the nursing process resources andrea ackermann, mount st. mary college,...
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The Nursing Process
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Resources
Andrea Ackermann, Mount St. Mary College, Critical-thinking-the-nursing-process 2001.
http://www.umanitoba.ca/nursing/courses/128,(2005)
Sara-jo Wiscombe, Nursing Process ,Wallace Community College ,May 22,2001.
Tucker C, MODULE A INTRODUCTION TO NURSING Process, August 21, 2002 .
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The Nursing Process
An organizational framework for the practice of nursing
Orderly, systematicCentral to all nursing careEncompasses all steps taken by the
nurse in caring for a patient
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Definition of the Nursing ProcessAn organized sequence of problem-
solving steps used to identify and to manage the health problems of clients
It is accepted for clinical practice established by the American Nurses Association
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Benefits of Nursing Process
Provides an orderly & systematic method for planning & providing care
Enhances nursing efficiency by standardizing nursing practice
Facilitates documentation of care Provides a unity of language for the nursing
profession Is economical Stresses the independent function of nurses Increases care quality through the use of
deliberate actions
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The Nursing Process Utilizes The Following
AssessmentNursing DiagnosisPlanningImplementationEvaluation
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Characteristics of the Nursing ProcessWithin the legal scope of nursingBased on knowledge-requiring critical
thinkingPlanned-organized and systematicClient-centeredGoal-directedPrioritizedDynamic
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Benefits of using the nursing process Continuity of care Prevention of
duplication Individualized
care Standards of care
Increased client participation
Collaboration of care
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Being Accountable
Using critical thinking before taking actions
Being responsible for your actions Entering the professional role Working at the level of your peers Using the nursing process
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Something to think about:
Nurses are responsible for a unique dimension of healthcare – “ the diagnosis and treatment of human responses to actual or potential health problems”
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MARTHA ROGERS, NURSE THEORIST
“When an apple is cut, others see seeds in the apple. We, as nurses, see apples in the seeds.”
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What Are Your Responsibilities?
Recognize health problems. Anticipate complications. Initiate actions to ensure appropriate
and timely treatment.
Begin to think CRITICALLY !!!!!!
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Critical Thinking
MENTAL OPERATIONS –decision making & reasoning
KNOWLEDGE-having the facts & understanding the reason behind the knowledge
ATTITUDES- curious/open-minded/non-judgmental….
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Critical Thinking Critical thinking in nursing is an essential component of professional
accountability and quality nursing care.
Critical thinking is careful, deliberate, and goal directed.
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Assessment of Well-Being
According to the World Health Organization is well-being in these domains:EmotionalPhysicalSocialSpiritual
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Lets Get Started :
Nurse collects background info from previous charts
Ensure environment is conducive Arrange seating Allow adequate time Nurse introduces self Identifies purpose of interview Ensure confidentiality of information Provide for patient needs before starting
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TYPES OF INTERVIEWS
DIRECTED NON-DIRECTED
THINGS THAT IMPAIR COMMUNICATION: PRESENTING QUICK SOLUTIONS UNWARRANTED CHEERFULNESS FALSE REASSURANCE GIVING ADVICE CHANGING THE SUBJECT
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ASSESSMENT
Observation Interview
Types of questionsEnvironment (physical and
emotional) Spiritual conciderations
Examination
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Types of Data To Collect:Objective data-observable and
measurable facts (Signs)Subjective data-information that only
the client feels and can describe (Symptoms)
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CULTURAL DIVERSITY
MUST PROVIDE CARE CONGRUENT WITH A CLIENT’S EXPECTATIONS
“This is not about you” ? Respect INDIVIDUAL’S DIFFERENCES,
What is the significance of the problem or illness to the client?
What does it mean in the family/community?
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COMMON Challenges:Defense Mechanisms
COMPENSATION DENIAL DISPLACEMENT
RATIONALIZATION
PROJECTION REPRESSION SUPPRESSION REGRESSION
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Continued
THE NURSING PROCESS HELPS NURSES UNDERSTAND THE STRATEGIES CLIENTS USE IN their attempt at coping:
This knowledge will help you FURTHER INDIVIDUALIZE THEIR CARE
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Resources
Client Other individuals Previous records Consultations Diagnostics studies Relevant literature
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Assessment
Data base assessment – comprehensive information you gather on initial contact with the person to assess all aspects of health status.
Focus assessment – the data you gather to determine the status of a specific condition.
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Sources of DataPrimary source: ClientSecondary source: Client’s family,
reports, test results, information in current and past medical records, and discussions with other health care workers
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Disease Prevention
Primary prevention – protection from a disease while still in a healthy state.
Secondary prevention – early detection and treatment of disease.
Tertiary prevention – prevent complications and to maintain health once the disease process has occurred.
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Verifying Data
Essential in critical thinking!!!!! Measurable data Double check personal observations Double check equipment Check with experts and team members Recheck out-liers Compare objective and subjective data Clarify statements
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Planning
Establish the goals, interventions and outcomes
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General Guidelines for Setting Priorities
1. Take care of immediate life-threatening issues.
2. Safety issues.3. Patient-identified issues.4. Nurse-identified priorities based on
the overall picture, the patient as a whole person, and availability of time and resources.
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Nurse Identified Priorities
Composite of all patient’s strengths and health concerns.
Moral and ethical issues. Time, resources, and setting. Hierarchy of needs. Interdisciplinary planning.
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Identifying Client-centered Outcomes State what the patient will do
or experience at the completion of care.
