The Nursing Process

muttchessAI and Robotics

Nov 8, 2013 (3 years and 7 months ago)

59 views

The Nursing Process


Module G


HOW OBERVANT ARE YOU????


Looking,
Listening, Feeling,
Smelling
----


Do the above in
order too
----


Assess, Diagnosis,
Plan, Implement,
and Evaluate

THE NURSING PROCESS


5 STEPS


1. Assessment


2. Diagnosis


3. Planning


4. Implementation


5. Evaluation


Each step is
dependent on the
accuracy of the step
preceding it.

Assessment
-

Data Collection is a Primary Tool


Puzzle Pieces


Gathering Info about pt


Data collection requires us to
examine the data


Does it fit the picture?


Formal vs Informal


Pt is our primary source for
this data


What are secondary sources?

Focus vs Data Base Assessment


Focus Ass’t



is
performed to gather
detailed information
about a specific
condition.


Baseline Data

-

is
gathered on initial
contact with pt to gather
info about
all

aspects of
health status

Two Types of Data


S


Subjective

-

What the
patient tells you


Subjective = Statements


“I’m itching”


O


Objective



Detectable
by an observer or can be
tested


O = Objective



What are some examples?

Nursing Diagnosis Process


Data Validation
\



> Interpretation of


Data Clustering /


Data



\
/



Identification of



Client needs



\
/



Formulation of



Nursing Diagnosis

Organizing Data


Your assessment
tool will assist you
with this


Clustering into
categories helps you
get a better picture


Maslow’s Heiarchary
of Needs helps you
too


Steps in Data Analysis


1. Do you see a pattern or
trend


2. Compare your data to
Standards (Norms) i.e., B/P
168/102 (Normal 110/70)


Rales heard in lung fields (
Normal


clear lung sounds)


3. Make a reasonable
conclusion

Four Methods Nurses use to:

Collect Data


1. Interview


2. Nursing Health
History


3. Physical
Examination


Head


4. Diagnostic and
Laboratory
Results

What’s Next ????


Once data collection & analysis is complete
we next
DIAGNOSE
using NANDA. You are
looking for the Diagnostic label (NANDA)
that addresses the problem.


Problem



is an unmet need or anything
that interferes with a persons ability to
meet their needs.


Related factors


Etiology

: Follows the
Diagnostic label & directs interventions


Ex: Impaired skin integrity R/T immobility


Three Types of Diagnoses


Actual



“Risk for”



Wellness

Legalities in Stating Nursing
Diagnoses


Don’t write the diagnostic statement in such a
way that it may be legally incriminating.


High risk for injury R/T Lack of side rails or
High Risk for injury R/T Disorientation


Don’t state the Nsg Dx using medical
terminology; focus on the person’s response to
the medical problems


Mastectomy R/T Cancer vs.


Body Image disturbance R/T effects of surgical
procedure.


Don’t use 2 problems @ the same time.


Planning


Setting


Establish:


1. Realistic patient
-
centered goals


2. Measurable goal criteria


Address: 7 guidelines when writing goals
and outcomes


1. Patient centered

2. Singular


3. Observable



4. Measurable


5. Time Limited


6. Mutual


7. Realistic


Two Types of Goals: Short vs. Long Term

Planning


Determining Nursing
Interventions


Types
: Nurse Initiated,
Physician initiated,
Collaborative


Elements
:


Requires decision making


Scientific rationale based


Psychomotor & IPR skills


Clinical functioning


Address
: Who, What, When,
Where, How

Components of a Goal


Subject


Behavior


Condition (Time)


Criteria


List


Each is a separate outcome


Each is specific & concrete


Each is measurable, seen,
heard, felt, observable


Must R/T goal


Realistic

Implementation


The actual process of
putting the PLAN into
action, a team effort
including:


1. Reporting


2. Performing the
care


3. Setting Priorities


4. Documentation


5. Assessing &
reassessing


6. Adhere to polices



Evaluation


To judge or appraise


Determine if expected
outcomnes were met


A constant on
-
going
process for
determining if patient
goal(s) are being met
or if patient needs are
changing


3 Goal Possibilities:


Met, Partially Met, Not
Met

Nursing Process is Dependent On:


Knowledge





What to


Why


Skills





How to


Caring





Willing to


Able to

Critical Thinking? Who needs it?


Critical Thinkers look
beyond the obvious =
Sound Judgment


Sound Judgments =
Safe Care


Safe Care =
Accountability because
we critically think.

Questions often asked by critical
thinkers


What if? Do I have
enough data (facts)?


How can I? How could I
have missed that? What
did I assume & why?


What did I learn
about?*Critical Thinkers
are always learning.

Critical Thinking


Confidence


Contextual perspective


Creativity


Flexibility


Inquisitiveness


Intellectual integrity


Intuition


Open=Minded


Persistence


Reflection


= Habits of the Mind