Nursing Process Flashcards
Nursing Process 5 Steps
-Assessment
-Nursing Diagnosis
-Planning
-Implementation
-Evaluation
What is the Nursing Process
-Series of organized steps designed to provide excellent care
-Intellectual process of reasoning
-Includes assessing, diagnosing, planning, implementing, and evaluating
What does the nursing practice do?
-Guides clinical judgement
-Decision making
-Reflective nursing practice
-Encourages critical thinking
-Not linear, steps continuously relate to each other
A-Assessment
Collection of data
D-Diagnosis
Diagnosis/Identify the problem, analyze data: makes decisions
P-Plan
Creation of formal plan/strategies
I-implementation
Care delivery
E-Evaluation
Clients responsiveness/effectiveness
Assessment Phase Methods of Data Collection
-Interpreting assessment data and making nursing judgements
-Physical examination
-Interviewing
-Observing client behaviour
-Diagnostic and lab data
Assessment Sources of Data: Primary
Patient/client
Assessment Phase Sources of Data: Secondary
-all sources other than the patient
-includes: family/support people, patient records, health care professionals
Subjective Data
-Patients perceptions or feelings
-Verbal data
-Symptoms
Objective Data
-What can be observed, perceives, and/or measured through the 5 senses or other instruments
-Non-verbal data
-Can be compared to a standard (BP, temp)
-Signs
Pt states they have chest pain
Symptom
Facial grimacing
Sign
BP 172/88
Sign
Reddened coccyx
Sign
Pain 6/10 written in chart
Symptom
Emaciated
Sign
Sad
Sign
What is a Cue
-Info the nurse obtains through use of the senses
-Info you perceive from the environment (subjective and objective data)
What is an Inference?
Ones judgement or interpretation of the cues
Cues vs Inference
Cue: Dry skin + reduced skin turgor
Inference: Dehydration
Cue: Incision hot, swollen, and reddened
Inference: Infected wound
Diagnosis =
Identify the clients problems
-Identify and prioritize the problem
-Clinical judgement
-Follows analysis of data
-Basis for interventions
-Which are most/least likely for THIS patient
-Which are most serious/dangerous/time sensitive
Identify the Problem =
-Not the same as a medical diagnosis
-Physicians licensed to treat diseases/pathological processes
-Use commonly accepted medical diagnosis to treat
-Nurses have a similar language = nursing diagnosis
-Determines health problems within domain of nursing
Nursing Diagnosis: NANDA
-Established in 1982
-Formerly the North American Nursing Diagnosis Organization
-Professional organization of nurses that standardize terminology for nursing process
-NANDA international Inc
-200 approved nursing diagnosis
Types of Nursing Diagnosis
Actual
Risk/potential
Wellness
Nursing Diagnosis: Actual
-Three part statements
-Represents a state that has been validated by major defining characteristics
-Actual problem, presence of major signs and symptoms
Example Actual Nursing Diagnosis
“Anxiety R/T asthmatic episodes AEB patient stating “I am afraid I won’t be able to breath”
Nursing Diagnosis: Risk (or high risk)
-Two part statement
-Represents a clinical judgement that the client is vulnerable to develop the problem/ a suspected problem, requires additional data
-Possible diagnosis
-No AEB because not actually occurring yet
Examples Risk Nursing Diagnosis
-Risk for impaired skin integrity R/T immobility
-Possible self care deficit R/T impaired ability to use left hand due to IV
Nursing Diagnosis: Wellness
-One part statement
-Represents the clients validated desire to move to a higher level of wellness
-Health promotion nursing diagnosis (related factors not present because all would be the same “motivated to achieve a higher level of wellness”
Example Wellness Diagnosis
Readiness for enhanced …
Medical or Nursing: Pt has LUL pneumonia
Medical
M or D: Impaired gas exchange
Nursing
M or N: Alteration in comfort
Nursing
M or N: Enhanced coping skills
Nursing
M or N: Stage 4 breast cancer
Medical
M or N: Depression
Both (said N in class)
M or N: Stage 1 Pressure Ulcer
Medical
M or N: Impaired skin integrity
Nursing
Examples of N and M diagnosis (both)
Anxiety
Hypothermia
Constipation
Problem Statement vs Nursing Diagnosis
-Most important to choose the problem that best fits the data
-Don’t get stuck on the language
-If you are using “nursing diagnosis” it need to be stated correctly (3/2/1 part statement, NANDA dx)
-Neither are medical diagnosis
-Priority problem; Problem statement; Hypothesis
How to chose the priority (priority diagnosis vs non-priority)
-Priority: Those nursing or collaborative problems that If not managed now will deter progress to achieve outcomes or will negatively affect client status
-Non-Priority: Those nursing or collaborative problems for which treatment can be delayed without compromising the client status
Priority can..
