Nursing Process Flashcards
What are the purposes of the diagnosing step in the Nursing Process?
- Identify how an individual, group, or community responds to actual or potential health and life processes
- Identify factors that contribute to, or cause, health problems (etiologies)
- Identify resources or strengths on which the individual, group, or community can draw to prevent or resolve problems
Patient Problems Statements focuse on what?
Problem statements focus on unhealthy responses to health and illness; may change from day to day as the patient’s responses change
Medical Diagnosis identifies what?
Identifies diseases
Medical Diagnosis describes what?
describe problems for which the physician or advanced practice nurses directs the primary treatment;
Does the medical diagnosis change?
remains the same for as long as the disease is present
Diagnostic Reasoning, Clinical Reasoning, and Clinical Judgment- how to?
Be familiar with lists of actual and potential problems and needs; read professional literature and keep reference guides handy
Trust clinical experience and judgment but be willing to ask for help when the situation demands more than your qualifications and experience can provide
Respect your clinical intuition, but before writing a problem statement without evidence, increase the frequency of your observations and continue to search for cues to verify your intuition
Recognize personal biases and keep an open mind
Steps of Data Interpretation and Analysis
Recognizing significant data: Comparing data to standards
Recognizing patterns or clusters
Identifying strengths and current or potential problems
Identifying potential complications
Reaching conclusions
Partnering with the patient and family
Types of Nursing Diagnoses
Problem-focused
Risk
Health promotion
Formulation of Nursing Diagnoses
Problem
Etiology
Signs and Symptoms
What is ‘Problem’ in the Formulation of Nursing Diagnoses?
Identifies what is unhealthy about patients
What is ‘Etiology’ in the Formulation of Nursing Diagnoses?
Identifies factors maintaining the unhealthy state
Goal of Outcome Identification and Planning Step
Establish priorities
Identify and write expected patient outcomes
Select evidence-based nursing interventions
Communicate the nursing plan of care
A Formal Care Plan Allows the Nurse to:
Individualize care that maximizes outcome achievement
Set priorities
Facilitate communication among nursing personnel and colleagues
Promote continuity of high-quality, cost-effective care
Coordinate care
Evaluate patient response to nursing care
Create a record used for evaluation, research, reimbursement, and legal reasons
Promote nurse’s professional development
Outcome Identification, Planning, and Clinical Reasoning #1: What should you be familiar with?
Be familiar with standards and agency policies for setting priorities, identifying and recording expected patient outcomes, selecting evidence-based nursing interventions, and recording the care plan
Outcome Identification, Planning, and Clinical Reasoning #1: What is the goal?
Remember that the goal of thoughtful, patient-centered practice is to keep the patient and the patient’s interests and preferences central in every aspect of planning and outcome identification
Outcome Identification, Planning, and Clinical Reasoning #1: What is the ‘big picture’ focus?
Keep the “big picture” in focus: What are the discharge goals for this patient, and how should this direct each shift’s interventions?
Outcome Identification, Planning, and Clinical Reasoning #2
Trust clinical experience and judgment but be willing to ask for help when the situation demands more than your qualifications and experience can provide; value collaborative practice
Respect your clinical intuitions, but before establishing priorities, identifying outcomes, and selecting nursing interventions, be sure that research supports your plan
Recognize your personal biases and keep an open mind
Three Elements of Comprehensive Planning
- Initial
- Ongoing
- Discharge
Initial Planning- who is it developed by?
Developed by the nurse who performs the nursing history and physical assessment
Initial Planning- what does it address?
Addresses each problem listed in the prioritized problem list
Initial Planning -identifies what?
Identifies appropriate patient goals and related nursing care
Ongoing planning- who is it carried out by?
Carried out by any nurse who interacts with patient
Ongoing planning- what does it do to the plan?
Keeps the plan up to date, manages risk factors, promotes function
Ongoing planning- what does it have to do with problem statements?
States problem statements more clearly
Develops new problem statements
Ongoing planning- what does it do to the outcomes and nursing interventions?
Makes outcomes more realistic and develops new outcomes as needed
Identifies nursing interventions to accomplish patient goals
Discharge Planning- who is it carried out by?
Carried out by the nurse who worked most closely with the patient
Discharge Planning- when does it begin?
