NUR142#7

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lwendt
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NUR142#7
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2010-10-06 10:11:36
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  1. Steps of the Nursing Process
    • Steps of the Nursing Process
    • ž Assessment
    • ž Diagnosis
    • ž Outcome Identification
    • & Planning-goals you wish patient to achieve, must be mutual
    • ž Implementing-do it!
    • ž Evaluating-were goals met
  2. Characteristics of the Nursing Process
    • Systematic-assess before you identify a problem
    • ž Dynamic-open to change at any given time
    • ž Interpersonal-must communicate
    • ž Outcome oriented-help patient achieve goals, good health and higher level of functioning
    • ž Universal
  3. Nursing Process - Purpose
    • ž Helps the nurse manage each client’s care
    • ¡ Holistically
    • ¡ Scientifically
    • ¡ Creatively

    ž Focus is on the human response!
  4. Problem Solving and the Nursing Process
    • Trial and Error: tests solutions until one is found, not always efficient
    • ž Scientific: appropriate for controlled lab settings, , ex: pedal pulse, use Doppler?
    • ž Intuitive Thinking: problem solving based on experience, knowledge, or skill
    • ž Critical Thinking: Intuitive, Logical or both
  5. Critical Thinking: A systematic way to form and shape one’s thinking.
    • ž Solves problems creatively
    • ž Thinking with a purpose-always a goal in mind
    • ž Comprehensive-need data to make accurate assessment
    • ž Well-reasoned
    • ž Necessary for the nursing process!
  6. The Four Blended Skills are essential to nursing practice and critical thinking :
    • ž Cognitive-thinking and reasoning
    • ž Technical-psycho motor skills
    • ž Interpersonal-applies to the way you work as a team
    • ž Ethical/legal-act in best interest of your patient ANA code of ethics, state board of practice act and recognize our own inadquacies. Practice within our scope. Document in a legal and advisable manner. You didn't chart it, you didn't do it.
  7. Developing Cognitive Skills:
    • ž Use scientific rationale when planning patient care-
    • ž Identify the purpose or goal of your thinking-what do I want to accomplish?
    • ž Determine if the knowledge is accurate, complete or relevant-collect good data
    • ž Divert Potential Problems by basing decisions on sound reasoning-
    • ž Identify self limitations and important resources for learning
    • ž After drawing a conclusion, critique your decision-evaluate Taylor pg.218
  8. Developing Technical Skills:
    ž
    • ž Includes the mastery of the manual skills essential to the nursing process-confidence comes with practice
    • ž Practice new skills
    • ž Learn new equipment, procedures and policies
    • ž Seek help from technical experts
  9. Developing Interpersonal Skills:
    • Caring behaviors are essential to nursing practice
    • ž Promote the dignity and the respect of patients
    • ž Communicate caring through patient interactions
    • ž Enjoy the rewards of patient and staff respect for your care and interactions
  10. Developing Ethical/Legal Skills:
    • ž Accept accountability for the care you delegate
    • ž Voice your concerns over the unmet needs of your patients
    • ž Document patient needs
    • ž Report incompetent, unethical, or illegal practice
  11. Characteristics of Critical Thinkers:
    • ž Independent thinker
    • ž Fair minded
    • ž Intellectually humble-never too proud to learn and help others
    • ž Intellectually courageous
    • ž Demonstrates good faith and integrity
    • ž Possesses curiosity and perseverance
    • ž Creative
    • ž Disciplined
    • ž Confident
  12. Blended Skills in Action
    • Attend inservices
    • ž Become a life-long learner
    • ž Refrain from labeling patients
    • ž Approach your patient as a person, not a disease
    • ž Document appropriately
    • ž Communicate and collaborate with the entire health care team
  13. Concept mapping
    • A critical thinking approach to care planning
    • ž An instructional strategy that links key concepts (problem, nursing intervention, patient response)
    • ž A visual map of why relationships exist among patient problems
    • Still the nursing process
  14. Nursing Assessment:
    • First step of the nursing process-upon admissions and interviewing
    • ž Nurse brings blended skills and experience to collecting data
    • ž A patient data base is started or revised
    • ž Accurate assessment is crucial to ensure needs are properly met
    • ž Serves as the pool about which all other steps proceed
  15. Unique Focus of Nursing Assessment:
    • ž Gathering information about the client upon admission
    • ž Does not duplicate medical assessments
    • ž Strives to determine the client’s RESPONSE to health problems or illness that lead the nurse to the development of the nursing diagnosis
    • ž No other health professional does this for the client and family
  16. Types of Assessments:
    • ž Initial-comprehensive, usually within 24 hours, follow protocol
    • ž Focused-used to identify newer and overlooked problems
    • ž Emergency-life may depend on it, life threatening
    • ž Time Lapsed-compares current condition to baseline ex: wounds, hemoglobin,
  17. Assessment Priorities:
    • ž Helps the nurse identify the type of data needed to develop a plan of care
    • ž Focus on the patients reason for needing nursing assistance
    • ž Includes the patients health orientation, developmental stage, need for nursing and practical considerations
  18. Assessment: The Data Base
    • ž Data collection
    • -Includes Objective data (includes the Physical Assessment and what you observe)
    • -Subjective Data (the Nursing Health History and what the patient tells you)
  19. Types of data:
    • ž Objective
    • ¡ Can be observed by another person
    • ¡ Can be verified
    • ¡ Uses the senses
    • ž Subjective
    • ¡ Information perceived then communicated verbally by another
    • ¡ Cannot objectively verify
  20. Objective
    • ž Height 6’4”
    • ž Weight 200 lbs
    • ž Bruises on arms and face
    • ž Facial grimacing
    • ž BSG 107
  21. Subjective Data
    • ž “I feel like I’m going to be sick”
    • ž “I didn’t sleep well”
    • ž “I don’t think I’ll ever get better”
    • ž “My hip hurts”
    • When documenting put in quotes
  22. Characteristics of Data:
    • Data needs to be:
    • ž Complete
    • ž Factual and accurate
    • ž Relevant
    • ž Purposeful
  23. Data sources:
    • Primary- most reliable
    • ¡Client/Patient
    • ž Secondary
    • ¡ Family, significant other
    • ¡ Health record
    • ¢ Lab results
    • ¢ Diagnostic procedures
    • ¡ Health team members
    • ¡ Literature/Internet
  24. Sources of Data: The Client Record
    • ž Physicians orders
    • ž History and physical
    • ž Progress notes
    • ž Diagnostic studies
    • ž Lab reports
    • ž Consultations
    • ž Flow sheets, intake/output etc
  25. Client Record:
    • ž Medical Admission records
    • ž Treatment records
    • ž Operative reports
    • ž Other Health Care Professionals
    • ž Computerized Medical Record
  26. Data Collection Methods:
    • ž Observation
    • ¡ Responses: what are they telling you?
    • ¡ Need for nursing care: what level of help is needed?
    • ¡ Immediate environment: what do you see?
    • ¡ Larger environment: where are they?
  27. Nursing History
    • ž Should be obtained as soon as possible after admission
    • ž Will be combined with the physical assessment
    • ž Focus should be getting to know the person
    • ž Should capture the uniqueness of the person
    • ž Information gained helps nurse identify patient strengths and weaknesses
  28. The Interview:
    • ž Purpose
    • ¡ Obtain a health history that contains information about the client’s health status
    • ž Needed
    • ¡ Strong interview skills
    • ¡ Active listening skills
    • ¡ Nonjudgmental non-verbal communication skills-eye level, takes about 20 minutes, private, face the patient, within 3-4 feet.
  29. Phases of the Interview:
    • ž Preparatory
    • ž Introduction
    • ž Working
    • ž Termination
  30. ž Preparatory Phase
    • Nurse may review information in the medical record
    • ž Approach client with open mind
    • ž Be sensitive to human needs
    • ž Use a non-judgmental approach- I accept you for who you are
    • ž Ensure privacy (family presence only if patient approves)
    • ž Conduct interview at opportune time
  31. Introduction
    • State purpose-lead in question
    • ¡ All information is for one purpose- to help nursing staff plan and provide care
    • ž Introduce self
    • ž Clarify roles
    • ensure privacy but let them know you may have to share info
  32. Working Phase
    • ž Focus on the patient
    • ž Use therapeutic communication skills, closed and open questions, use terms they will understand
    • ž Gather information
    • ž Accuracy, completeness and relevance depends largely upon nurse’s interviewing skills
  33. Termination:
    • Conclude carefully, not abruptly,
    • ž Encourage client/family to give nurse additional information in order to help nursing staff to plan care
    • ž “Is there anything else you think we need to know?”
    • ž Thank them for answering the questions
  34. Problems Related to Data Collection
    • ž Inappropriate organization of the data base
    • ž Omission of data
    • ž Inclusion of irrelevant data
    • ž Failure to establish rapport
    • ž Failure to observe appropriate behavior
    • ž Failure to update the data base
    • ž Failure to document accurately, clearly & timely
  35. Validation of Data
    • Confirm or verify discrepancies
    • ¢ Between objective and subjective data
    • ¢ Between sources, client and family or record

