Nursing Process Jane R Bordner, RN, BSN Nursing Instructor HACCN100 Spring 2014.
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Transcript of Nursing Process Jane R Bordner, RN, BSN Nursing Instructor HACCN100 Spring 2014.
Nursing ProcessJane R Bordner, RN, BSN
Nursing InstructorHACCN100
Spring 2014
Nursing
The Changing Face of Nursing
What Do Nurses Do?
Nursing process gives us a direct and precise way to answer
Nursing process = a problem solving approach used to meet client needs
Nursing Process
Is an organized, systematic method of giving individualized nursing care that focuses on identifying and treating unique responses of individuals or groups to an actual or potential alteration in health.
Nursing Process continued…
Based on the fundamental belief that every person is endowed with personal worth and dignity, and has a right to high quality care regardless of socioeconomic status, cultural background, or religious belief.
Purpose of Nursing Process
ID nursing-related client health care needsEstablish a plan of care to meet needs Implement nursing interventions/actionsProvide basis for ongoing evaluation
Nursing Process and Critical Thinking
Critical thinking is very important in nursing decision making
Critical thinking is necessary to make complex decisions involved in patient care
Critical thinking answers the question: who benefits and whose outcomes are being met by my nursing actions?
Nursing Process and Critical Thinking
Critical thinking : analyze assumptions, challenge status quo, recognize limitations, and take actions to improve it.
Steps in the Nursing Process
Step 1 Assessment
Step 2 Nursing Diagnosis
Step 3 Planning Care
Step 4 Implementation
Step 5 Evaluation
Use of Nursing Process
Family member illnessAssessmentDiagnosisPlanningImplementationEvaluation
Role of the LPN
Assessment
Nursing Diagnosis
Planning
Implementation
Evaluation
Assist in data collection
Assist in choosing ND
Assist in formulating and choosing interventions
Carry out plan within scope of practice
Assist in evaluation and revision of plan of care
Step 1: Assessment Thorough and holistic Based on:
clinical and laboratory data medical history patient’s account of symptoms.
Requires: data collection data validation data sorting data documentation
Types of DataSubjective Data/Signs
Client’s perceptionsWhat the client tells
you.Example: “I am in pain.”
“I feel nauseous.”
Objective Data/SymptomsObservations or
measurementsThings the nurse
sees, hears, and feels.
Example: Vital signs, bowel sounds, temperature of skin
Subjective vs. Objective Data
1. ___ My leg pain is a throbbing pain2. ___ 2 seconds capillary refill3. ___ Lung sounds clear bilaterally4. ___ I have no allergies5. ___ I fell last night6. ___ Apical pulse 68 and regular7. ___ Patient moaning8. ___ Moderate yellow sputum9. ___ I am extremely tired10. ___ Skin warm and dry to touch
Shift Assessment
OrganizedSystematicBriefAccurateOrder depends upon presenting S&S
Types of Assessments
Shift Assessment
Focused Assessment
Comprehensive Health Assessment
Focused Assessment
Detailed assessment of particular systemBrief (2 to 5 minutes)“Quick check” ID changes in areas most likely to changeBased on problems ID’d in shift assessment
or new problems that ariseFind changes early and avoid complications
Example
Patient admitted with pneumonia. Though the nurse asks questions and assesses all systems, he/she will focus much more attention on the respiratory system - listening to breath sounds, asking about shortness of air, cough, etc…
Example
Next shift, same patient, New nurse enters his room and he reports
abdominal pain. The nurse will briefly assess all systems, but in addition to focusing on the respiratory system, he/she will also do a detailed assessment of the GI system.
WHATSUP guide to Symptom Assessment
W Where is it? H How does it feel? Describe it? A Aggravating and alleviating factors? T Timing: When did it start? How long
does it last? S Severity on scale of 1 to 10 U Useful other data. Other symptoms? P Patient’s perception of problem
Using WHATSUP
Mrs. Cooper, age 47, had a hysterectomy 2 weeks ago. She is admitted with a right calf deep vein thrombosis that she thinks resulted from having surgery. She rated her pain, which began 2 days ago and is constant, at 8. She has increased calf tenderness with leg movement. Leg elevation and Tylenol #3 increases her comfort. Her calf is hot to touch and red. Her legs measure: R calf 9 inches; L calf 8 inches; R thigh 14 inches; L thigh 14 inches.
