Nursing Process - class lec PDF

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BOX 13-9

Checklist for Evaluating Your Use of the Nursing Process Assessing ❑ The initial database is obtained by means of a nursing history and nursing examination. ❑ Assessment data are documented: ❑ Accurately—Questionable data are validated. ❑ Completely—Use of a systematic guide ensures that recorded data describe (1) the patient’s functional ability to meet each basic human need, and (2) responses to health and illness. ❑ Concisely—Irrelevant data and meaningless generalizations are avoided. ❑ Factually—Patient behaviors are recorded rather than the nurse’s interpretation of these behaviors. ❑ Timely—Current data are recorded for the team. ❑ The initial database communicates a “real sense” of the patient that makes possible individualized care . ❑ Focused assessment data are recorded for each patient problem. ❑ Data collection and documentation are ongoing and responsive to changes in the patient’s condition. Diagnosing ❑ A prioritized list of nursing diagnoses/problems is in the care plan. ❑ Each nursing diagnosis describes an actual or potential patient health problem that independent nursing intervention can prevent or resolve. Each nursing diagnosis: ❑ Is derived from an accurate and validated interpretation of a cluster of significant pat ient data or “cues” ❑ Contains a precise problem statement describing what is unhealthy about the patient and what needs to change—suggests patient goals ❑ Identifies factors that contribute to the problem (etiology)—these suggest nursing interventions ❑ Uses nonjudgmental language and is written using legally advisable terms ❑ Old nursing diagnoses are deleted from the care plan once resolved, and new diagnoses are added as soon as identified. Outcome Identification and Planning ❑ A comprehensive, individualized, and up-to-date care plan that specifies patient outcomes and nursing orders for each nursing diagnosis is developed with the assistance of the patient and family. ❑ Planning is comprehensive: ❑ Initial ❑ Ongoing ❑ Discharge ❑ Long-term goals alert the entire nursing team to realistic patient expectations after discharge. ❑ Short-term outcomes: ❑ When achieved, demonstrate a resolution of the problem specified in the nursing diagnosis ❑ Describe a single, observable, and measurable patient behavior ❑ Are valued by the patient and family ❑ Are realistic in terms of the resources of the patient and the nurse ❑ Nursing orders: ❑ Clearly and concisely describe the nursing intervention to be performed (ongoing assessment; nursing treatments and procedures; teaching, counseling, advocacy) ❑ Are individualized to the patient ❑ Are consistent with standards of care and supportive of other therapies ❑ Are effective in accomplishing the desired patient outcomes ❑ The care plan encourages patient and family participation. Implementing ❑ The patient record contains daily documentation of the nursing measures used to (1) assist the patient to meet basic human needs, (2) resolve health problems, and (3) implement select aspects of the medical care plan. ❑ The care plan is implemented: ❑ Competently

❑ Confidently ❑ Caringly ❑ Creatively Evaluating ❑ Evaluative statements are recorded on the care plan to document the patient’s level of outcome achievement at targeted times. ❑ Ongoing evaluation of the patient’s responses to the care plan is used to make decisions about terminating, continuing, or modifying nursing care.

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NURSING PROCESS (ADOPIE): CH. 14 - 18 CHAPTER 14: ASSESSMENT

Assessing: systemic & continuous collection, analysis, validation, & communication of patient data or info Database: includes all the pertinent patient info collected by the nurse & other health care professionals

5 Types of Assessments pg.339 1. INITIAL: performed shortly after admission PURPOSE – est. a COMPLETE DATABASE for problem id or care planning NURSE – collect data concerning ALL ASPECTS of pt’s health, est. priorities for focused assessment, & creating a reference baseline 2. FOCUSED: PURPOSE – gathering data concerning 1) SPECIFIC problem that has ALREADY BEEN IDENIFIED 2) INDENIFY a NEW or OVERLOOKED problem QPAs (quick priority assessments)- do to gain most important info you need to have first; “FLAG” existing risks or problems

3. EMERGENCY: PURPOSE – id LIFE THREATENING problems (physiologic or psychological crisis) • ABCs

4. TIME-LAPSED PURPOSE – COMPARES CURRENT status to BASELINE • Can be comprehensive or focused

5. PT. CENTERED PURPOSE – assess pt. complexity using social determinants (ask q’s concerning… social environments, communication skills)

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NURSING VS MEDICAL ASSESSMENT pg. 337 NO NURSING ASSESSMENT DUPICATES A MEDICAL ASSESSMENT Medical Assessments – target more of the pathologic condition Nursing Assessments – focus on patient responses to health issues