Begins when the patient is admitted for treatment
Discharge planning: what does it use?
Uses teaching and counseling skills effectively to ensure that home care behaviors are performed competently
What is the first part of the nursing diagnosis? (problem statement)
Identifies the unhealthy response
Indicates what should change
What does the first part of the nursing diagnosis LEAD to?
Suggests patient goals/outcomes (expectations for change)
What is the second part of the nursing diagnosis? (etiology)
Identifies factors causing or contributing to the undesirable response and preventing desired change.
What is the second part of the nursing diagnosis? (etiology) lead to?
Suggests nursing interventions
What are the priorities that need to be established?
Maslow’s hierarchy of human needs
Patient preference
Anticipation of future problems
Critical thinking/clinical reasoning and judgement
Maslow’s hierarchy of human needs
Physiologic needs
Safety needs
Love and belonging needs
Self-esteem needs
Self-actualization needs
Clinical Reasoning and Establishing Priorities #1
What problems need immediate attention and which ones can wait?
Which problems are the responsibility of the nurse and which need to be referred to someone else?
Which problems can be dealt with by using standard plans (e.g., critical paths, standards of care)?
Which problems are not covered by protocols or standard plans but must be addressed to ensure a safe hospital stay and timely discharge?
Clinical Reasoning and Establishing Priorities #2
Have changes in the patient’s health status influenced the priority of nursing diagnoses/problems?
Have changes in the way the patient is responding to health and illness or the care plan affected those nursing diagnoses/problems that can be realistically addressed?
Are there relationships among diagnoses/problems that require that one be worked on before another can be resolved?
Can several patient problems be dealt with together?
Categories of Outcomes
Cognitive:
Psychomotor:
Affective:
Categories of Outcomes: Cognitive
describes increases in patient knowledge or intellectual behaviors
Categories of Outcomes: Psychomotor
describes patient’s achievement of new skills
Categories of Outcomes: Affective
describes changes in patient values, beliefs, and attitudes
Clinical outcomes
Clinical outcomes describe the expected status of health issues at certain points in time, after treatment is complete. They address whether the problems are resolved or to what degree they are improved
Functional outcomes
Functional outcomes describe the person’s ability to function in relation to the desired usual activities
Quality-of-life outcomes
Quality-of-life outcomes focus on key factors that affect someone’s ability to enjoy life and achieve personal goals
IOM’s Six Aims to Be Met by Health Care Systems Regarding Quality of Care
Safe:
Effective:
Patient-centered:
Timely:
Efficient:
Equitable:
IOM’s Six Aims to Be Met by Health Care Systems Regarding Quality of Care: SAFE
Safe: avoiding injury
IOM’s Six Aims to Be Met by Health Care Systems Regarding Quality of Care: EFFECTIVE
Effective: avoiding overuse and underuse
IOM’s Six Aims to Be Met by Health Care Systems Regarding Quality of Care: Patient-centered
Patient-centered: responding to patient preferences, needs, and values
IOM’s Six Aims to Be Met by Health Care Systems Regarding Quality of Care: TIMELY
Timely: reducing waits and delays
IOM’s Six Aims to Be Met by Health Care Systems Regarding Quality of Care: EFFICIENT
Efficient: avoiding waste
IOM’s Six Aims to Be Met by Health Care Systems Regarding Quality of Care: EQUITABLE
Equitable: providing care that does not vary in quality to all recipients
Joint Commission National Patient Safety Goals (7 Goals)
Identify patients correctly
Improve staff communication
Use medicines safely
Use alarms safely
Prevent infection
Identify patient safety risks
Prevent mistakes in surgery
Types of Nursing Interventions
Nurse-initiated:
Physician-initiated:
Collaborative:
Types of Nursing Interventions: Nurse Initiated
Nurse-initiated: autonomous action based on scientific rationale that a nurse executes to benefit the patient in a predictable way related to the nursing diagnosis and projected outcomes
Types of Nursing Interventions: Physician initiated
Physician-initiated: actions initiated by a physician in response to a medical diagnosis but carried out by a nurse under doctor’s orders