Comprehensive Health Assessment
Assessment of all body systems and detailed health history
Provides baseline of client’s health status and functional abilities at that time
Helps nurse determine plan of action to address client’s nursing needs
Abnormal assessment findings signal nurse to gather additional data in that area
Parts of Comprehensive Health Assessment
Interview
Physical ExamComplete shift assessment
Auxiliary Data
Components of Nursing Interview
Biographical DataChief ComplaintHistory of Present IllnessPast Medical HistoryEnvironmental HistoryPsychosocial and Cultural HistoryReview of Systems (ROS)
Important Interview Techniques Introduce yourselfUnhurried mannerGood eye contact (if culturally appropriate)Silence/Listening skills/Clarifying Observation skills (Get objective data
during interview)Age and developmental considerationsContinually work on developing therapeutic
relationship
What is Caring?
RespondingSensing emotionsAcceptanceMaking a connection“Caring for the Whole Person”
Critical Thinking: Data Collection
Your neighbor, Mr. Lewis, age 76, knocks on your door. He says “Look at my left foot. It is very swollen. I wore new shoes yesterday that felt tight. Now I can hardly get any shoes on this foot. There is a tender area on the top of my foot. I think something is wrong. Can you help me?”
Sources of Data
ClientFamily members or significant othersOther members of health care teamCurrent and previous hospital recordsDiagnostic studies/Laboratory reports
Documentation of Data
ALL objective and subjective data must be documented
Only what was observed by or stated to you
Subjective data using direct quotes NOT DOCUMENTED, NOT DONE
Common Diagnostic Tests
Blood CBC
Electrolytes
ABG’s
Blood Glucose
Urine Urinalysis (UA)
Urine Culture and sensitivity
Common Diagnostic Tests
Radiological Chest X-ray
Exams Upper GI
Lower GI
CT & MRI scans
Stool Ova and Parasites
Clostridium difficile (C. diff)
Occult blood
Common Diagnostic Tests
Sputum Culture and Sensitivity
Acid Fast BacilliCytology
Other EKG or ECGStress TestTB Test
Patient History
Medications
Laboratory Studies Assessment Data
Step 2: Nursing Diagnosis
Standardized label that identifies client’s problem
Makes it understandable to all nursesLanguage of nursesAddress actual or potential health
problems
Step 2: Nursing Diagnosis
ID’d by nurse after analyzing assessment data and comparing it with what is considered to be normal
Abnormal findings are organized into data clusters
Nursing diagnoses are developed from data cluster
Nursing, Medical, Collaborative Diagnoses
Nursing diagnoses: problems which can be treated independently by nurses
Medical diagnoses: those that require care that only a physician or nurse practitioner can render
Collaborative diagnoses: problems that can be helped by both medical and nursing interventions
Medical VS. Nursing Diagnoses
MedicalID’s pathological
basis for illnessFocuses on
physical condition only
Addresses actual problems
NursingID’s response to
illnessFocuses on
physical, psychosocial, and spiritual needs
Addresses actual and potential problems
Medical VS. Nursing Diagnoses
MedicalNot validated with
clientUses standardized
treatments and goals
May not be resolvable
NursingValidated with
clientUses individualized
goals and interventions
Usually resolvable
Medical VS. Nursing Diagnosis
Client admitted with medical diagnosis of congestive heart failure (CHF)
Look up medical diagnosis in front of your Nursing Diagnosis Handbook.
Many potential nursing diagnosis based on one medical problem
Assessment data will reveal which may best FIT YOUR client
Writing Nursing DiagnosesPart 1 Nursing Diagnosis
Label related to (R/T)
Part 2 Etiology (cause)as evidenced by (AEB)
Part 3 Signs and Symptoms
Example
Client has abdominal surgery this am. Assessment data reveals that the client is experiencing pain. It is rated by the patient as 4 on a scale of 0 to 5. The patient is also exhibiting facial grimacing and is moaning.
The nursing diagnosis related to this assessment data is ACUTE PAIN.
Writing Nursing DiagnosisPart 1 Acute pain
related to…
Part 2 actual tissue damage from abdominal
surgeryas evidences by…
Part 3 Patient stating “My pain is 4 of 5.”
Moaning/ facial grimacing
Part 1 of StatementNANDA list of approved nursing diagnosis
labelsProblems that nurses routinely address in
practiceList in back of your Nursing Diagnosis
Handbook“I am so nauseated from my chemo
treatments that I cannot eat anything.”
Part 2 of StatementEtiology or causeStatement follows nursing problem and
words “related to” = R/TComes from your nursing knowledge and
assessment dataEtiology is individualized for each clientNO MEDICAL DIAGNOSIS“I am so nauseated from my chemo
treatments that I cannot eat anything.”
