The nursing process
Published on Nov 18, 2015
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PRESENTATION OUTLINE
The nursing process
Traci Boren, MS, RN, CNOR
"Diagnose and treat human responses to actual or potential health problems"
The nursing process is:
* specific to the nursing profession
*a framework for critical thinking
* client-focused problem solving
* dynamic and flexible
* goal-oriented
* reflective of the scientific method
* specific to the nursing profession
*a framework for critical thinking
* client-focused problem solving
* dynamic and flexible
* goal-oriented
* reflective of the scientific method
ADPIE/AAPIE
- ASSESSMENT
- DIAGNOSIS/ANALYSIS
- PLANNING
- IMPLEMENTATION
- EVALUATION
ASSESSMENT - GATHER INFORMATION
- NURSING INTERVIEW - History
- HEALTH ASSESSMENT
- PHYSICAL EXAM
- Interpret & Analyze
- Organize & Cluster
Assessment
Primary Source - Client/Family
Secondary Source - Physical exam, nursing history, team members, lab reports, diagnostic tests, etc.
Subjective and Objective Data
- Make sure information is complete and accurate
- Validate prn
- Compare trends in data
-
Primary Source - Client/Family
Secondary Source - Physical exam, nursing history, team members, lab reports, diagnostic tests, etc.
Subjective and Objective Data
- Make sure information is complete and accurate
- Validate prn
- Compare trends in data
-
Assessment
- Client diagnosed with hypertension
- Current blood pressure: 160/90
- 2 Gram Na diet
- Antihypertensive medications prescribed
- Client states "I really don't watch my salt."
NURSING DIAGNOSIS
Identify Client Problems
Formulate a Diagnosis (NANDA)
NANDA = North American Diagnosis Association
Nursing diagnoses are based on how a client is RESPONDING to an actual or potential problem that requires a nursing intervention
Sometimes a NANDA diagnosis can be limiting in determining priority problems and/or seeing the big picture
Current nursing care focuses on clinical reasoning
Nursing diagnoses are based on how a client is RESPONDING to an actual or potential problem that requires a nursing intervention
Sometimes a NANDA diagnosis can be limiting in determining priority problems and/or seeing the big picture
Current nursing care focuses on clinical reasoning
Nursing diagnosis
- PROBLEM - based on your assessment
- ETIOLOGY - what is causing the problem
- DEFINING CHARACTERISTICS - a.e.b
3 parts to a traditional nursing diagnosis:
1. The problem or diagnostic statement; based on your gathered assessment data; NANDA dx or not
2. Etiology - what the problem is caused by or related to
3. Defining characteristics - what your evidence is that the problem exists
1. The problem or diagnostic statement; based on your gathered assessment data; NANDA dx or not
2. Etiology - what the problem is caused by or related to
3. Defining characteristics - what your evidence is that the problem exists
EXAMPLE:
Ineffective Therapeutic Regimen Management
R/T difficulty maintaining lifestyle changes and lack of knowledge
AEB B/P 160/90, dietary sodium restrictions not being observed, client statement of "I don't watch my salt"
TYPES OF NURSING DIAGNOSES:
ACTUAL
RISK
WELLNESS
EXAMPLES:
ACTUAL - Imbalanced nutrition: less than body requirements R/T chronic diarrhea, nausea, and pain AEB height 5'5" weight 105 pounds
RISK - Risk for falls R/T altered gait and generalized weakness
WELLNESS - Family coping: potential for growth R/T unexpected birth of twins
ACTUAL - Imbalanced nutrition: less than body requirements R/T chronic diarrhea, nausea, and pain AEB height 5'5" weight 105 pounds
RISK - Risk for falls R/T altered gait and generalized weakness
WELLNESS - Family coping: potential for growth R/T unexpected birth of twins
planning
Prioritize Client Problems
PLANNING -
Establishing Priorities
Priorities are often established using Maslow's heirarchy of needs
Nurse works with client to establish goals
Expected outcomes are identified
Interventions are selected to aid in reaching goals
Priorities can change
Nurse works with client to establish goals
Expected outcomes are identified
Interventions are selected to aid in reaching goals
Priorities can change
PLANNING - "SMART" GOALS & Outcomes
- Specific
- Measurable
- Attainable
- Relevant
- Time Bound
Goals and Outcome statements are:
- client-focused
- worded positively
- measurable, specific, observable, time-limited and realistic
Goal is a broad statement
Expected outcome describes objective criterion for measurement of goal
NOC - nursing outcomes classification
Short-term: behavior or response expected within hours to a week
Long-term: behavior or response expected within days, weeks, or months