Types of Nursing Interventions: Collaborative
Collaborative: treatments initiated by other providers and carried out by a nurse
Structured Care Methodologies
Procedure:
Standard of care:
Algorithm:
Clinical practice guideline:
Structured Care Methodologies: Procedure
Procedure: set of how-to action steps
Structured Care Methodologies: Standard of care:
Standard of care: description of acceptable level of patient care
Structured Care Methodologies: Algorithm:
Algorithm: set of steps used to make a decision
Structured Care Methodologies: Clinical practice guideline
Clinical practice guideline: statement outlining appropriate practice for clinical condition or procedure
Formats of Care Plans
Computerized care plans
Concept map care plans
Change of shift reports
Multidisciplinary (collaborative) care plans
Student care plans
Purposes of Implementation
Help the patient achieve valued health outcomes
Promote health
Prevent disease and illness
Restore health
Facilitate coping with altered functioning
Focus of Nursing Implementation
Scope of Practice: Who, what, where, when, and why
Nursing interventions taxonomy structure
Care coordination and continuity
Types of Nursing Interventions
Those providing direct and indirect care
Independent and collaborative interventions
Protocols and standing orders
Care bundles
Implementing Guidelines #1
Act in partnership with the patient/family
Before implementing, reassess the patient to determine whether the action is still needed
Approach the patient competently
Approach the patient caringly
Modify nursing interventions according to specific criteria.
You modify nursing interventions according to what?
- Developmental and psychosocial background
- ability and willingness to participate in the care plan
- responses to previous nursing measures and progress toward goal/outcome achievement
Implementing the Plan of Care #1
Determine the patient’s new or continuing need for assistance
Promote self-care
Assist the patient to achieve valued health outcomes
Reassess the patient and review the plan of care
Use patient boards or whiteboards
Plan ahead and organize resources
Clarify prerequisite nursing competencies
Implementing the Plan of Care #2
Anticipate unexpected outcomes and solutions
Ensure quality and patient safety
Promote self-care: teaching, counseling, and advocacy
Assist patients to meet health outcomes
Reassessing the Patient and Reviewing the Care Plan
Be sure that each nursing intervention is supported by a sound scientific rationale, as demanded by an evidence-based practice
Be sure that each nursing intervention is consistent with professional standards of care and consistent with the protocols, policies, and procedures of the institution or agency
Be sure that the nursing actions are safe for this particular patient and individualized to the patient’s preferences
Clarify any questionable orders
Variables Influencing Outcome Achievement
Patient variables
Nurse variables
Variables Influencing Outcome Achievement: Patient variables
Developmental stage
Psychosocial background and culture
Variables Influencing Outcome Achievement: Nurse variables
Resources
Scope of practice and current standards of care
Research findings
Ethical and legal guides to practice
Common Reasons for Noncompliance
Lack of family support
Lack of understanding about the benefits
Low value attached to outcomes
Adverse physical or emotional effects of treatment
Inability to afford treatment
Limited access to treatment
Five Rights of Delegation
- Right Task
- Right Circumstances
- Right person
- Right directions and communication
- Right supervision and evaluation
During evaluation what does the Nurse and patient do together?
Nurse and patient together measure how well the patient has achieved the outcomes specified in the care plan
During evaluation, what does the nurse identify?
The nurse identifies factors that contribute to the patient’s ability to achieve expected outcomes and, when necessary, modifies the plan of care
What is the purpose of evaluation?
The purpose of evaluation is to allow the patient’s achievement of expected outcomes to direct future nurse-patient interactions
Five Classic Elements of Evaluation:
- Identifying evaluative criteria and standards
- Collecting data to determine whether criteria and standards are met
- Interpreting and summarizing findings
- Documenting judgment
- Terminating, continuing, or modifying the plan
Evaluating outcome: what do you evaluate?