Part 3 of StatementDefining characteristicsFollows words “as evidenced by” = AEBList signs and symptoms obtained from
assessment S&S that supports your statementUse all relevant information
ObjectiveSubjective
“I am so nauseated from my chemo treatments that I cannot eat anything.”
Nursing Diagnosis
Nausea R/T
treatment/medications AEB
pt stating “I am so nauseated from my chemo treatment that I cannot eat anything”.
Nursing Diagnosis: Actual vs. High Risk Problems
ActualExisting problemClient has S&S of
problemRequires 3 part
nursing diagnosis statement
High RiskHigh probability of
occurring in futureThere are no S&SRequires 2 part
nursing diagnosis statement
High Risk Diagnosis
Assessment DataPatient has been on bedrest for 1 weekPatient is incontinent of urinePatient unable to move or turn self in bedSkin is clean and intact
High Risk Diagnosis
Risk of impaired skin integrity: Risk factors: incontinence and physical immobility.
*Note: This is a risk problem because no skin breakdown has occurred yet. You are going to use your nursing skill to prevent skin breakdown.
Nursing Diagnosis
Nursing Diagnosis Practice
Assessment DataPatient states she is feeling “nervous and
anxious”.Her hand are shaking.Staff observes her crying.Progress notes state that her physician told
her earlier that her lung biopsy was positive for cancer.
Nursing Diagnosis
Anxiety R/T
change in health status AEB
pt stating that she feels “anxious and fearful” and episodes of crying and shakiness.
Nursing Diagnosis Practice
Assessment Data92 year old female.Patient has weakness in all extremities.Fatigues rapidly with activity.Unable to perform ADL’s without becoming
fatigued. Frequently makes statements such as “I feel
so tired and weak”.
Nursing Diagnosis
Activity intolerance R/T
generalized weakness AEB
inability to perform ADL’s without fatigue and stating “I feel so tired and weak”.
Nursing Diagnosis Practice
Assessment Data82 year old malePast medical history of a stroke with left-sided
weakness and bilateral cataracts Walks with a walkerShuffling gait
Nursing Diagnosis
Risk for falls R/T
impaired vision/impaired mobility
Impaired physical mobility R/T
neuromuscular impairment AEB
left-sided weakness and using walker to ambulate
Nursing Process Worksheet
READ and HIGHLITE abnormal data IDENTIFY objective vs. subjective dataWhat does abnormal data tell us?What are some nursing diagnoses?
Nursing Diagnoses
What problems do you see here?Are they actual problems or high risk
problems?How would you write them?Look at NANDA list. What works for this
patient?
Nursing Diagnosis Worksheet
ACTIVITY PROBLEMS
1. Activity intolerance related to ____________ AEB ______________________________.
2. Sleep deprivation related to ____________ AEB ______________________________.
Nursing Diagnosis Worksheet
3. Fatigue related to ____________________ AEB ______________________________.
Nursing Diagnosis Worksheet
• PAIN1. Chronic pain related to
_________________ AEB ______________________________.
• NUTRITION1. Imbalanced nutrition: less than body
requirements related to ________________ AEB _______________________________.
Nursing Diagnosis Worksheet• SAFETY
1. Impaired skin integrity related to _________________ ABE ___________________________________.
• RISK PROBLEMS1. Risk for injury related to
______________________________.
Nursing Diagnosis Worksheet
• OTHERS?1. Impaired physical mobility related to
_________________________ AEB ______________________________.
Nursing Process Summary
The nursing process is a problem solving approach. Experienced nurses engage in this type of thinking as a matter of routine.
You need to learn how to think this way in order to be a successful nurse.
