Chapter 2. Nursing Process

[Audio] Steps in the Nursing Process The nursing process is the Chapter 2. infrastructure of nursing practice in all health care settings The steps in the nursing process Nursing Process Nursing practice has evolved from are: Assessment, Diagnosis, Outcome Identification, Planning, Implementation, and Evaluation actions based on common sense and experience to independent planning and implementation of client care Standards of Clinical Nursing Practice Nurses are responsible and Standard I: The nurse collects patient health data Standard II: The nurse analyzes the accountable for providing safe and appropriate care that reflects currently accepted standards for nursing practice assessment data to determine diagnoses Standard III: The nurse identifies Gerontologic Considerations Medicare- and Medicaid-funded expected outcomes individualized to the patient Standard IV: The nurse develops a plan of care that prescribes interventions to attain expected outcomes nursing homes and home care agencies must complete the Minimum Data Set (MDS) for Resident Assessment and Care Screening Standard V: The nurse implements The MDS is a standardized tool for the interventions identified in the plan of care improving care based on ongoing assessments Standard VI: The nurse evaluates the patient's progress toward attainment of outcomes Definition of Nursing Process The nursing process is an Characteristics of the Nursing Process The nursing process is within the organized sequence of problem-solving steps used to identify and manage the health problems of clients legal scope of nursing It is a dynamic process of It is based on knowledge and critical thinking interacting feedback loops among the various components It is planned and systematic It is client-centered 1.

[Audio] Baccalaureate Nurse: Identifies the The Nursing Process Goal-directed: A united effort information needed from individuals or groups to provide an appropriate nursing database between the client and the nursing team to achieve desired outcomes Prioritized: A focused way to Types of Data in Assessment Objective data: Observed and resolve the problems that represent the greatest threat to the client's health Dynamic: A continuous loop, with measurable facts, such as a client's blood pressure measurement Subjective data: Information evaluation involving data collection and beginning the process again obtained from the client's perspective, such as their symptoms or feelings Steps of the Nursing Process Assessment: Systematic collection Data Collection of facts or data Diagnosis: Identification of health Assessment begins with the nurse's problems or issues Planning: Setting goals and developing a plan of care first contact with a client and continues as long as a need for health care exists Implementation: Carrying out the During assessment, the nurse plan of care Evaluation: Measuring the outcomes of the plan of care collects information to determine areas of abnormal function, risk factors that contribute to health problems, and client strengths Objective and Subjective Data Responsibilities in the Nursing Process Objective data: Information that Practical/Vocational Nurse: can be observed and measured, such as a client's blood pressure or incisional scar Subjective data: Information that is Gathers data by interviewing, observing, and performing a basic physical examination of people with common health problems with predictable outcomes Associate Degree Nurse: Collects based on the client's feelings and experiences, such as pain or fatigue Examples of objective data: Weight, temperature, skin color, blood cell count Examples of subjective data: Pain, data from people with complex health problems with unpredictable outcomes, their families, medical records, and other health team members nausea, depression, anxiety 2.

[Audio] Primary source of objective and Objective Data: Weight, Blood subjective data is the client, pressure, Heart rate, Incisional scar secondary sources include the Subjective Data: Pain, Nausea, Fatigue, Depression Sources of Data client's family, reports, test results, information in current and past medical records, and discussions with other health care providers Primary source: Client Secondary sources: Client's family, Types of Assessments Database assessment: Obtained on reports, test results, information in current and past medical records, and discussions with other health care providers Types of Assessments Database assessment: Obtained on admission, consists of predetermined questions and systematic head-to-toe examination, findings documented on an admission assessment form, time-consuming and comprehensive Focus assessment: Completed admission, time-consuming, comprehensive, provides a broad, comprehensive volume of data, reflects the client's condition upon entering the health care system Focus assessment: Completed throughout subsequent care, consists of unstructured questions and a collection of physical assessments, findings documented on a checklist or in progress notes, provides more details about specific problems and expands the original database throughout subsequent care, collected in a brief amount of time, collects limited data, supplies more details about specific problems and expands the original database Functional assessment: Completed Functional assessment: Completed within the first 14 days of admission, repeated at least every 12 months or immediately after a significant change in physical or mental status, identifies physical, psychological, and social factors that affect self-care, findings documented on various assessment tools, one of which is standardized MDS within the first 14 days of admission, repeated at least every 12 months or immediately after a significant change in physical or mental status, identifies physical, psychological, and social factors that affect self-care, comprehensive evaluation of current strengths and the potential for avoidable decline Examples of Objective and Subjective Data 3.

[Audio] Nursing Diagnosis Assessment and Data Organization Diagnosis is the identification of Assessment is the process of health-related problems based on the collected data. Nursing diagnoses are categorized collecting data about a client's condition and responses to therapeutic interventions. Data can be organized into related into four groups: problem-focused, risk diagnosis, syndrome diagnosis, and health promotion. clusters to make interpretation easier. For example, a problem-focused For example, cough, dry skin, diagnosis could be impaired gas exchange related to abnormal blood gases and respiratory diagnosis, while a risk diagnosis could be infection risk for potential infection from injury or surgery. Collaborative Problems infrequent urination, fever, nasal congestion, and thirst can be grouped into two clusters: symptoms related to illness (fever, cough, thick sputum) and symptoms related to dehydration (dry skin, infrequent urination, thirst). Collaborative problems are Functional Assessment A functional assessment is a potential complications from a disorder, test, or treatment that the nurse cannot treat independently. Examples include hemorrhage, sepsis, and respiratory failure. Collaborative problems represent comprehensive evaluation of a client's physical strengths and weaknesses in areas such as activities of daily living, cognitive abilities, and social functioning. The results of the functional an interdependent domain of nursing practice and require collaboration with other healthcare professionals for treatment and management. assessment help formulate an individualized plan for care that identifies specific interventions for achieving the maximum possible functioning to ensure a better quality of life. Nursing Practice and Collaborative Problems For example, a functional The role of the nurse is to monitor for complications and manage them cooperatively with nurse- and physician-prescribed interventions assessment for bathing would evaluate a client's ability to bathe independently and identify any assistive devices or interventions needed to support their bathing ability. 4.

