Nursing Process: Foundation for

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8 Νοε 2013 (πριν από 3 χρόνια και 8 μήνες)

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Nursing Process: Foundation for
Practice

NPN 105

Joyce Smith RN, BSN

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What is the “Nursing Process”?


It is a systematic method that directs the nurse and
patient in planning patient care, and enables you to
organize and deliver nursing care


It is patient centered and outcome oriented


The steps are interrelated and dependent on the
accuracy of each of the preceding steps


It is used to identify, diagnose, and treat human
responses to health and illness


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Together the nurse and the patient
accomplish the following:


Assess the patient to determine need for
nursing care


Determine nursing diagnoses for actual and
potential health problems


Identify expected out comes and plan care


Implement care


Evaluate the results

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Five Steps of the Nursing Process


Assessment


collection of patient data


Diagnosis


identifies patients strengths and
potential problems


Planning


develop the specific holistic desired
goals and nursing interventions to assist the
patient


Implementation


carry out the plan of care


Evaluation


determine the effectiveness of the
plan of care

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Assessment: Phase One of the
Nursing Process


Purpose:


Establish a baseline of information on the client
and develop a data base


Determine client’s normal function


Determine client’s risk for dysfunction


Determine presence or absence of dysfunction


Determine client’s strengths


Provide data for diagnostic phase

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Unique Focus of Nursing
Assessment


Nursing assessments do not duplicate
medical assessments


Medical assessments target data pointing to
pathologic conditions


Nursing assessments focus oh the patient’s
responses to health problems or potential
health problems

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Assessment


The purpose is to establish a database by:


Collecting data


Subjective versus objective


Interviewing and taking a health history


Subjective and organized


Performing a physical examination


Vital signs, patient’s behavior, diagnostic and
laboratory data, medical records

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Approaches for Data Collection


Gordon’s 11 Functional Health Patterns


Uses a series of questions which assist in
formulating a nursing diagnosis


Problem focused assessment


Focuses on the patient’s problem and develop
you plan of care around the problem

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Gordon’s Health Patterns


Health perception
-
management


Nutritional
-
metabolic


Elimination


Activity
-
exercise


Sleep
-
rest


Cognitive
-
perceptual


Self
-
perception
-
self
-
concept


Role
-
relationship


Sexuality
-
reproductive


Coping
-
stress
-
tolerance


Value
-
belief

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Types of Nursing Assessments


Initial assessment


Focused assessment


Emergency assessment


Time
-
lapsed assessment

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Types of Data


Subjective Data


Information perceived only the affected person


Cannot be perceived or verified by another
person


Examples: feeling nervous, nauseated, chilly

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Types of Data


Objective Data


Observable and measurable data


Data that can be see, heard or felt by someone
other than the person experiencing it


Examples: elevated temperature (>101 F),
moist skin, refusal to eat, vital signs



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Characteristics of Data


Complete


Factual and accurate


Relevant

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Components of Data Collection


Interview


Orientation phase


Working phase


Termination

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Sources of Data


Primary


patient


Secondary


Family members


Significant other


Other healthcare professionals


Health records

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Components of Data Collection


Nursing History


Biographical information


Reasons for seeking healthcare


Present illness or health concern


Health history


Environmental history


Psychosocial and cultural history


Review of systems or functional health patterns


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Interpreting Assessment Data


Data interpretation and validation


Data clustering


Data documentation

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Diagnosis: Phase 2 of the Nursing
Process


Data is useless if not used


An important part of nursing practice is
determining what the client needs


Developing a nursing diagnosis is the next step in
planning for the care of the patient


Looking at the data, we can see both problems
treated by nursing (nursing diagnosis) and treated
by other disciplines (collaborative problems).


Nursing diagnosis are not medical diagnosis

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Purpose of a Nursing Diagnosis


1. Identify how and individual, group or
community responds to an actual or
potential health and life processes


2. Identify factors that contribute to or cause
health problems (etiology).


3. Identify resources or strengths the
individual, group or community can utilize
to prevent or resolve problems

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Health Problem


A condition that necessitates intervention to
prevent or resolve the disease or illness or
to promote coping and wellness

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Health Problems for Nursing Focus


Monitoring for changes in health status


Promoting safety and preventing harm


Identifying and meeting learning needs


Tailoring treatment and medication
regimens for each individual

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Health Problems for Nursing Focus


Promoting comfort and managing pain


Promoting health and a sense of well being


Recognizing and addressing barriers to an
independent, healthy lifestyles


Determining human responses

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Nursing Diagnosis


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


The goal of a nursing diagnosis is to
identify actual and potential responses

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Medical Diagnosis


Identification of a disease condition based
on a specific evaluation of physical signs,
symptoms, history, diagnostic tests, and
procedures


The goals of a medical diagnosis is to
identify the cause of a illness or injury and
design a treatment plan

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Nursing Diagnosis


Actual or potential health problems that can
be prevented or resolved by independent
nursing interventions

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Nursing Diagnosis


Nursing diagnoses provide the basis for
selecting nursing interventions that will
achieve valued patient outcomes for which
the nurse is responsible

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NANDA


NANDA: North American Nursing
Diagnosis Association



Established in 1973 to identify standards
and classify health problems treated by
nurses

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NANDA


NANDA conferences are held every two
years to continue progress in defining,
classifying and describing diagnoses

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NANDAS’ Definition of Nursing
Diagnosis


Nursing diagnosis is a clinical judgment
about individual, family, or potential health
problems/life processes. Nursing diagnosis
provides the basis for selection of nursing
interventions to achieve outcomes for which
the nurse is accountable

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Nursing Diagnosis


Clinical judgment about individual, family or
community


Response to actual or potential health or life
process


Provides basis for nursing interventions


Label and action of describing functional
problems


Identify and synthesize information gathered
during assessment


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Nursing Diagnosis vs. Medical
Diagnosis


Medical diagnosis


Identify disease


Nursing diagnosis


Focus on unhealthy response to health or illness


Medical diagnosis


Physician directs treatment


Nursing diagnosis


Nurse treats problem within scope of independent
nursing practice

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Nursing Diagnosis vs. Medical




Diagnosis


Medical Diagnosis


Remains the same as long as the disease is
present


Nursing Diagnosis


May change from day to day as the patient’s
responses change

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Nursing Diagnosis


Medical Diagnosis


Myocardial infarction


Nursing Diagnosis


Fear


Altered health maintenance


Knowledge deficit


Pain


Altered tissue perfusion

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Development of Nursing Diagnosis


Assess the patient


Review data and find actual and potential
problems


Use diagnostic reasoning to identify patient needs


Arrange data in clusters or defining characteristics


Use all data available


Reach conclusions for patient needs


Determine Nursing Diagnosis according to
NANDA approved diagnoses



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Components of a Nursing Diagnosis


Diagnostic label


name of the nursing diagnosis with
descriptors


Related factors


includes factors which contribute to the
problem and are not the cause ,but are associated with it.
THESE ARE NOT MEDICAL DIAGNOSIS.


Defining characteristics
-

Assessment data which supports
the nursing diagnosis


Subjective data


what the patients tells you


Objective data


what you observe or data obtained


Risk factors


clues which point to potential problems


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Nursing Diagnosis


Types of diagnoses


Actual


Risk


Wellness


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What a Nursing Diagnosis is Not


A nursing diagnosis is NOT a medical
diagnosis



A nursing diagnosis is NOT a statement of
patient need

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Legal Ramifications of Nursing
Diagnosis


A nurse


Can only identify problems within the scope of
practice


Cannot diagnose or treat medical disease


Must identify problems within his/her scope o
practice, abilities and education