Cognitive:
Psychomotor:
Affective:
Physiologic:
Evaluating outcome: what do you evaluate?Cognitive
Cognitive: asking patient to repeat information or apply new knowledge
Evaluating outcome: what do you evaluate? Psychomotor
Psychomotor: asking patient to demonstrate new skill
Evaluating outcome: what do you evaluate? Affective
Affective: observing patient behavior and conversation
Evaluating outcome: what do you evaluate? Physiologic
Physiologic: using physical assessment skill to collect and compare data
Variables Affecting Outcome Achievement
Patient
Nurse
Health care system
Variables Affecting Outcome Achievement: Patient example
For example, a patient gives up and refuses treatment
Variables Affecting Outcome Achievement: Nurse example
For example, a nurse is suffering from burnout
Variables Affecting Outcome Achievement: Health care system
For example, inadequate staffing
Actions Based on Patient Response to Care Plan
Delete or modify the diagnosis/problem
Make the outcome statement more realistic
Ime criteria in outcome statement
Change nursing interventions
Seven Crucial Conversations in Health Care
Broken rules
Mistakes
Lack of support
Incompetence
Poor teamwork
Disrespect
Micromanagement
Documentation
Written or electronic legal record of all pertinent interactions with the patient
Includes data related to assessing, diagnosing, planning, implementing, and evaluating
Facilitates quality, evidence-based patient care
Serves as financial and legal record
Helps in clinical research
Supports decision analysis
Elements of Documentation
Content
Timing
Format
Accountability
Confidentiality
What Is Confidential?
All information about patients written on paper, spoken aloud, saved on computer
What Is Confidential? Examples
Name, address, phone, fax, social security number
Reason the person is sick
Treatments patient receives
Information about past health conditions
Potential Breaches in Patient Confidentiality
Displaying information on a public screen
Sending confidential e-mail messages via public networks
Sharing printers among units with differing functions
Discarding copies of patient information in trash cans
Holding conversations that can be overheard
Faxing confidential information to unauthorized persons
Sending confidential messages overheard on pagers
Patient Rights
Patients have the right to:
See and copy their health record
Update their health record
Get a list of disclosures
Request a restriction on certain uses or disclosures
Choose how to receive health information
Policy for Receiving Verbal Orders
Must be given directly by the physician or nurse practitioner to a registered professional nurse or registered professional pharmacist
Record the orders in patient’s medical record with the initials VO
Read back the order to verify accuracy
Date and note the time orders were issued
Record verbal order and name of the physician or NP issuing the order, followed by nurse’s name and initials
Should be limited to urgent situations
Methods of Documentation
Computerized documentation/Electronic health records (EHRs)
Source-Oriented Records
Problem-Oriented Medical Records
PIE Charting: Problem, Intervention, Evaluation
Focus Charting
Charting by Exception
Source-Oriented Records include
Progress notes; narrative notes
Problem-Oriented Medical Records include
SOAP notes
Formats for Nursing Documentation
Initial nursing assessment
Care plan; patient care summary
Critical collaborative pathways
Progress notes
Flow sheets and graphic records
Medication
administration record
Acuity record
Discharge and transfer summary
Home health care documentation
Long-Term care documentation
Reporting Care or Requesting Action
Change of Shift/Handoff Report
ISBARR
Telephone/Telemedicine Report
Transfer and Discharge Reports
Reports to Family
Members or Significant Others
Incident/Variance Reports
Hand-off Communication/ISBARR
Identity/Introduction
Situation
Background
Assessment
Recommendation
Read back of orders/response
Change of Shift/Hand-off Reports
Basic identifying information about each patient: name, room number, bed designation, diagnosis, and attending and consulting physicians
Current appraisal of each patient’s health status
Current orders (especially any newly changed orders)
Abnormal occurrences during your shift
Any unfilled orders that need to be continued onto the next shift
Patient/family questions, concerns, needs
Reports on transfers/discharges
Telephone/Telemedicine Reports
Identify yourself and the patient, and state your relationship to the patient
Report concisely and accurately the change in the patient’s condition that is of concern and what has already been done in response to this
condition
Report the patient’s current vital signs and clinical manifestations
Have the patient’s record at hand to make knowledgeable responses to any physician’s inquiries
Concisely record time and date of the call, what was communicated, and physician’s response
Conferring about Care
Consultations and referrals
Nursing and interdisciplinary team care conferences
Nursing care rounds
Purposeful rounding
Eight Behaviors of Purposeful Rounding
Use Opening Key Words (C-I-CARE) with PRESENCE
Accomplish scheduled tasks
Address four Ps
Address additional personal needs, questions
Conduct environmental assessment
Ask “Is there anything else I can do for you? I have time.”
Tell the patient when you will be back
Document the round