[Audio] Medical diagnosis or treatment can Selecting appropriate lead to collaborative problems interventions Examples of collaborative Documenting the plan of care Setting Priorities Determine which problems require the most immediate attention problems include dysrhythmias, pulmonary edema, hypovolemic shock, immunodeficiency, alkalosis, electrolyte imbalance, hemorrhage, etc. Rank those that are most serious or Responsibilities of the Nurse immediate to those of lesser importance Correlate medical diagnoses or Maslow's Hierarchy of Human treatment measures with the risk for unique complications Needs is used to determine priorities Document the complications for which clients are at risk Prioritizing Nursing Diagnoses Make pertinent assessments to Human needs are divided into detect complications Report trends that suggest development of complications Manage the emerging problem physiologic, safety and security, love and belonging, psychosocial/spiritual needs, and self-actualization Examples of nursing diagnoses for with nurse- and physician-prescribed measures each human need are provided Evaluate the outcomes Establishing Outcome Criteria Outcome criteria identify specific Nursing Diagnostic Statement (PES) Disturbed sleep pattern = Problem Excessive intake of coffee = Etiology evidence for each nursing diagnosis that a client's problem is trending toward resolution or has been resolved Difficulty in falling asleep, feeling Short-term goals are more often used in acute care settings tired during the day, and irritability with others = Signs and symptoms Planning in Nursing Process Components of Short-Term Goals Nursing diagnostic statements Third step in the nursing process Prioritizing nursing diagnoses and identify a client's health problem collaborative problems Identifying measurable expected outcomes 5.

[Audio] Short-term goals are developed interventions for meeting the individualized client's needs from the problem portion of the diagnostic statement Plans of care can be written by Goals are client-centered, measurable, realistic, and accompanied by a target date for accomplishment hand, standardized on printed forms, computer-generated, or based on an agency's written standards or clinical pathways Agency-specific standards for care Long-Term Goals Nurses identify long-term goals and clinical pathways help nurses use their time efficiently and ensure consistent client care Writing Nursing Orders that report, record, evaluate, and promote early detection and treatment Goals are written in a specific Nursing orders (directions given by a licensed nurse to provide care to a client) are written in a specific format Orders include the client's name, format, such as "The nurse will monitor for, manage, and minimize (complication) by (evidence of assessment, communication, and treatment activities)" the date, the intervention, the frequency, and the nurse's signature Selecting Nursing Interventions Critical thinking is used to select Nursing Care Plan Identifies the what, when, where, nursing interventions that are directed at eliminating the etiologies Interventions must be safe, within and how for performing nursing interventions Provides specific instructions for nursing team members the legal scope of nursing practice, and compatible with medical orders Signed to indicate accountability Initial interventions are generally Components of a Nursing Order limited to selected measures with the potential for success Encourage fluids Weaknesses: lacks specificity, likely Documenting the Plan of Care to be interpreted differently, may result in inconsistent or less than adequate care The Joint Commission requires that Improvement: Provide 100 mL of oral fluid every hour while awake every client's medical record provides evidence of the planned 6.

[Audio] Use of the nursing process is the Communicating the Plan of Care Shared with nursing team standard for clinical nursing practice members, client, and client's family It is a systematic approach to client Client signs the plan of care in some agencies care that consists of a series of steps Permanent part of the client's medical record Steps in the Nursing Process Reviewed and revised daily Collect information about the according to changes in the client's condition client Organize the data Analyze the data for what is normal Implementation and abnormal Identify problem-focused, risk, Fourth step in the nursing process Involves the client and one or more members of the health care team Medical record is legal evidence of syndrome, and health promotion nursing diagnoses and collaborative problems the plan of care Nurses are accountable for Prioritize the problem list Establish specific criteria for carrying out nursing orders Evaluation evaluating whether the problems have been prevented, reduced, or resolved Select a limited number of Fifth and final step in the nursing appropriate nursing interventions process Give specific directions for nursing Determines whether a client has care reached a goal Document the plan of care using whatever format is acceptable Ongoing process Helps determine the effectiveness Discuss the plan with nursing team of nursing care members, the client, and the family Outcomes from Evaluation Analysis, reason, and action taken Put the plan into action Observe the client's responses Chart all nursing activities and the client's responses based on the client's response to the plan of care Compare the client's responses Revision of the plan of care as with the outcome criteria necessary Discuss the progress, or lack of it, Discussion with the client about lack of progress with the client, family, and other nursing team members Nursing Process 7.

[Audio] Change the plan in areas that are no longer appropriate Continue to implement and evaluate the revised plan of care Benefits of using the Nursing Process It helps to ensure that all aspects of the client's care are addressed It promotes critical thinking and evidence-based decision making It facilitates communication and collaboration among the nursing team, the client, and the family Nursing Care Plans Nursing care plans are written documents that outline the nursing interventions for a specific client They are based on the steps of the nursing process They are used to guide the delivery of nursing care and to evaluate the effectiveness of the interventions Learning Strategy Nursing educational programs use learning strategies to develop nursing care plans that incorporate the steps in the nursing process This learning strategy may serve as a bridge between theory and practice by allowing students to organize knowledge, prioritize care, link relationships, and promote critical thinking 8.