Give direction to the patient’s overall care.
Patient behaviors not nurse behaviors!!
“The patient will…”
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DIAGNOSIS Sort, cluster, analyze information Identify potential problems and
strengths Write statement of problem or
strength Risk of infection related to
compromised nutrition
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Nursing Diagnosis (cont.)
Potential for effective breastfeeding related to knowledge level and support system
Prioritize the problems Not a medical diagnosis
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Steps for deriving outcomes from Nursing Diagnosis
Look at the first clause of the nursing dx and restate in a statement that describes improvement, control or absence of the problem.
Risk for infection r/t surgical procedure.
The client will demonstrate no signs or symptoms of infection.
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Components of Outcomes
Subject: who is the person expected to achieve the outcome?
Verb: what actions must the person take to achieve the outcome?
Condition: under what circumstances is the person to perform the actions?
Performance criteria: how well is the person to perform the actions?
Target time: by when is the person expected to be able to perform the actions?
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Nursing Interventions
Road maps directing the best ways to provide nursing care.
Evidence based nursing.
1. Monitor health status.
2. Minimize risks.
3. Resolve or control a problem.
4. Assist with ADLs.
5. Promote optimum health and independence.
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Interventions
Direct interventions: actions performed through interaction with clients.
Indirect interventions: actions performed away from the client, on behalf of a client or group of clients.
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Nursing DiagnosisHealth issue that can be prevented,
reduced, resolved, or enhanced through independent nursing measures
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Documenting the Plan of Care To ensure continuity of care, the plan
must be written and shared with all health care personnel caring for the client.
Consists of:
1. Prioritized nursing diagnostic statements.
2. Outcomes.
3. Interventions.
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Documentation
Clear and concise Appropriate terminology
Usually on a designated form Physical assessment
Usually by Review of Systems• Overview of symptoms• Diet• Each body system
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Documentation
Use patient’s own words in subjective data – enclose in “ ___” (quotation marks)
Avoid generalizations – be specific Don’t make summative statements –
describe - e.g. patient is being ornery should be patient resists instruction or patient states “Don’t talk to me, I don’t care about that”
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Evaluation
1. Determining outcome achievement
2. Identifying the variables affecting outcome achievement
3. Deciding whether to continue, modify, or terminate the plan
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Determining Outcome Achievement Must be aware of outcomes set for the
client. Must be sure patient is ready for evaluation. Is patient able to meet outcome criteria? Is it: Completely met? Partially met? Not met at all? Record in progress in notes. Update care plan.
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Identifying Variable Affecting Outcome Achievement Maintain individuality of care plan:
1. Is the plan realistic for the client?
2. Is the plan appropriate at the time for this particular client?
3. Were changes made in the plan when needed?
4. How does the client feel about the plan?
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Predict, Prevent, and Manage
Focus on early intervention Based on research Predict and anticipate problems Look for risk factors
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Diagnostic StatementsName of the health-related issue or
problem as identified in the NANDA listEtiology (its cause)Signs and SymptomsThe name of the nursing diagnosis is
linked to the etiology with the phrase “related to,” and the signs and symptoms are identified with the phrase “as manifested (or evidenced) by”
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Collaborative Problems-Nurse’s Responsibility
Correlating medical diagnoses or medical treatment measures with the risk for unique complications
Documenting the complications for which clients are at risk
Making pertinent assessments to detect complications
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Continued
Reporting trends that suggest development of complications
Managing the emerging problem with nurse- and physician-prescribed measures
Evaluating the outcomes
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The Nursing Process
Nursing DiagnosisJudgment or conclusion about the risk for—
or actual—need/problem of the patientNANDA format
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NANDA – North American Nursing Diagnosis Association
Identifies nursing functions Creates classification system Establishes diagnostic labels
Risk of infection related to compromised nutritional state
Potential complication of seizure disorder related to medication compliance
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PlanningThe process of prioritizing nursing
diagnoses and collaborative problems, identifying measurable goals or outcomes, selecting appropriate interventions, and documenting the plan of care.
The nurse consults with the client while developing and revising the plan.
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Setting PrioritiesDetermine problems that require
immediate actionMaslow’s Hierarchy of Human Needs
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Short-Term GoalsOutcomes achievable in a few days or
1 week Developed form the problem portion of
the diagnostic statementClient-centeredMeasurableRealisticAccompanied by a target date
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Long-Term GoalsDesirable outcomes that take weeks
or months to accomplish for client’s with chronic health problems
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The Nursing Process
PlanningIdentification of goals and outcome criteriaPrioritizationTime frame
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Selecting Nursing InterventionsPlanning the measures that the client
and nurse will use to accomplish identified goals involves critical thinking.
Nursing interventions are directed at eliminating the etiologies.
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Selecting an intervention
The nurse selects strategies based on the knowledge that certain nursing actions produce desired effects.
Nursing interventions must be safe, within the legal scope of nursing practice, and compatible with medical orders.
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Communicating The PlanThe nurse shares the plan of care with
nursing team members, the client, and client’s family.
The plan is a permanent part of the record.
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EvaluationThe way nurses determine whether a
client has reached a goal. It is the analysis of the client’s
response, evaluation helps to determine the effectiveness of nursing care.
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The Nursing Process
EvaluationOngoing part of the nursing processDetermining the status of the goals
and outcomes of care
Monitoring the patient’s response to drug therapy
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Documentation
Clear and concise Appropriate terminology
Usually on a designated form Physical assessment
Usually by Review of Systems• Overview of symptoms• Diet• Each body system