Nursing Process Summary
Types of Assessments
Shift Assessment
Focused Assessment
Comprehensive Health Assessment
Shift Assessment
Involves a brief systemic review of client’s condition at beginning of a shift
Nurse compares assessment findings with those from previous shift
Takes 10 to 15 minutes
Preparation ID clientPrivacyKeep client comfortableBody mechanicsLighting Quiet Equipment
Shift Assessment
Equipment NeededStethoscopeBP cuffThermometerWatch with a second handPen lightMeasuring Tape (maybe)
Cultural Sensitivity
Cultural differences influence a patient’s behavior
Recognition of cultural diversity helps to respect the patient
Consider a patient’sHealth beliefsUse of alternative therapiesNutritional habitsFamily relationshipsUse of personal space
Physical Assessment Includes
InspectionPalpationPercussionAuscultation
Inspection
The use of vision and hearing to distinguish normal from abnormal findingsUse adequate lightingPosition and expose body partsInspect for size, shape, color, symmetry,
position, and abnormalitiesSide to side comparisonPay attention to detail
Palpation
Involves using the handsExamine accessible body partsPalpate skin
Temperature, moisture, texture, turgor, tenderness, and thickness
Palpate abdomenTenderness, distention, or masses
Percussion
Tapping the body with fingertips to produce a vibration
Character of soundDetermines location, size, and density of
structuresDepends on the density of tissuesAbnormal sounds can be mass, air, or fluid
Auscultation
Listening to sounds produced by the bodyAssess sounds heard in the heart, lungs,
and gastrointestinal systemsRequires the use of a stethoscopeCharacteristics include
FrequencyLoudnessQualityDuration
General Survey
Begins when you first meet a patientBegins with review of primary health
patternThe survey provides information regarding
Characteristic of illnessHygieneSkin conditionBody imageEmotional stateDevelopmental status
General Appearance and Behavior
Gender and Race Age
Signs of Distress Body Type
Posture Gait
Body Movements Hygiene and Grooming
Dress Body Odor
Affect and Mood Speech
Patient Abuse Subculture Abuse
Shift Assessment Includes
Vital signs IntegumentaryNeurologicalMusculoskeletalCirculatoryRespiratoryGastrointestinalGenitourinaryPsychosocial
Skin
AssessmentNursing history
ColorMoistureTemperatureTextureTurgorVascularityEdemaLesions
Nails
Inspection and palpationCondition of nails reflects
General healthNutritional statusOccupationsLevel of self-care
Hair and Scalp
Use inspectionAssess
DistributionThicknessTextureLubrication
Neurological
Mental StatusOrientationSpeech
Neurological System
Conduct a nursing historyAssess
LanguageIntellectual functionCranial nerve functionSensory nerve functionMotor function
Head and Neck
Inspection and palpationAssess
Headache, dizziness, seizures, poor vision, loss
of consciousnessHead size, shape contour of head and skullFacial symmetry
Nose and Sinuses
Inspection and palpationAssess for exposure to
DustPollutantsAllergiesNasal obstructionTraumaDischarge, postnasal dripHeadaches
Mouth and Pharynx
Assesses overall healthDetermine oral hygiene needsDevelop therapies for dehydrationAssess oral traumaAssess for airway trauma
Oral Cavity
Neck
Neck musclesLymph nodesCarotid arteriesJugular veinsThyroid glandTrachea
Eyes
Vision
Ears
Hearing
Circulatory
Core Body TemperatureSkin
ColorTemperature
Turgor
Capillary Refill
Edema
Skin Integrity/Alterations
BP
APICAL PULSE
Peripheral Pulses
Radial Pulses80A/80R
IV’s
Peripheral
PICC
Mediport
Breasts
Examine both female and male breastsTake a health history Use inspection and palpation
Respiratory
RespirationsCough
O2
nasal cannula
face mask
Lung Sounds
RUL LULRML LLLRLL
LUNG SOUNDS
Gastrointestinal
NutritionDiet% eatenN&VHt. & Wt.
LOOK, LISTEN, & FEEL
Abdomen
Right Upper Quadrant Left Upper Quadrant
Right Lower Quadrant Left Lower Quadrant
RUQ LUQ
RLQ LLQ
BowelsWhat is “normal”?Ask about
FrequencyColorConsistencyAmount
Genitourinary
UrineIntake and OutputPerineal Area
Foley CatheterDraining urine
Female Genitalia
Examination of the genitalia includes external and internal sex organs
Must provide privacyNeed to understand cultural sensitivityConduct a nursing historyUse inspection and palpation
Male Genitalia
Assess the integrity of external genitalia, inguinal ring, and canal
Conduct a nursing historyUse inspection and palpation
MusculoskeletalGaitPostureExtremities
Contractures/AmputationsEnlargementAlignment/SymmetryHeat, tenderness, edema
ROM
Muscle Strength
Abnormal Sensations
Musculoskeletal
BUE RUE LUE
BLELLERLE
Psychosocial
EmotionalSupport SystemCulturalSpiritual/ReligionSocial Interaction
Additional Data
PainSelf-care Deficits
Wounds/Incisions 1. Kocher/Subcostal
2. Midline
3. McBurney
4. Battle
5. Lanz
6. Paramedian
7. Transverse
8. Rutherford Morrison
9. Pfannenstiel
Tubes/Drains