Change within minutes
Types of priority:
Priority diagnosis
Intermediate
Low priority
Priority
If left untreated will result in harm to the patient (oxygenation, safety)
Intermediate
Non emergency, non life threatening
Low priority
Affect clients future well-being
Priority Problem Statement
-What are the reasons why this problem might be happening?
-Do the assessment findings support this choice ?
-Why have you made this the priority?
Prioritizing based on
-Based on hierarchy of needs
-Urgency or need for action
-What the client sees as a priority
-Time needed to resolve problem
-Availability of resources
Problem Statement (what to do)
-Cluster the data
-What is not relevant?
-What else do you want to know?
-How could you get that info?
-What are the problems?
-What is the priority problem?
-What is the problem statement?
Supportive Data
-Info that validates the problem statement/hypotheses and adds to the overall understanding of the patients situation
-Evidence/assessment findings
-Contributing factors
Supportive data/problem case
Problem statement: Student late for AM classes
Evidence/Assessment Findings:
1) Student getting a zero on quizzes given at start of class because they miss the quiz
2) Student always seen frantically running through the hallway to get to classes in AM
3) Student frequently must sit on stairs of lecture theatre because no seats left
Contributing Factors:
1) Student needs coffee because only getting 3 hours of sleep a night
Planning Phase 3 Components
- Set client cantered objectives/goals
- Determine expected outcomes
- Select appropriate nursing interventions
Example Goal (Planning)
Student will be on time for class
Planning Phase: SMART
S-Specific
M-Measurable
A-Attainable
R-Relevant
T-Time based
Expected outcomes of planning
-Specific, measurable change in clients health status
-Physiological, psychological, social, developmental, spiritual
-Several expected outcomes for each goal
-Include time frames
-Measurable
Examples Data Supporting Problem Statement & Expected Outcome Criteria
1) Nauseated for past 2 days
1) Client will report decreased nausea in 8 hours
2) Emesis x3
2) Client will retain clear fluid diet in 24 hours
3) Mucous membranes dry
3) Client will display moist mucus membranes in 24 hours
4) Unable to keep food or fluids down for past 24 hours
4) Client will have a balanced intake and output in 48 hours
Implementation Phase: Nursing Intervention
-What are you going to do?
-“Implementing interventions” =carrying out the plan
-Preparation, control environment and practice safely
-Client needs
-Anticipating and preventing complications
Independent Nursing Interventions
-No direction or orders from another health care professional required to implement
Dependent Nursing Intervention
-Require orders or directions from a health care professional to implement (require independent judgement by the nurse)
Collaborative Interventions
Require the combined knowledge, skill, and expertise of numerous health care providers
Examples of Nursing Interventions
1) Assessment
2) Providing direct care
3) Assisting self care and ADL
4) Positioning
5) Dressings
6) Medications
7) Communicating
8) Lifesaving measures
Rationale for interventions
Rationale: Are evidence based support for the nursing interventions
-Need rationale for each individual intervention
Evaluation 2 components
1) An examination of a condition
2) Judgement as to whether change has occurred
-Ideally an intervention will lead to an improvement
-Reviews expected outcomes for client and judges whether or not successful
Evolution
-Ongoing process whenever a nurse has contact with a patient
-Dynamic and ever-changing
-Make clinical decisions and redirect nursing care
Positive Evaluations
Desired outcomes are met
Unmet/undesirable outcomes
Interventions not effective
Documenting Evaluations
-Continue the care plan: if the diagnosis is still present and the goals and interventions are still appropriate
-Modify/Revise: if the diagnosis is still present, but the goals or interventions require revision
-Achieved: the goals have been achieved and that portion of the care plan is discontinued
Nursing Care Plans
Written documentation of the nursing process you use to solve one or more of a patients nursing problems
Nursing Care Plan Purpose
-Provide the direction for the individualized care of the client
-Continuity of Care (communication, organization, constantly changing staff)
-Helps documentation
What is the contributing factor
Factor maybe leading to or causing the problem
What is supportive data
Additional info that validates the chosen nursing diagnosis/hypothesis/problem statement and adds to the overall understanding of the patients situation