OBJECTIVE VS. SUBJECTIVE pg.346 Subjective: (comes from SUBJECT) what affected person perceives -

Cannot be perceived or verified by another person

These are SYMPTOMS

Objective: (what an OBSERVER sees) observable or measurable data that can be seen, felt, heard, or measured other than the person experiencing it -

Can be verified or validated by another person

These are the SIGNS SOUCES OF PT. DATA pg.347 -the pt. -family, friends, or significant other -pt. report (Hx, consultations, lab results, therapist) -assessment technology -other healthcare providers -healthcare literature PURPOSE FOR NURSING OBSERVATION, INTERVIEW, PHYSICAL ASSESSMENT OBSERVATION: uses the (5) senses to gather data -what are pt. current responses?, can manage their own care?, factors?, safety of environment? Nursing Hx INTERVIEW: planned communication; (4) stages: preparatory, introduction, working, termination PHYSICAL ASSESSMENT: examination of pt. for objective data; helps to better define pt. condition, verify data, & help nurse plan specific care Nursing Hx→ interview→ physical assessment 4

NURSES PHYSICAL EXAM FOCUSES PRIMARILY on… FUNCTIONAL ABILITIES! PURPOSE: appraisal health status, ID health problem, est. database for nursing interventions IMPORTANCE OF KNOWING REPORT SIGNIFANCE & DOCUMENTATION pg.366 Describe the importance of knowing when to report significant patient data and of proper documentation. 1. ∆ in a patient’s usual health patterns; unexplained by expected norms for growth & development 2. Deviation from an appropriate population norm 3. Behavior that is nonproductive in the whole-person context 4. Behavior that indicates a developmental lag or evolving dysfunctional pattern

Initial database should be entered into the computer or recorded in ink, using the designated agency forms, the same day the patient is admitted to the agency. -

If, for any reason, important data cannot be obtained during the initial assessment, needs to be documented so can be obtained as soon as possible.

Objective and subjective patient data should be summarized and written so that data communicate a unique sense of the patient and are comprehensive, concise, and easily retrievable. -

data should be presented under clearly marked headings.

subjective data: recorded using the patient’s own words. Quotation marks should be used: “I feel tired from the moment I first get up in the morning. Any more it seems I have no energy at all.” -

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Patient reports may also be paraphrased: Patient reports feeling dyspneic, has difficulty catching breath when walking one flight of stairs. The tendency to record data using nonspecific terms that are subject to individual definition or interpretation— words like adequate, good, average, normal, poor, small, large—should be avoided, BE SPECIFC

CHAPTER 15: DIAGNOSING

PURPOSES OF DIAGNOSING: Identify… 1) how pt. responses to actual or potential health or life processes 2) factors that contribute to or cause problem (etiology) 3) resources or strengths that can help prevent or resolve problems “nurse interprets & analyzes data gathered from nursing assessments, ID pt. strengths, ID resources pt. can use”

NURSING DX VS MEDICAL DX VS COLLABORATIVE PROBLEM pg. 361 & 364 Medical dx: identify DZ.

Nursing dx: focus on actual or potential health problems, prevented or resolved by independent nursing interventions

Collaborative problem: actual or potential health PE that may occur from complication of disease, diagnostic studies, or the treatment regimen; the nurse works together with other members of the health care team towards its resolution

USE GUIDELINES FOR WRITING DIAGNOSTIC pg. 374 (1) Phrase nursing dx as a patient problem or alt. in health state rather than as a patient need. (2) Check to make sure that the pt problem precedes the ethiology & that the 2 are linked by the phrase "related to" (3) Define characteristics, when included in the nursing dx. should follow etiology & be linked by the phrase "as manifested by" or "as evidenced by." (4) Write in legally advisable terms (5) Use nonjudgmental language

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(6) Be sure problem statement indicates what is unhealthy about the patient or what the patient wants to change (enhance) (7) Avoid using defining characteristics, medical dx or something that cannot be changed in the prob. statement (8)Reread the dx to make sure that the problem statement suggest pt outcomes and that the etiology will direct the selection of nursing dx (4) STEPS: DATA INTERPRET & ANALYSIS 1. recognizing significant data 2. recognize patterns or clusters 3. identify strengths & problems 4. identify potential complications (5) TYPES OF NURSING DIAGNOSIS 1. Problem/Actual - validated by the presence of major defining characteristics and possessing four components: label, definition, defining characteristics, and related factor (what a DX is used for) 2. Risk - individual, family, or community is more vulnerable to develop the problem than others in the same or similar situation 3. Possible - Statements describing a suspected problem for which additional data are needed to confirm or rule out the suspected problem 4. Wellness - transition from a specific level of wellness to a higher level of wellness 5. Syndrome – specific cluster of nursing interventions that occur together through similar interventions FORMULATING NURSING DX

