Nursing Process Flashcards
Maslows hierarchy of needs
- Guideline for priority of nursing care
- Basic needs must be met first
1) physiologic needs- oxygen, water, food, temperature, elimination
2) safety needs ( physical and emotional) - protection from potential or actual harm
- nursing responsibility to promote safety
3) Love and belonging needs- understanding and acceptance of others, giving and receiving love
4) self-esteem needs- Pride, sense of accomplishment
5) self actualization needs- need to reach full potential
Steps in nursing process
“ADd PIE” Assessment diagnosis outcome identification and planning implementation of outcomes evaluation
Assessment
First step in the nursing process data collection and analysis and validation of data communication and recording of data and ongoing process
Assessment data collection
Subjective data: Perceived or reported by the patient, caregiver, or family member, symptoms
Objective data: Can be measurable, observed, or sent by someone besides the patient, signs
Assessment data collection sources
- patient: primary source of data collection
- Family, caregivers, significant other: if patient has a limited ability to communicate
- patient record: information gathered and documented in the patient’s chart, history, progress notes, consultation, lab results, can be written information from other members of the healthcare team
- other healthcare professionals: Important during patient transfer
Assessment: how do nurses collect data; physical assessment
- review if systems: usually in a head to toe sequence
- patient examination and observation of objective data
- nursing physical assessment focus on the patients functional abilities
- assessment techniques may depend on the nursing setting and purpose of the assessment
Assessment: how do nurses collect data; history obtained from interviews
- patient profile: age, gender, race, marital status, occupation etc
- complains or reason for seeking care
- health habits
- cultural preferences
- current medications, allergies, immunization
- family health history
- determine needs: learning needs and abilities, participation in care, expectations
- personal resources
- identifies risk
Types of assessment
- initial: comprehensive, detailed; establish baseline to identify problems and direct the plan of care
- focused: data gathered about specific problems or complaint
- emergency: identifies any life threatening problems
- time lapsed: comparison of patients progress or current status to previous data
Data analysis
- compares patient data with standards and recognize trends
- confirm data collected
- recognize and eliminate errors, biases and miscommunication of info
Data reporting / recording
- necessary to report significant findings in a timely manner to prevent harm
- any findings should be documented in the patients chart
- should be easy to retrieve and understand
- record subjective data in the patients words if possible
Diagnosis
- second step
- RN identifies and writes nursing diagnosis; lpn and student write nurses problems
- nurse interprets data to identify health problems
- clarifies the nature of the problem
- identifies concerns unique to patient
- identifies patients human response to health process
- identifies patient resource and strength
- prioritize diagnosis depending on the threat to patient health and safety !!
Nursing diagnosis
- Actually a health problem that can be prevented or resolved by independent nursing interventions
- NOT a medical diagnosis
- Collaborative problems certain complications
• uses both physician prescribed and nursing complications
• primary nursing responsibilities
• When writing a collaborative problem statement word as “potential complication” “complication that may occur”
Five types of nursing diagnosis
1) ACTUAL- Present a problem that has been validated by defining characteristics
2) RISK- clinical judgments that a patient is bravo to develop a certain problem
3) POSSIBLE- suspected problem that requires additional information
4) WELLNESS- Chemical judgments about a patient from a specific level of promise to a higher level of wellness
5) SYNDROME- actual or risk that are predicted to you to a certain
Writing a nursing diagnosis
Statement listing the problem, cause and problems defining characteristics
- problem statement
- cause (etiology)
- defining characteristics
Problem statement
- describe patients health status or health problem in a clear and specific manner
- identifies what is unhealthy and defined the need for change
- suggest patients outcome
Etiology
- cause or contributing factors that is assumed to be related to the problem
- suggest the appropriate nursing interventions
- should be worded as “related to..”
Defining characteristics
- Subjective and objective data that reflects/prove that the problem exist
- the signs and symptoms
- such as the criteria used to evaluate the effectiveness of the intervention
Should be worded as “manifested by” or “ as evidenced by”
Outcome identification and planning
- third step
- result from problem statement
- set priorities
- identifies and documents expected outcomes!
