Foundations

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alyn217
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159191
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Foundations
Updated:
2012-06-23 18:59:03
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FT2 Nursing process
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Nursing Process and Critical Thinking
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  1. Role In Planning Care
    • Eliminate gaps in the patient’s care to insure quality of care
    • Provides a means of professional communication
    • Provides legal protection for the nurse
    • Regulatory agencies require documentation of the planning of care
  2. Assessment strategies
    • Multi – Source Data Collection
    • Direct Observation
    • Patient Interview
    • Review of records: look for trends in vitals, special considerations, baselines, etc. Look for H&P (hx and physical) = goldmine of information.
    • Critical thinking and observation skills are essential: In clinicals, always review pt chart night before and begin formulating nursing diagnosis, care plan, intervensions, etc.  Also look at literature review related to pt's condition.
    • Communication skills & knowledgeable assessment skills are necessities
    • PATIENT IS ALWAYS THE PRIMARY DATA SOURCE: Rely on hearsay and pt's friend's family as a secondary or tertiary source.
    • Other data sources?
  3. Assessment Interviews
    Subjective
    • Special attention should be paid to clients own words or expressions of their problem
    • Remember subjective/objective
    • PQRSTU: Paliative, Quality, Region, Severity, Timing, Understanding (pick a good time/place to educate.)
  4. Assessment strategies
    Objective
    • Privacy and remove distractions
    • Nurse has to critically think about what to assess /  determined by clinical knowledge, clinical specialty and experience
    • Use of all the senses for assessment
    • Comprehensive approach moves from general to specific
    • Allows for use of key assessment data to respond to priorities (ABCs)
  5. Data Grouping
    • Organizing the information into sets or categories to identify emerging patterns & potential problems
    • Clustering of descriptive, concise, and complete data 
    • The goal of data grouping is to arrive at a nursing diagnosis
  6. What are Gordon’s Functional Health Patterns?
    • Organizes individual nursing diagnoses into categories  to assist in organization of data collection
    • Are interrelated and represent the basic needs that must be met for all life’s functions within developmental considerations.
    • Assists the nurse in differentiating between areas for independent nursing intervention and areas requiring collaboration or referral
    • Can offer a BIG clue as to the priority of care for the patient at any given point in time.
  7. Health Perception/Health Management
    • Problems in this health pattern are a result of lack of perception and management
    • Assists individuals families or groups who may have
    • limited knowledge/understanding of their current health status and/or how to achieve/maintain good health
  8. Activity and Exercise
    • Focuses on ADL’s and the amount of energy available to the individual to support these activities
    • Includes all aspects of maintaining self and leisure activities
    • Will include dysfunctions of cardiac, respiratory and neuromuscular function because energy and mobility are dependent upon them
    • May be the primary reason that the pt. is admitted to the health care system
    • Must be aware that any admission to the hospital can promote the development  of problems within this health pattern
    • Potential problems may develop as a result of a medical diagnosis (bedrest) or agency rules and regulations (limited visiting hours)
  9. Nutrition/Metabolism
    • Focuses on food and fluid intake and the body’s use of that intake
    • Looks at the whole relationship between food and function
    • Problems may arise from a physiologic illness  or psychological illness, ie.  stress-->under/over eating.
    • Sociologic - income, inadequate storage, cultural food preferences
  10. Elimination
    • Focuses on bowel and bladder functioning
    • May be primary reason for seeking healthcare or may be a secondary problem to impaired mobility
    • Includes habits of excretory irregularity, aids for regularity, or devices for incontinence
  11. Sleep/Rest patterns
    • Includes relaxation sleep and rest
    • Looks specifically on how a pt. rates / judges the adequacy in terms of quantity or quality
    • Looks at energy level in response to adequacy and use of sleep aids
  12. Cognitive/Perceptual
    • Initial step in assessment paramount in maintaining and returning to health
    • How a pt thinks, perceives, and incorporates those processes in their life to best adapt and function
    • Deals with how a pt thinks, their thought processes, and knowledge (both acquisition and application
    • Perception – interpretation of sensory stimuli
  13. Self Perception/Self-Concept
    • Composed of beliefs attitudes and values about the self, body image, self esteem and information about abilitiesClient contributes self-knowledge through interactions with the nurse or other members of the healthcare team
    • Determinant of pts. interaction with others
    • Affected by experiences prior to and during the course of Illness
  14. Role/Relationship
    • Concerned with how a person feels they are performing an expected behavior delineated by the self and others
    • Can include family and work roles/responsibilities roles, work and social/cultural roles
    • Can also be important in patient teaching as a source of strength
  15. Sexuality/Reproductive
    • Focuses on the sexual/reproductive aspects of an individual over the entire life span.
