis --------------- Ineffective Airway Clearance

r/t Etiology -----------------------Weakness secondary to Stroke EX: Maj. Defining Characteristic (Symptoms)- non productive Ineffective cough Broad Outcome ----------------Effective Airway by 10/4/04 Time frame

aeb Outcome Criteria--------- (symptoms) productive cough

Planning cont.

Purpose of Outcomes and Criteria

Indicators of achievement was the airway effective?

Measuring sticks Did problem ( cough) stay the same,get or , disappear?

Direct Interventions Interventions will be directed toward facilitating a productive

cough

Motivating factors Goal motivates, something to aim for

Diagnosis Ineffective Breathing Patterns

Related to r/t

))EE(( Immobility and chest pain

Secondary to abdominal surgery

As evidenced by

))PP((

))SS(( in respiratory rate from 12 to 22

pulse rate 88 to 104 and irregular

Outcome /goal Effective Breathing

Date: by 10/22/04 respiratory rate to 12 to 16

pulse rate to 80 and regular

Establishing client goal/desired outcomes

Goal(broad):improved nutritional status.

Desired outcome(specificDesired outcome(specific): gain 5 k by April.Purpose of desired goal/outcomes:1- provide direction for planning nursing

intervention.2-serve as criteria for evaluation client progress.3- enable the client and nurse to determine

when the problem has been resolved.4-Help motivate the client and nurse by

providing a sense of achievement.

Long-Term vs. Short-Term Outcomes

Long-term Long-term — requires a longer period to be achieved and may be used as discharge goals.

Short-termShort-term — may be accomplished in a specified period of time

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?

Common Errors in Writing Patient Outcomes

Expressing patient outcome as nursing intervention.

Using verbs that are not observable or measurable.

Including more than one patient behavior or manifestation in short-term outcomes.

Writing vague outcomes

Nursing Care Plan

A written guide, organizing client data into a formal statements of strategies to assist the client have optimal health

Nursing care plan design

Date / timeNursing diagnosis

Client’s goal

Nursing intervention

Outcome criteria and evaluation

13-3- 1429 13-3- 1429 A.HA.H

@10:30@10:30

Ineffective Ineffective airway airway clearance R/T clearance R/T accumulated accumulated secretion secretion aeb. aeb. Cyanosis & Cyanosis & abnormal abnormal breathing breathing sound.sound.

Client can Client can be expel be expel the the secreationsecreation

1-Decrease 1-Decrease oxygen oxygen consumption by consumption by *rest*rest

*setting or semi *setting or semi fowler’s fowler’s positionposition

2-increase fluid 2-increase fluid intakeintake

3- B&C 3- B&C exercises .exercises .

Has no secretion Has no secretion aeb no cyanosis & aeb no cyanosis & normal breathing normal breathing sound.sound.

Documenting the Plan of Care

To ensure continuity of care, the plan must be written and shared with all health care personnel caring for the client.

Consists of:1. Prioritized nursing diagnostic statements.2. Outcomes.3. Interventions.

Types of Institutional Plans of Care

Kardex plans of careComputerized plans of careCase management plans of care

Clinical pathways, care maps

Student plans of careConcept map care plan

Guidelines for writing nursing care plans

Date and sign the plan Use category heading. Use standardized /approved medical or English symbols

and key word. Be specific. Refer to procedure book or other source information. Tailor the plan to the unique characteristics of the client by

ensuring that the client choice. Ensure that the nursing plan incorporates preventive and

health maintenance aspect as well as restorative one. Ensure that plan contain intervention for ongoing

assessment of the client Include collaborative and coordination activities in the

plan Include plan for the client’s discharge and home care need.

4- IMPLEMENTAION4- IMPLEMENTAION

IMPLEMENTAION

Interventions or implementation

Categoriesa. Dependent‑implementing M.D. orders-- give Vioxx

medication per order

b. Interdependent‑in cooperation with other health team members----follow P.T. plan for exercise

c. Independent‑ performed without M.D. order----turn patient

q.2. hrs

* 4th steps in the nursing process.