- use nursing interventions based on evidence!
- necessary to design patient care plan!
- communicates the care plan with the patient/family and other members of the healthcare team
Types of outcomes
1) COGNITIVE- increase the patient’s knowledge
2) PSYCHOMOTOR- patient develops new skill
3) AFFECTIVE- transform patient values, beliefs and attitudes
4) PHYSIOLOGIC- target physical change in patient
Expected outcome
Measurable standard used to assess whether or not the goal has been met; written by RN
- at least one patient outcome should be documented (for EACH nursing diagnosis or problem statement) that proposes a direct resolution to that problem
Must include: Subject Verb Performing criteria Time frame
Writing an outcome statement
1) SUBJECT- patient or family
2) VERB- action word that is observable / measurable
3) PERFORMANCE CRITERIA- observable / measurable words that describe the expected behavior or change
4) TIME FRAME- specific time in which the goal will be achieved or met
May or may not include special considerations required to meet outcome
Outcome identifies and planning: intervention
- treatment performed by the nurse to achieve the patient outcome
- initiated by the nurse, doctor or collaborative
- related the nursing diagnosis and expected outcome
- based on scientific rationales (evidence based)
- nursing intervention addresses the cause or the problem
Types of outcome and planning interventions
- PHYSICIAN INITIATED: initiated by opposition in response to a medical diagnosis for caring out by the nurse; nurses carry out physician orders ( giving pain med)
- NURSE INTERVENTION: autonomous, based on scientific rationale, executed by the nurse to benefit the patient; do not require doctors orders ( Turning patient q2h)
- COLLABORATIVE: Performed by the nurse but initiated by other members of the healthcare team such as pharmacist therapist and nurse practitioners
Writing nursing interventions
- data
- verb or action
- subject: who will perform task
- descriptive phrase
Always provide a rationale based on scientific evidence to support the nursing intervention
The care plan
Nursing diagnosis + expected outcome + nursing interventions
- can be notified, dated, and signed throughout course of treatment
- utilizes evidence in current research
- must be updated as the patient’s condition changes
- helps the nurse prioritize specific patient needs
Implementation
- fourth step
- phase of the nursing process where the plan of care is carried out
- clarifies any questions and plans for unexpected occurrences
- in addition to the patient may involve family members and other healthcare team members
- acquires assessment every assessment of the patient’s condition nursing interventions are appropriate ( are the working?)
Implementation do’s
- always consider the agency/facility policies and procedures
- Always document the caregiving as well as the patient’s response and involvement in the intervention
- Be aware of any new patient problems or safety risk that may arise during the implementation process
- prioritize nursing interventions based on the patient’s well-being and perform bed interventions first (maslow’s hierarchy)
Evaluation
- final step
- determines if the patient achieved the outcome
- Determines if the care plan will be continued, modified or completed/terminated
- should begin during the Initial implementation of interventions in at the specified time for the expected outcome to be met
- a continuous process
Evaluation steps
1) select criteria to evaluate
2) collect data to be evaluated
3) interpret and summarize data that is gathered
4) document findings
5) ?decide if the care plan will be continued, modified or completed
Evaluating outcomes
COGNITIVE: Have the patient repeat information teach information to a family member or apply new knowledge to his/her situation
PSYCHOMOTOR: ask the patient to demonstrate new skills
AFFECTIVE: Observe patient’s behavior and conversations with family members
PHYSIOLOGIC: Collect and compare assessment data, no lab/diagnostic test results, and subjective and objective findings
Evaluative statement
Two part statement: how will the outcome is met in the patient information or evidence to support this conclusion
Outcome met
Outcome partially met
Outcome not met
Concept map
- diagram of patient problems and nursing interventions
- require critical thinking to determine patient needs and problem identification
- includes concepts or ideas about the patient’s health problems
- Allows the nurse to set priorities for interventions and care
- provides a holistic view of the patient by identifying relationships in patient data
- allows the nurse to organize patient care