Problem

Etiology

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Define ID what is unhealthy about pt; the NEED for change ID factors that are maintaining the unhealthy state of response

Purpose Suggest pt outcome

e.g. Risk for Impaired Skin Integrity

Suggest appropriate nursing measures

R/T prescribed bed rest

Defining Characteristics

ID SUBJ & OBJ data that signal existence of PE

Evaluative criteria

As evidenced by reddening areas of skin on heels and backs

CHAPTER 16: OUTCOME IDENTIFICATION & PLANNING

PURPOSE & BENEFITS PURPOSE: Design plan of care for & with pt (that once implemented) results in prevention, reduction, or resolution of pt. health PE BENEFITS: - set priorities - ID & write expected patient outcomes - Select evidence based nursing interventions - Communicate (3) ELEMENTS OF COMPREHENSIVE PLANNING 1. Initial planning – in admission 2. Ongoing - keep plan up to date, become more individualized 3. Discharge – for the nurse who worked most closely with pt. PRIORITIZE PT. HEALTH PE & NURSING RESPONSES High priority— greatest threat to patient well-being Medium priority— nonthreatening diagnoses Low priority—dx not specifically related to current health problem Consider the following: 1. Maslow's Hierarchy of Needs a. Physiologic needs High b. Safety needs c. Love and belonging needs d. Self-esteem needs e. Self-actualization needs Low 2. Patient preference

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meet needs that the patient thinks are most important 1st as long as it doesn't interfere with anything vital 3. Anticipation of future problems consider future problems, even if patient is reluctant to comply you must educate as to avoid charges of negligence PT. GOALS/EXPECTED OUTCOMES A. Initial Planning 1. Developed by the nurse who performs the nursing history and physical assessment 2. Addresses each problem listed in the prioritized nursing diagnoses 3. Identifies appropriate patient goals and related nursing care B. Ongoing Planning (problem oriented) 1. Carried out by any nurse who interacts with patient 2. Keeps the plan up to date 3. States nursing diagnoses more clearly 3. Develops new diagnoses 4. Makes outcomes more realistic and develops new outcomes as needed 5. Identifies nursing interventions to accomplish patient goals C. Discharge Planning 1. Carried out by the nurse who worked most closely with the patient 2. Begins when the patient is admitted for treatment 3. Uses teaching and counseling skills effectively to ensure home care behaviors are performed competently NURSE, PHYSICIAN, INITITATED INTERVENTIONS Nurse-initiated based on scientific rationale that a nurse executes to benefit the patient in a predictable way related to the nursing diagnosis and projected outcomes. -

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do not require a physician's order and are derived from the nursing diagnosis.

Physician-initiated initiated in response to a medical diagnosis but carried out by the nurse -

physician and nurse are legally responsible for the interventions and nurses are expected to be knowledgeable about how to execute them safely and effectively.

Collaborative treatments initiated by other providers and carried out by the nurse

RATIONALE FOR STANDARDIZED OUTCOMES: NOC & NIC NURSING nursing intervention classification NIC - first comprehensive, validated list of nursing interventions applica- ble to all settings that can be used by nurses in multiple spe- cialties, greatly facilitates the work of identifying appropriate interventions nursing outcomes classification NOC - first comprehensive standardized language used to describe the patient out- comes that are responsive to nursing intervention

DEVELOP OWN OUTCOMES Develop a plan of nursing care with properly constructed outcomes and related nursing interventions Outcomes must be measurable & should have: 1. Subject 2. Verb 3. Conditions 4. Performance criteria 5. Target time Actions Performed in Nurse-Initiated Interventions 1. Monitor health status. 2. Reduce risks. 3. Resolve, prevent, or manage a problem. 4. Facilitate independence or assist with ADLs. 5. Promote optimum sense of physical, psychological, and spiritual well-being.

