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What is a process?
It is a series of steps or components leading to achievement of a goal.
Characteristics of a process:
A process is a continuous progression from one point to another to ahcieve a specific goal.
A system is made of separate parts or elements. The parts rely on one another and are interrelated have a common purpose and together form a whole.
A system has a specific goal.
The content is the product and info obtained from the system.
3 Components of a System:
Which type of system:
Interacts with it's environment
Exchange of info between the system and the environment
Which type of system:
Does not interact with the environment
No exchange of info
Nursing Process as a system:
- Purpose - provide systematic, individualized and appropriate care to client
- Process - 5 components of the Nursing Process
- Content - Info is obtained and used from each component
The Nursing Process is a ___ system.
Because it interacts with it's environment continually changing as the client's needs change.
Nursing Process as a system:
- Input - assessment and from nursing interventions
- Output - evaluation component
- Feedback - evaluation component returned and reassessment occurs on basis of client's health care needs.
Theoretical approach to the Nursing Process:
Problem solving method
- Foundation for the nursing process
- A specific method for obtaining a solution to a problem
- Is a 6 step process
6 Step Problem Solving Method:
- 1.) Encountering a problem
- 2.) Collecting data
- 3.) Identifying exact nature of the problem
- 4.) Determining a plan of action
- 5.) Carrying out the plan
- 6.) Evaluating the plan and the new situation
What does the Nursing Process provide us with?
- Organized framework
- Independent nursing action
A method for organizing and delivering nursing care.
Provides the organizational structure and framework for nursing care, yet it is creative and flexible enough to be used in a variety of settings.
Is an organized systematic method of giving individualized nursing care that focuses upon identifying and treating unique responses of individuals or groups to actual or potential alteration in health.
Purpose of the Nursing Process:
- Identifies problems
- Establishes line of communication and establishes a database
- Delivers method to give nursing care and provides continuity of nursing care
The Nursing Process organization has 5 components that are interrelated.
*These 5 components are:
- 1.) Assessment
- 2.) Nursing diagnosis
- 3.) Planning
- 4.) Implementation
- 5.) Evaluation
To gather, verify and communicate data.
Establish the data base
Collecting nursing health history
Perform physical exam
Collect lab data
To identify health care problems and needs of the client.
To formulate nursing diagnostic statement.
Interpret, cluster and validate data
Formulate nursing diagnostic statement
Identify client goals
Design nursing strategies
Determine outcome criteria
Identify client goals
Select nursing actions
Write NCP (nursing care plan)
Complete nursing actions necessary for accomplishing plan
Perform nursing actions
Review and modify existing care plan
Determine the extent to which goal of care has been accomplished
Evaluate according to the established evaluation criteria
Compare client response to criteria
Analyze reasons for results and conclusions
Goals of Nursing:
- Promote, maintain or restore health
- Enable individuals to manage their own health
- Provide nursing care
History of Nursing Process:
- Introduced in 1950, was a 3 step process:
History of Nursing Process:
- 1976 - 5 step process
- Classification of nursing diagnoses
- Advanced the profession
- Focus of nursing care is established through the nursing care plan
- Specific nursing responsibility defined
Nursing autonomy and accountability are enhanced through the identification of health care problems within the domain of nursing practice.
Data collection and Data organization
What the client actually SAYS
May not be validated
May not be factual
Based on what you see, hear, smell and feel.
Includes objective and subjective data
- Screening Assessment
- Baseline assessment
Assessment on a specific area
Subjective statements and objective data
Something you see or hear
Influenced by nurses knowledge
Assessment is an on-going continuous process it occurs throughout each phase of the nursing process.
- Maslow's Heirarchy
- Nursing Diagnosis
States the actual or possible problems.
Three Steps in the area:
- 1.) Analysis
- 2.) Identification (actual or risk diagnosis)
- 3.) Statements
Problems identified are those the nurse is licensed and competent to treat.
Identification of a disease based on physical signs, symptoms, history, lab tests and procedures.
Derived from the physiological psychological sociocultural developmental and spiritual dimensions.
Goals are to identify and cure the disease.
The focus is curative.
Identifies health are needs.
Present level of health
Response to a disease
Goals and objectives are to identify health problems and develop a plan of care.
Focus is to help the client reach a maximal level of wellness.
Advantage of Nursing Diagnosis:
- Facilitates communication
- Focus for quality assurance and peer review.
Limitation of Nursing Diagnosis:
NANDA (North American Nursing Dx Associates) does what:
Approve nursing diagnosis
Statement of actual or possible problem that requires nursing intervention to resolve or less or prevent.
PES format includes:
- Signs and symptoms
Ask yourself three questions when making a nursing diagnosis:
- What is the problem?
- What is causing the problem?
- How do you know the problem exists?
Problem = nursing diagnosis
Etiology = what is causing the problem?
Signs & Symptoms = always supports the nursing diagnosis it NEVER supports the etiology
Avoid using medical diagnosis as etiology.
Do not use for a newly diagnosed paraplegic
no: impaired walking
yes: impaired mobility
Nursing diagnosis should be simple, brie, specific and based on collected data.
Nursing diagnosis statement:
- Actual problem
- related to
- Contributing Factors (etiology)
- as shown by
Do not say "due to"
- Defining characteristics
- as manifested by
May use "of unknown etiology"
Acute pain of unknown etiology...
Impaired walking (nursing diagnosis
Related to post op status (etiology)
As shown by requiring physical support during ambulation (signs and symptoms)
Acute pain related to fractures, trauma and immobility as manifested by client reporting pain of 6 on a pain scale. BP 120/76, P 100, R 30 & moaning.