"Specific nursing activities /actions that a nurse must perform to prevent complications , provide comfort(physical, psychological and spiritual) and promote, maintain and restore

health."

Process of implementation or intrvetion

Reassessing the client.Determining the nurse’s need for assistance.Implementing the nursing interventions.Supervising the delegated care.Documenting nursing activities.

interventions

Diagnosis

Altered Skin Integrity

Broad Outcome

Pt. will experience wound healing

Etiology

R/t immobilitysecondary to fracture

INTERVENTIONS

Defining Characteristics

3cm diameterankle wound

Outcome Criteria

diameter to 2cm

interventionsCharacteristics a. consistentb. scientific basis c. law, professional standards, agency accrediting bodies

Intervention Rationale Teach client to rotate Repeated use of the same insulin injection sites site may cause fibrosis,

and decreased insulin absorption

interventionsINDIVIDUALIZED Donna‑‑17 year old, immobilized by skeletal traction for a FX. Lt. leg due to a motorcycle accident

Betsy‑‑84 year old nursing home resident, slightly dehydrated , confused and confined to bed from a hip fracture

Dx Risk for skin breakdown r/t immobility secondary to ...........................

DonnaDonna BetsyBetsyBed trapeze specialized, air mattress

Position cue to turn turn q. 2 hours

Nutrition protein, zinc etc.tube feeding, fluids

Criteria for choosing nursing intervention

The plan must be:1. Safe and appropriate for the individual's age,

health, and condition.2. Congruent with client’s values, beliefs, and

culture.3. Congruent with other therapies.4. Based on nursing knowledge and experiences.5. Within establish standards of care as

determined by state laws, professional association and the policies of the institution.

interventions

Guidelines for Writinga. date and signb. list specific activities

Incorrect Correct Teach colostomy care 1. demonstrate steps us

applying colostomy pouch

2. identify equipment needed with colostomy care

3. provide printed instructions and discuss content

4. Have client do return demonstration

EVALUATION

Evaluation

5th step in the nursing process.Importance of the evaluation:Determines if client goals are met or not.Determines of continued or cessation of

plan.Determining outcome achievement.Identifying the variables affecting outcome achievement.Deciding whether to continue, modify, or terminate the plan

Determining Outcome Achievement

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.

EvaluationEvaluation

Process to determine how well the plan worked:

1 .Gathering data2 .Compare data with outcome criteria

3 .Make judgmenta. outcome achievedb. outcome not achievedc. partially achieved

If not----‑check interventions

human responsesoutcomes

related factors

Identifying Variable Affecting Outcome Achievement

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?

Predict, Prevent, and Manage

Focus on early intervention Based on research Predict and anticipate problems Look for risk factors

The interactions between and among health professionals, clients, their families, and health care organizations

The administration of tests, procedures, treatments, and client education; and

The results of, or client’s response to, diagnostic tests and interventions

Documentation Defined

Communication with other healthcare professionals

Record of diagnostic and therapeutic ordersCare planningQuality of care reviewingResearchDecision analysisEducationLegal and historical documentationReimbursement

Effective Documentation

Follow the nursing process Date & time, Observation, Intervention & Evaluation Use of healthcare facility approved

vocabulary and abbreviations. Signature Accurate

Methods of Documentation

Narrative charting: describes the client’sstatus, interventions and treatments in astory form. Source-oriented charting: narrative charting

by individual disciplines on separate records. Problem-oriented charting: problem- oriented medical record (POMR)

Methods of Documentationcont.

PIE charting: problem, intervention and evaluationFOCUS charting: uses a columnar format

tochart data, action and response (DAR)Computerized documentation: electronic medical record

Formats for Nursing Documentation

Initial nursing assessmentKardex and patient care summaryPlan of nursing careCritical collaborative pathwaysProgress notesFlow sheetsDischarge and transfer summaryHome healthcare documentationLong term care documentation

Types of Flow Sheets

Graphic record24-hour fluid balance recordMedication record24-hour patient care records and acuity

charting forms