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Informal planning – ID pt strengths or problem , and providing an appropriate response Formal planning – prioritizing dx, formally planning interventions, coordinating home care

STANDARDIZED PLANNING – care plans that ID nursing dx, outcomes, nursing interventions Structured Care Methodologies 1. Procedure—set of how to action steps 2. Standard of care—description of acceptable level of patient care 3. Algorithm—set of steps used to make a decision 4. Clinical practice guideline—statement outlining appropriate practice for clinical condition or procedure

DIFFERENT OUTCOMES Affective – ∆ in pt. values, beliefs, & attitudes Cognitive – a. describe increase in pt. knowledge or intellectual behaviors; psychomotor outcomes b. describe he pt. achievement of new skills c. describing physical ∆ clinical: expected status of health issues at certain points in time, after tx complete functional: person’s ability to fxn in relation to the desired usual activities quality of life: focus on key factors that affect someone’s ability to enjoy life & achieve personal goals affective: ∆ in pt. values, beliefs, & attitudes WRITING AN OUTCOME & AVOIDING ERRORS Expressing pt as an nursing intervention Incorrect: OFFER Ms.Monkey bananas every 2 hours Correct: Ms. Monkey WILL eat bananas every 2 hours Using verbs that are not observable or measurable Incorrect: “Miss Stevens will know how to be with her newborn.” - Verbs to be avoided when writing goals include “know”, “understand”, “learn”, and “become aware” Correct: After attending the infant care class, Miss Stevens would correctly demonstrate the procedure for bathing her newborn

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Including more than one patient behavior/manifestation in short term outcomes, use dates Outcomes that are vague; makes nurses unsure about outcome

CHAPTER 17: IMPLEMENTING

IMPLEMENTING: the evidence based nursing actions planned in the previous step ARE carried out PURPOSE: help pt. achieve valued health outcomes, promote health, prevent dz, restore health, coping mechanisms NURSING INTERVENTIONS: “any tx based upon clinical judgement & knowledge that a nurse performs to enhance pt/client outcomes” EXAMPLES OF NIC & NOC nursing intervention classification NIC - first comprehensive, validated list of nursing interventions applica- ble to all settings that can be used by nurses in multiple spe- cialties, greatly facilitates the work of identifying appropriate interventions nursing outcomes classification NOC - first comprehensive standardized language used to describe the patient out- comes that are responsive to nursing intervention

NOC Clinical documentation Standardized communication regarding care Research on intervention effectiveness

ONGOING DATA COLLECTION 12

NIC Sleep pattern control Compliance with diet Infection control Alcohol abuse control Positioning therapy Bedbound care Postpartum care

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be sensitive to both subtle and dramatic changes in the patient's condition. monitor the patient's responses to planned interventions to determine if the plan of care is working. If the plan of care is/not working. These assessment findings are used to update and revise the plan of care.

DELGATING TO UAPs FIVE RIGHTS OF DELGATING 1. RIGHT TASK: requires little supervision, are repetitive, noninvasive, and have predictable results 2. RIGHT CIRCUMSTANCE: consider the pt. setting, available resources, and other relevant factors before delegating 3. RIGHT PERSON: appropriate task to the right healthcare person 4. RIGHT DIRECTION/COMM: “4 Cs” - Clear - Concise - Complete - Correct 5. RIGHT SUPERVISION: provide monitoring & evaluation as well as intervention if needed

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CHAPTER 18: IMPLEMENTING

EVALUATING: the nurse & pt together measure how well the pt achieved the outcomes specified in their care plan -

Nurse identifies which factors that contributed to the ability of the pt to achieve the expected outcomes When necessary, modifies

PURPOSE: allow the pt achievement of expected outcomes to direct future nurse pt interactions 1. Terminate plan 2. Modify plan *review each step of nursing process (ADOPIE) 3. Continue plan STANDARDS ARE… “levels of performance that are EXPECTED & ACCEPTED” 5 Elements of Evaluation: 1. 2. 3. 4. 5.

ID expected pt. outcome Collect the data to see if whether the criteria was met Interpret & summarize the findings Document judgement Terminate – continue – modify

4 TYPES OF OUTCOMES 1. Cognitive Outcome- increases in patient knowledge

2 . Psychomotor Outcome- describe the patient's achievement of new skills; they are evaluated by asking the patient to demonstrate the new skill.

3 . Affective Outcome- pertain to changes in patient values, beliefs, and attitudes and are more complex to evaluate.

4 . Physiologic Outcome- physical ∆ in the patient are the targeted outcome.

QUALITY DIFFERENCES quality-assurance: enables nurses to be accountable to society for the quality of nursing care

quality – improvement: is the commitment and approach used to continuously improve every process in every part of an organization, with the intent of meeting and exceeding customer expectations and outcomes

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