The Nursing Process

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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, systematic
• Central to all nursing care
• Encompasses all steps taken by the nurse in
  caring for a patient

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Definition of the Nursing Process

• An 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

• Assessment
• Nursing Diagnosis
• Planning
• Implementation
• Evaluation

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Characteristics of the Nursing Process

• Within the legal scope of nursing
• Based on knowledge-requiring critical thinking
• Planned-organized and systematic
• Client-centered
• Goal-directed
• Prioritized
• Dynamic

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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
• Emotional
• Physical
• Social
• Spiritual

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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 questions
• Environment (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 CLIENTS
  EXPECTATIONS
• This is not about you ?
• Respect INDIVIDUALS 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 ChallengesDefense 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 Data

• Primary source Client
• Secondary source Clients 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 patients 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 patients
  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.
• Monitor health status.
• Minimize risks.
• Resolve or control a problem.
• Assist with ADLs.
• 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 Diagnosis

• Health 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
• Prioritized nursing
  diagnostic statements.
• Outcomes.
• 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 patients own words in subjective data
  enclose in ___ (quotation marks)
• Avoid generalizations be specific
• Dont make summative statements describe -
  e.g. patient is being ornery should be patient
  resists instruction or patient states Dont talk
  to me, I dont 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 Statements

• Name of the health-related issue or problem as
  identified in the NANDA list
• Etiology (its cause)
• Signs and Symptoms
• The 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-Nurses 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 Diagnosis
• Judgment or conclusion about the risk foror
  actualneed/problem of the patient
• NANDA 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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Planning

• The 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 Priorities

• Determine problems that require immediate action
• Maslows Hierarchy of Human Needs

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Short-Term Goals

• Outcomes achievable in a few days or 1 week
• Developed form the problem portion of the
  diagnostic statement
• Client-centered
• Measurable
• Realistic
• Accompanied by a target date

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Long-Term Goals

• Desirable outcomes that take weeks or months to
  accomplish for clients with chronic health
  problems

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The Nursing Process

• Planning
• Identification of goals and outcome criteria
• Prioritization
• Time frame

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Selecting Nursing Interventions

• Planning 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 Plan

• The nurse shares the plan of care with nursing
  team members, the client, and clients family.
• The plan is a permanent part of the record.

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Evaluation

• The way nurses determine whether a client has
  reached a goal.
• It is the analysis of the clients response,
  evaluation helps to determine the effectiveness
  of nursing care.

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The Nursing Process

• Evaluation
• Ongoing part of the nursing process
• Determining the status of the goals and outcomes
  of care
• Monitoring the patients 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