    • Involve sex role behavior (and how we relate to each other, gender ID, physiologic and biologic functioning, cultural/societal expectations of sexual behavior capability to procreate and express sexual feelings
    • Problems may result from illness, lifestyle, violence, or self - concept
  16. Coping/Stress Tolerance
    • Ability to respond is affected by a complex interaction of physical social and emotional reactions (physiological/psychosocial). Assessment focuses on gaining an understanding of how these factors interact.
    • Stress Tolerance implies responses to the usual amount of stress
    • Coping refers to the pattern of responding to non-routine threats
    • Disfunction results when when the usual  routine or automatic response may be not readily available
  17. Value/Belief System
    • At core of existence: judgment and interpretation of the meaning of life
    • Interconnectedness with the spiritual side and the environment
    • Disturbances may be mild or severe depending on health problem
    • Faith retention/ability to maintain religious practices beliefs practices and spiritual life. Often will relate to end-of-life issues.
  18. What is a Nursing Diagnosis?
    • is a clinical judgment about  individual, family, or community responses to actual/potential health problems/ life processes. 
    • provides the basis for selection of  nursing interventions to achieve outcomes for which the nurse is responsible
    • changes as the patient’s situation or condition changes. As pt condition changes, diagnosis can be altered, added to, or subtracted.
    • Is always individualized to the pt. Care plans do not necessarily have ALL interventions/goals, etc for every pt.
  19. Use critical thinking to...
    • Analyze and interpret data
    • Draw conclusions about the client's health status
    • Verify problems with the client
    • Prioritize the problems
    • Record the diagnostic statements
  20. What are the 6 steps of Diagnotic Reasonsing?
    • 6 Steps of Diagnostic Reasoning:
    • --Problem Sensing 
    • --Rule - Out Process
    • --Synthesize the Data
    • --Evaluating/Confirming the Hypothesis
    • --List the Patient’s Problems/ Needs
    • --Reevaluate the Problem List
  21. Nursing Diagnosis facts.
    • Are not parallel to medical diagnoses
    • Involve independent nursing activities as well as collaborative roles and actions
    • A conclusion which describes a health need drawn from the data collected about a patient that is amenable to treatment by nurses
    • Defining characteristics are clinical criteria that represent the presence of the diagnostic category
  22. How are Nursing and Medical Diagnoses different?
    • Holistically considers both the problem and the effect of the problem on the individual's ability to function as him/herself.
    • Nursing complements the work of our medical brethren
    • Focus is the patient response instead of the disease process
    • Ensures meeting on needs unique to the individual
  23. Components of a NANDA diagnosis
    • Diagnostic Label: Human Response (Problem) as giving by the NANDA Definition. Distinguishes it from similar diagnoses
    • Defining characteristics (Etiology) (SnSs) and root causes.
    • Indication of the factors contributing to that response
    • Related Factors: Phrases used to link the response to the etiologic factors which include "related to" (r/t), "secondary to", or "due to"
    • Risk Factors
  24. Writing a Diagnostic Statement
    • Nursing Diagnosis (NANDA) + etiology (reason i.e. why it’s a problem or the cause of the problem) + as evidenced by (symptoms)
    • --Connecting Phrase“related to (r/t)”  (need at least 2 of these to make a diagnosis)
    • --Actual Diagnosis use the direct relationship of symptoms and etiology to the problem is established by the phrase:“as evidenced by (aeb)”
    • Example: Body image disturbance related to amputation of right lower limb as evidenced by patient not looking at the limb.
  25. Status classification of patient problems/needs
    Actual
    • Describes a human response (problem or need) to health conditions/life processes that exists (currently present) and is supported by defining characteristics (manifested by signs and symptoms).
    • The problem/need is written as a three part statement.
  26. NANDA
    Risk
    • Describes a human response (problem or need ) to health conditions/life processes that  are likely to develop.  It ( the problem) has not occurred, but is supported by risk factors that contribute to increased vulnerability.