Psychological and Physiological
Intermediate and Non life threatening
Not directly related to specific illness or disease process
Acute pain related to surgical incision as manifested by client stating the incision hurts.
- Etiology? surgical incision
- Problem? acute pain
- Supporting evidence? client states incision hurts
- Priority? 1 week - medium; 6 hr post op - high
Two part statement
Risk of problem developing and probable cause or etiology
There are NO signs and symptoms!
Incorrect statements of the nursing diagnosis:
- Nursing diagnosis stated as a medical diagnosis - such as an MI
- Use of medical terminology to describe the cause (decrease cardiac output r/t MI)
Common Errors in writing nursing diagnosis:
- Statement may legally inadvisable and may show implications of blame
- Problem and etiology say the same thing
- Environmental problems are put into the problem statement
- Identified problem is not necessarily unhealthy
- Identified problem cannot be changed
- Incomplete data
- Incorrect clustering
- Incorrect interpretation
- Diagnosing of non existent problems
Goals to lessen, prevent or resolve the problem
A category to develop nursing behaviors/nursing interventions
3rd step in nursing process.
- Goals are determined
- Priorities are established
- Outcomes -something that the client can accomplish that you can measure
- Nursing care plan
- Modifiying care
- Documentation - document what the outcomes and interventions are
Goals must be specific to patient.
- Goals must be important to client.
- What is important to them may not be important to you.
Nursing care plan:
- Goals for every problem
- Nursing actions for every goal
- Projected outcomes
- Evaluation - how do you know you have accomplished the goal
Purpose of nursing care plan:
- Documentation - of what is impt to the client
- Coordination of care
- Promotion of health and wellness
- Criteria for evaluation
- Lower risk of inaccurate care
Nursing care plans also:
- Identify problems
- Cost effective (may decrease length of hospital stay)
- Organization of information
- Discharge planning
3 types of Nursing Care Plans:
Institutionalized care plan:
Everyone is treated the same, similar medical problems
Standardized care plan:
Associated with specific medical disease (ex: MI has same basic needs)
Student care plan:
More specific to the patient, includes all of the patient's problems.
- Setting Priorities
- Writing goals/objective/outcomes
- Planning nursing actions must be specific to goals/objectives.
- Achievement of maximal level of wellness
- Involve client, family, SO
- (ex: wife will learn how to prepare low fat meals)
Projected outcomes of planning:
- Determination if goal has been met or not
- Measurable behaviors
- Criteria used for evaluation
- Time frame
Components of Goal Statement:
Who will do what when?
- Subject/Noun (who)
- Verb (will do)
- Criteria/Task (what)
- Condition (when)
Client will verbalize understanding of decreased caloric intake.
Manipulation and motor skills
Client will walk 10 feet without assistance.
Value, judgements, and emotion.
Client will express feelings about lonliness.
Pain at cellular level; pain at incision site
Pain due to grief or emotions
- What the client will accomplish
- Outcome criteria
- Realistic time frame to accomplish the objective
- Realist for the nurse's level of skill
- Congruent with and supportive of medical regime
- Important and valued b the client, nurses and physicians.
- Must be written behaviorally.
- (client will do something specific themselves: state something, perform a task)
3 Goals/Objective Categories:
Prevents problem from occurring
Prevents the problem
Teaches the patient about the problem.
Impaired skin integrity related to prolonged bed rest and immobility as evident by a 3 x 2stage II decub ulcer on right buttocks.
The client's decubitus ulcer on right buttock will decrease to 2 cm x 1 cm by 2/28/2012.
- psychomotor (cellular level)
The client will understand the importance of repositioning self to prevent further skin breakdown by 2/28/2012 as evident by verbalization
Client's decubitus ulcer on right buttocks will be completely healed as evidenced by no redness, drainage or bread in epidermal layer by 2/28/2012
Client will experience no additional skin break down by 2/28/12
Evaluation Outcome Criteria (EOC):
When you have a BROAD goal statement EOC's may be needed for measurement.
Client will experience decreased pain experience by 2/28/12 as evidence by:
1. Decreased requests for pain med, requests for pain med at 8 hour intervals instead of 6 hour intervals.
2. Correct use of muscle relaxation techniques
3. Verbalization of decreased pain on a pain scale of 1-10 with 10 being the most severe pain.
Client will perform quad exercises every 1 hour while awake.
Client will appreciate the need to ambulate.
Client will verbalize the need to ambulate.
Mother will be instructed on proper infant care.
Incorrect this is an nursing intervention.
Wife will list 10 foods high in Na by the end of the week.
Weight reduction group will attend classes weekly.
Client will understand major purpose of his meds 2 days prior to expected discharge by 2/28/12
- Incorrect, you cannot measure "understand"
- Client will verbalize, instead.
Client will ambulate by 2/28/12.
Client will write his menu for a week by 2/28/12
Common Mistakes in writing Goals/Objectives:
- Written in terms of nursing actions rather than client actions.
- Cannot be observed or measured through one of the senses.
- Task not specific to the individual client.
Improve & more specific goal statements:
Client will state 1 major purpose for each of his four meds 2 days prior to expected discharge of 2/28/12
Client will walk without assistance from this room to the nurses station by 2/28/12
Client will select one food from each of the four basic food groups for his dinner by 2/28/12
Planning nursing actions:
Nursing strategies are developed to achieve a client goal.
- Based upon client center goals
- Determine priorities
- Specify nursing actions
- Use collaborative approach