Nursing Process: Foundation for Practice

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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 clients normal function
• Determine clients risk for dysfunction
• Determine presence or absence of dysfunction
• Determine clients 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 patients
  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, patients behavior, diagnostic and
  laboratory data, medical records

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Approaches for Data Collection

• Gordons 11 Functional Health Patterns
• Uses a series of questions which assist in
  formulating a nursing diagnosis
• Problem focused assessment
• Focuses on the patients problem and develop you
  plan of care around the problem

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Gordons 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 (gt101 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 patients
  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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Differentiating Nursing Diagnosis versus Medical
Diagnosis 
Nursing Diagnosis Medical Diagnosis
- focus on unhealthy responses to health and illness. - identify diseases
- describe problems treated by nurses within the scope of independent nursing practice. - describe problems for which the physician directs the primary treatment .
- may change from day to day as the patients responses change - remains the same for as long as the disease is present
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• Myocardial infarction (heart attack) is a medical
  diagnosis.
• Examples of nursing diagnoses for a person with
  myocardial infarction include Fear, Altered
  Health Maintenance, Knowledge Deficit, Pain, and
  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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• Types of Nursing Diagnoses
• 1- Actual Nursing Diagnoses
• Describe a human response to a health problem
  that is being manifested. They are written as
  three- part statements diagnostic label, related
  factors, defining characteristics.
• Example Acute pain related to surgical trauma
  and inflammation, as evidenced by grimacing and
  verbal reports of pain.

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• 2- Risk nursing diagnosis
•  
• As defined by NANDA, describes human responses
  to health conditions that may develop in a
  vulnerable individual, family, or community. It
  is supported by risk factors that contribute to
  increased vulnerability.

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• Risk nursing diagnoses are two part statements
  because they do not include defining
  characteristics (diagnostic label, risk factors).
•  
• Example - Risk for infection related to surgery
  and immunosuppression.
• Risk for aspiration related to reduced level of
  consciousness
• Risk for Impaired Skin Integrity related to
  inability to turn self from side to side in bed.
•  

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• 3- Wellness nursing diagnosis
• Is a diagnostic statement that describe the human
  response to levels of wellness in an individual,
  family, or community that have a potential for
  enhancement to a higher state (NANDA, 2005).
•  

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• Wellness nursing diagnosis are one part statement
  includes diagnostic label.
•  Example
• Readiness for enhanced spiritual well being
• - Readiness for Enhanced Self-Esteem.
•  
•  Q- Which One is accurate nursing diagnosis?
• 1- Readiness for Enhanced Family Coping
• 2- Family coping potential due to desire for
  better health

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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

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Nursing Planning

•  The third step of the nursing process includes
  the formulation of guidelines that establish the
  proposed course of nursing action in the
  resolution of nursing diagnoses and the
  development of the clients plan of care.
•  The planning of nursing care occurs in three
  phases initial, ongoing, and discharge. Each
  type of planning contributes to the coordination
  of the clients comprehensive plan of care.

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• - Initial planning involves development of
  beginning of care by the nurse who performs the
  admission assessment and gathers the
  comprehensive admission assessment data. Initial
  planning is important in addressing each
  prioritized problem, identifying appropriate
  client goals, and correlating nursing care to
  hasten resolution of the clients problems.

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• - Ongoing planning entails continuous updating of
  the clients plan of care. Every nurse who cares
  for the client is involved in ongoing planning.
•  
• - Discharge planning involves critical
  anticipation and planning for the clients needs
  after discharge.

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• The four critical elements of planning include
•  
• Establishing priorities
• Setting goals and developing expected outcomes
  (outcome identification)
• Planning nursing interventions (with
  collaboration and consultation as needed)
• Documenting

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• The four critical elements of planning include
•  
• Establishing priorities
• Setting goals and developing expected outcomes
  (outcome identification)
• Planning nursing interventions (with
  collaboration and consultation as needed)
• Documenting

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• The clients basic needs, safety, and desires, as
  well as anticipation of future diagnoses must be
  considered. One of the most common methods of
  selecting priorities is the consideration of
  Maslows hierarchy of needs, which requires that
  a life-threatening diagnosis be given more
  urgency than a non life threatening diagnosis.
• The client must participate in the identification
  of priorities so that the nature of the problem,
  as well as the clients values, are reflected in
  the selected course of action.

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3rd Component of the Nursing Process-
Implementing

• The provider carries out the plan of care

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During Implementing, the care provider

• Carries Out The Plan Of Nursing Care or Setting
  your plans in motion and delegating
  responsibilities for each step.
• Continues Data Collection And Modifies The Plan
  Of Care As Needed
• Documents Care

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Implementing

• Consists of doing and documenting the activities
  that are the specific nursing actions needed to
  carry out the interventions or nursing orders.
  The first three nursing process phases-assessing,
  diagnosing, and planning-provide the basis for
  the nursing actions performed during the
  implementing step. In turn, the implementing
  phase, provide the actual nursing activities and
  client responses that are examined in the final
  phase, the evaluating phase.

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• Process of Implementing
• Reassessing the client
• Determining the nurses need for assistance
• Implementing the nursing interventions
• Supervising the delegated care
• Documenting nursing activities

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• Documenting Nursing Activities, the nurse
  complete the implementing phase by recording the
  interventions and client responses in the nursing
  process notes. The nurse may record routine or
  recurring activities such as mouth care in the
  client record at the end of shift, while some
  actions recorded in special worksheets according
  to agency policy. Immediate recording helps
  safeguard the client to prevent double actions.

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During Evaluating, the care provider

• Measures The Clients Achievement Of Desired
  Goals/Outcomes
• Identifies Factors That Contribute To The
  Clients Success Or Failure
• Modifies The Plan Of Care, If Indicated

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• Process of Evaluating Client Responses
• Collecting data related to the desired outcomes
• Comparing the data with outcomes
• Relating nursing activities to outcomes
• Drawing conclusions about problem status
• Continuing, modifying, or terminating the nursing
  care plan.

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• When determining whether a goal has been
  achieved, the nurse can draw one of the three
  possible conclusions
• The goal was met, that is the client response is
  the same as the desired outcomes.
• The goal was partially met, that is either a
  short term goal was achieved but the long term
  was not, or the desired outcome was only
  partially attained.
• The goal was not met.

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• Thank you.