- client-focused
- worded positively
- measurable, specific, observable, time-limited and realistic
Goal is a broad statement
Expected outcome describes objective criterion for measurement of goal
NOC - nursing outcomes classification
Short-term: behavior or response expected within hours to a week
Long-term: behavior or response expected within days, weeks, or months
EXAMPLE GOAL STATEMENT:
CLIENT WILL achieve therapeutic management of disease process
AEB B/P readings of 110-120/70-80 and client statement of understanding of dietary sodium restrictions by day of discharge
PLANNING - INTERVENTIONS
Utilize clinical judgement & knowledge
Must be feasible and acceptable to client
INTERVENTIONS
- INDEPENDENT - Nurse can initiate
- DEPENDENT - Requires an order
- COLLABORATIVE - Performed jointly
Clinical guidelines and protocols - systematically developed to assist HCPs make decisions about care
Standing orders - routine therapies, monitoring guidelines and/or diagnostic procedures for specific patients/clinical problems
Critical Pathways - patient care plans that guide the team with tasks to be performed sequentially
NIC = Nursing interventions classification
A listing of suggested interventions for each NANDA dx
ANA Standards of Professional Practice
Standing orders - routine therapies, monitoring guidelines and/or diagnostic procedures for specific patients/clinical problems
Critical Pathways - patient care plans that guide the team with tasks to be performed sequentially
NIC = Nursing interventions classification
A listing of suggested interventions for each NANDA dx
ANA Standards of Professional Practice
IMPLEMENTATION
Carrying out interventions
Includes monitoring, teaching, further assessment, incorporation of physician orders
IMPLEMENTATION - EXAMPLE
- Monitor VS q 4hr
- Maintain prescribed diet (2 gm Na)
- Client teaching - lifestyle changes
- Client teaching - medications
- Consult with dietary
EVALUATION
Outcome criteria met or not met?
Factors that can impede goal attainment:
- Incomplete information
- Unrealistic client outcomes
- Nonspecific interventions
- Inadequate time for client to achieve outcomes
- Incomplete information
- Unrealistic client outcomes
- Nonspecific interventions
- Inadequate time for client to achieve outcomes
Nursing Care Delivery Models
- Team Nursing
- Total Patient Care
- Primary Nursing
- Case Management
Team nursing = collaborative style where tasks are performed with help of other nurses
Total patient care = direct care of the patient with little delegation. Not cost-effective, but high patient satisfaction
Primary nursing = one nurse assumes flexible caseload depending on acuity
Case management = oversees patient needs and options for complex care.
Total patient care = direct care of the patient with little delegation. Not cost-effective, but high patient satisfaction
Primary nursing = one nurse assumes flexible caseload depending on acuity
Case management = oversees patient needs and options for complex care.
5 Rights of delegation
- Right Task
- Right Circumstance
- Right Person
- Right Direction/Communication
- Right Supervision/Evaluation
Appropriate delegation:
- Nurse Practice Act
- Institutional Policies and Procedures
- Job description of NAP in facility
Right task - repetitive, require little supervision, relatively noninvasive, predictable results and minimal risk
Right circumstance - appropriate to setting and resources
Right communication - clear description and expectations
Right supervision - appropriate monitoring, follow-up and feedback as needed
- Nurse Practice Act
- Institutional Policies and Procedures
- Job description of NAP in facility
Right task - repetitive, require little supervision, relatively noninvasive, predictable results and minimal risk
Right circumstance - appropriate to setting and resources
Right communication - clear description and expectations
Right supervision - appropriate monitoring, follow-up and feedback as needed
Documentation
Purposes of the Record
- Communication
- Reimbursement
- Research/Education
- Legal documentation
- Auditing/Monitoring
The move toward EHR
Goal: Improve quality of care and patient safety
Do's and Dont's in Documentation
Privacy, Confidentiality & Security
Guidelines
- Factual
- Accurate
- Complete
- Current
- Organized
Problem-Oriented Record
Database
Problem List
Care Plan
Progress Notes
Progress Notes: SOAP(IER)
PIE
DAR
Narrative
Charting by Exception
Critical Pathways
Narrative
Charting by Exception
Critical Pathways
Documentation: Home & Long-Term Care
Incident reports
Actual events and "Near Misses"
