Nursing Process: Foundation for Practice

1. Nursing Process: Foundation for Practice NPN 105 Joyce Smith RN, BSN

2. 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

3. 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

4. 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

6. Assessment: Phase One of the Nursing Process • Purpose: • Establish a baseline of information on the client and develop a data base • Determine client’s normal function • Determine client’s risk for dysfunction • Determine presence or absence of dysfunction • Determine client’s strengths • Provide data for diagnostic phase

7. 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 patient’s responses to health problems or potential health problems

8. 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, patient’s behavior, diagnostic and laboratory data, medical records

9. Approaches for Data Collection • Gordon’s 11 Functional Health Patterns • Uses a series of questions which assist in formulating a nursing diagnosis • Problem focused assessment • Focuses on the patient’s problem and develop you plan of care around the problem

10. 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 Gordon’s Health Patterns

11. Types of Nursing Assessments • Initial assessment • Focused assessment • Emergency assessment • Time-lapsed assessment

12. Types of Data • Subjective Data • Information perceived only the affected person • Cannot be perceived or verified by another person • Examples: feeling nervous, nauseated, chilly

13. 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 (>101 F), moist skin, refusal to eat, vital signs

14. Characteristics of Data • Complete • Factual and accurate • Relevant

15. Components of Data Collection • Interview • Orientation phase • Working phase • Termination

16. Sources of Data • Primary • patient • Secondary • Family members • Significant other • Other healthcare professionals • Health records

17. 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

18. Interpreting Assessment Data • Data interpretation and validation • Data clustering • Data documentation

19. 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

20. 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

21. Health Problem • A condition that necessitates intervention to prevent or resolve the disease or illness or to promote coping and wellness

22. 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

23. 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

24. 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

25. 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

26. Nursing Diagnosis • Actual or potential health problems that can be prevented or resolved by independent nursing interventions

27. Nursing Diagnosis • Nursing diagnoses provide the basis for selecting nursing interventions that will achieve valued patient outcomes for which the nurse is responsible

28. NANDA • NANDA: North American Nursing Diagnosis Association • Established in 1973 to identify standards and classify health problems treated by nurses

29. NANDA • NANDA conferences are held every two years to continue progress in defining, classifying and describing diagnoses

30. 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

31. 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

32. 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

33. 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 patient’s responses change

34. Nursing Diagnosis • Medical Diagnosis • Myocardial infarction • Nursing Diagnosis • Fear • Altered health maintenance • Knowledge deficit • Pain • Altered tissue perfusion

36. Differentiating Nursing Diagnosis versus Medical Diagnosis

37. 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.

40. 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

41. 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

42. Nursing Diagnosis • Types of diagnoses • Actual • Risk • Wellness

43. 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.

44. 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’’.

45. 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 Integrityrelated to inability to turn self from side to side in bed.

46. 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).

48. 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

49. What a Nursing Diagnosis is Not • A nursing diagnosis is NOT a medical diagnosis • A nursing diagnosis is NOT a statement of patient need

50. 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