M.N.PriyadarshanieBSc. In Nursing

Specific to the nursing profession A framework for critical thinking It’s purpose is to:

“Diagnose and treat human responses to actual or potential health problems”

Organized framework to guide practice Problem solving method - client focused Systematic- sequential steps Goal oriented- outcome criteria Dynamic-always changing, flexible Utilizes critical thinking processes

ID problem Collect data Form hypothesis Plan of action Hypothesis testing Interpret results Evaluate findings

Provides individualized care

Client is an active participant

Promotes continuity of care

Provides more effective communication among nurses and healthcare professionals

Develops a clear and efficient plan of care

Provides personal satisfaction as you see client achieve goals

Professional growth as you evaluate effectiveness of your interventions

Assessment Nursing Diagnosis

Planning Implementing Evaluating

First step of the Nursing Process Gather Information/Collect Data

Primary Source - Client / FamilySecondary Source - physical exam, nursing

history, team members, lab reports, diagnostic tests…..

Subjective -from the client (symptom) “I have a headache”

Objective - observable data (sign) Blood Pressure 130/80

Nursing Interview (history) Health Assessment -Review of Systems Physical Exam

InspectionPalpationPercussionAuscultation

Make sure information is complete & accurate

Validate problems Interpret and analyze data Compare to “standard norms”

Organize and cluster data

Obtain info from nursing assessment, history and physical (H&P) etc…...

01. Client diagnosed with hypertension B/P 160/90 mmHg 2 Gm Na diet and antihypertensive

medications were prescribed Client statement “ I really don’t watch my

salt” “ It’s hard to do and I just don’t get it”

Second step of the Nursing Process

Interpret & analyze clustered data

Identify client’s problems and strengths

Formulate Nursing Diagnosis (NANDA : North American Nursing Diagnosis Association)-

Statement of how the client is RESPONDING to an actual or potential problem that requires nursing intervention

Within the scope of nursing practice

Identify responses to health and illness

Can change from day to day

Within the scope of medical practice

Focuses on curing pathology

Stays the same as long as the disease is present

Composed of 3 parts: Problem statement- the client’s response

to a problem Etiology- what’s causing/contributing to

the client’s problem Defining Characteristics- what’s the

evidence of the problem

Problem( Diagnostic Label)-based on your assessment of client…(gathered information), pick a problem from the NANDA list...

Etiology- determine what the problem is caused by or related to (R/T)...

Defining characteristics- then state as evidenced by (AEB) the specific facts the problem is based on...

Ineffective therapeutic regimen management R/T difficulty maintaining lifestyle changes and lack of knowledge AEB B/P= 160/90, dietary sodium restrictions not being observed, and client statements of “ I don’t watch my salt” “It’s hard to do and I just don’t get it”.

ActualImbalanced nutrition; less than body requirements RT chronic diarrhea, nausea, and pain AEB height 5’5” weight 105 lbs.

RiskRisk for falls RT altered gait and generalized weakness

WellnessFamily coping: potential for growth RT unexpected birth of twins.

Require both nursing interventions and medical interventionsEXAMPLE: Client admitted with medical dx of pneumonia

Collaborative problem = respiratory insufficiencyNsg interventions: Raise HOB, Encourage C&DBMD interventions: Antibiotics IV, O2 therapy

Third step of the Nursing Process This is when the nurse organizes a nursing care

plan based on the nursing diagnoses. Nurse and client formulate goals to help the

client with their problems Expected outcomes are identified Interventions (nursing orders) are selected to

aid the client reach these goals.

Prioritize list of client’s nursing diagnoses using Maslow

Rank as high, intermediate or low

Client specific Priorities can

change

Goal and outcome statements are client focused.

Worded positively Measurable, specific

observable, time-limited, and realistic

Goal = broad statement

Expected outcome = objective criterion for measurement of goal

Utilize NOC as standard

EXAMPLE Goal:

Client will achieve therapeutic management of disease process….

Outcome Statement:AEB B/P readings of 110-120 / 70-80 and client statement of understanding importance of dietary sodium restrictions by day of discharge.

Short term goals Long term goals Cognitive goals Psychomotor goals Affective goals

Specific Measurable Attainable Relevant Time BoundPt will walk 50 ft.Pt will eat 75% of mealPt will be OOB 2-4hrsPt will maintain HR<100Pt will state pain level is acceptable 6 (0-10)

Interventions are selected and written. The nurse uses clinical judgment and

professional knowledge to select appropriate interventions that will aid the client in reaching their goal.

Interventions should be examined for feasibility and acceptability to the client

Interventions should be written clearly and specifically.