    • A possible diagnosis is based on partial (or incomplete) data   
    • The problem/need is written as a two part statement (will not have "aeb")
  27. Common Errors in Creating and Writing a patient diagnostic statement.
    • Using the Medical Diagnosis
    • Relating the Problem to an Unchangeable Situation
    • Confusing the Etiology/Signs & Symptoms for the Problem
    • Use of a Procedure Instead of a Human Response
    • Writing a Legally Inadvisable Statement
    • Lack of Specificity
    • Combining Two Nursing Diagnoses
    • Relating One Nursing Diagnosis to Another
    • Use of Judgmental / Value-Laden Language
    • Making Assumptions
  28. Nursing Process
    Planning
    • Developing a plan of action with the patient to reduce or eliminate the problems and promote health
    • Key Activities include:
    • Setting Priorities
    • Establishing Goals/Outcomes
    • Determining Nursing Interventions
    • Documenting the Nursing Care Plan
  29. What are some considerations for setting priorities in health plan?
    • Priorities may be influenced by the following:
    • Overall health status of the client
    • Client’s own perception of priorities.
    • Overall treatment plan
    • Presence of potential problems
    • Rationale: Priority will be influenced by viewing the entire picture of the problems & how they affect the client’s health status
  30. Outcomes/Goals
    • NOC: Nursing Outcome Classification (goals)
    • NIC: Nursing Intervention Classification (intervension)
    • NANDA says: The problem--> goal: if you know what the symptoms are, you know when you've reached your goal (they symptoms will go away)
    • Etiology--> interventions: If you know the root cause, you know which steps are needed to address that cause.
  31. Writing a Quality Nursing Plan
    • Clearly stated in terms of patient behavior and observable assessment factors
    • Are realistic, achievable, safe, and acceptable to the patient
    • Written in specific concrete terms depicting patient action
    • Directly observable by use of one of  the five senses
    • Are patient-centered
  32. Long Term vs. Short Term goasl
    • Goals (giant steps!!)
    • --Long Term
    • --Overall broad directions to guide the plan of care
    • Outcomes (baby steps!!)
    • --Short Term
    • --Measurable steps  to achieve the goals of treatment/discharge criteria (etiology of the ND)
  33. Guidlines for goas/outcomes
    • Client-Centered factors
    • Singular factors
    • Observable factors
    • Measureable factors
    • Time Limited factors
    • Mutual factors
    • Realistic Factors
  34. Outcomes
    • Patient responses that are achievable.
    • Can be attained within a defined time period given the present situation and resources
    • Be specific, realistic. C
    • onsider the patients circumstances and desires
    • Provide measurable evaluation criteria for determining success or failure
  35. What are Nursing Intervension
    • Prescriptions for behaviors, treatments, activities or actions that assist the patient in achieving the expected outcomes
    • Method of individualizing care
    • Provide  an environment  conducive to carrying out the planned interventions
    • Consider which interventions can be combined
  36. Qualities of a good Intervension
    • Date the intervention was written
    • Action verb to describe the activity to be performed
    • Qualifiers/Specificity – frequency, amount, location
    • Rationale for stated interventions
    • The outcome of the intervension will be good for the patient.
    • Estimate the probability that each of the consequences will occur
  37. Nursing plan implementation
    • Performing nursing activities and interventions
    • Continuing to collect data
    • Recording and Communicating the Patient’s Health Status & Response to Interventions
  38. Qualities of effective Intervensions
    • Identify Caregiving Priorities
    • Timely. Will account for Anticipatory, & Preventive care.
    • Cost Effective
    • Considerate of ethical and legal concerns
    • Simple--> Complex Procedures
    • Identify who is responsible for the implementation of an intervention
  39. Qualities of good documentation of Intervensions
    • It is legally required that all healthcare settings document nursing observations, the care provided, and the patient’s response
    • Continue monitoring the patient. 
    • Important to continue documenting data collected throughout the implementation phase
  40. What are some questions a Nursing Evaluation of health plan should answer?
    • Have the goals been achieved?
    • Have you partially achieved the goals, or not at all?
    • What changes (if any) need to be made?
    • Focus on appropriateness of the care provided
    • Appropriate revisions of nursing interventions and/or patient outcomes may be necessary
    • Evaluating the clients response to care
  41. Reassessment
    • The need to revise the interventions.
    • The development of new patient problems or needs
    • The need to rearrange priorities to meet the changing demands of care
    • The need for referral to other sources
  42. Termination of Services
    D/C
    • Discharge planning started at time of admission
    • Verify patient/significant other/pt support has received verbal & written instructions regarding treatments, medications,  & activities
    • Signs and symptoms indicating the need for continued contact with healthcare providers are reviewed

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