Independent ( Nurse initiated )- any action the nurse can initiate without direct supervision

Dependent ( Physician initiated )-nursing actions requiring MD orders

Collaborative- nursing actions performed jointly with other health care team members

The fourth step in the Nursing Process This is the “Doing” step Carrying out nursing interventions (orders)

selected during the planning step This includes monitoring, teaching, further

assessing, reviewing NCP, incorporating physicians orders and monitoring cost effectiveness of interventions

Utilize NIC as standard

Monitor VS q4h Maintain prescribed

diet (2 Gm Na) Teach client amount

of sodium restriction, foods high in sodium, use of nutrition labels, food preparation and sodium substitutes

Teach potential complications of hypertension to instill importance of maintaining Na restrictions

Assess for cultural factors affecting dietary regime

Teach the client- hypertension can’t be cured but it can be controlled.

Remind the client to continue medication even though no S/S are present.

Teach client importance of life style changes: (weight reduction, smoking cessation, increasing activity)

Stress the importance of ongoing follow-up care even though the patient feels well.

Final step of the Nursing Process but also done concurrently throughout client care

A comparison of client behavior and/or response to the established outcome criteria

Continuous review of the nursing care plan Examines if nursing interventions are

working Determines changes needed to help client

reach stated goals.

Outcome criteria met? Problem resolved!

Outcome criteria not fully met? Continue plan of care- ongoing.

Outcome criteria unobtainable- review each previous step of NCP and determine if modification of the NCP is needed.

Were the nsg interventions appropriate/effective?

Factors that impede goal attainment:

Incomplete database Unrealistic client outcomes Nonspecific nsg interventions Inadequate time for clients to achieve

outcomes.

Identify which stage of the nursing process

is being described below:

The nurse writes nursing interventions A goal is agreed upon The nurse performs a physical assessment A revision is made to the NCP The nurse administers antibiotic medication A statement is written that outlines the

clients response to a potential health problem

RR 22/min, even unlabored “I can only walk 3 blocks before my

legs start to hurt” Pain rated 3 on a scale of 0-10 Skin pink, warm and dry Urine output 300ml/8 hr “My wife doesn’t come to visit very

often” Dressing clean, dry and intact.

Which of following, the nurse records the following data in the client’s medical record:

A.Breath sounds clear to auscultation B.Amber urine in sufficient quantities C.Pain intensity 8 out of 10 D.Skin warm and dry

When interviewing a client, the nurse uses the following open-ended style sentence:

A.Do you have any concerns right now?

B.Is your family worried about you being in the hospital?

C.How many times do you get up to go to the bathroom at night?

D.What do you mean when you say, “I don’t feel quite right?”

In order for an actual nursing diagnosis to be valid it must have one or more supporting:

A.Laboratory results B.Diagnostic data C.Defining characteristics D.Medical diagnoses

Nursing diagnoses are aimed at identifying client problems that are treatable by _______.

A.The physician B.The nurse C.Invasive techniques D.Complementary strategies

82 y/o male w/30 + year history of COPD presents to the ER with C/O SOB and chest pain and now is to be admitted to your unit. He has a IV at TKO and O2 per NP at 2L. He was given a Nitro and an aspirin in the ER.

Admitting Dx: CHF, R/O MI Past Medical Hx: Mild CHF, COPD x 30

years, CAD, HTN PE: Skin pink and dry, brisk capillary refill,

oriented x 4, S3 heart sounds, SOB with any exertion, audible expiatory and inspiratory wheezes, crackles at bases bilaterally, 1+ pitting edema to mid calf.

Formulate complete nursing care plan based on above case scenario.

50 year age male patient admitted to the emergency room with the complaining of severe vomiting from the early in the morning. She complained of loss of appetite since last wk and complained right site abdominal pain. His BP was 140/90mmHg and HR was 102bt /mint, RR- 22brt/mnt. Wt- 40kg. After complete assessment and USS result taking, Dr. diagnosed as Appendicities is the problem with the patient. Arrange 3 complete nursing care plans .

45 years woman admitted to a hospital c/o severe SOB. Her signs and symptoms were ascitis, pitting edema(+2). She was complaining of severe vomiting from the morning. She was diagnosed as chronic renal failure. Her temperature -37.80C.HR- 100bts/mint, spo2-93%.RR-24BRT/MINT

* Arrange 3 complete nursing care plans.

53 years old women admitted to your ward complaining of urinary incontinence since last week. She had 5 children and with cough, she passed urine accidently. She was worrying a lot and she looked so nervous and tired. She told that, she is not having any idea of the condition. her bp- 110/70mmHg, HR-104bts/mint, RR – 23bts/mint. Arrange 3 complete nursing care plans.