    • Explore data which lacks objectivity
    • ¢ Suspicions or conflicting data
    • ¢ Intuition that information is not accurate
    • ¢ Use cues and inferences to assist in validation
  36. Cues and Inferences:
    • ž Cues -- pieces of information obtained through assessment;
    • --an indication that something may be wrong
    • --can be objective or subjective
    • ojective + subjective = inference
    • ž Inference -- assignment of a meaning to the cue
  37. Inferencing:
    • *Temp 102F *Temp 102F
    • *Scattered rhonchi *Decreased turgor
    • *Thick green mucous *Dry tongue
    • *Shortness of breath *Urine output--200 cc/8hr, &
    • concentrated

    • *Problem: Pneumonia *Problem -Dehydration
    • *Nursing DX: *Nursing DX:
    • -Ineffective Airway -Deficient Fluid Volume
  38. Inferencing:
    • *Always thirsty
    • *Urinates 8-12 x’s/day
    • *Weight 224 pounds
    • *Height 5’1”
    • *Having blurred vision
    • *Tires easily
    • Problem: Diabetes Mellitus
    • Inference: Unstable blood glucose
  39. Use Critical Thinking to Identify the Problem:
    • ž 72 year old man
    • ž Blind
    • ž Lives alone
    • ž States: “I am always bumping myself”
    • ž States: “I get around by using my cane”
    • ž Has visible bumps and bruises on his head and arms
  40. Identification of Patient Problem:
    • After data collection is complete, the nurse clusters data (cues) to form inferences.
    • ž Inferences lead the nurse to identification of the patients problem
    • ž Nursing Diagnosis becomes the clinical judgment product of critical thinking
    • Complete Health Assessment
  41. Identification of Patient Problem:
    • After data collection is complete, the nurse clusters data (cues) to form inferences.
    • ž Inferences lead the nurse to identification of the patients problem
    • ž Nursing Diagnosis becomes the clinical judgment product of critical thinking
    • Complete Health Assessment
  42. Two components
    ¡ Nursing history

    ¡ Physical assessment
  43. Guide to Collecting the Nursing History
    ž Collection of subjective data

    • ž If the patient cannot give you accurate information, ask for the name of a friend or relative who can provide the information
    • Biographical Data

    ž Patient initials, age, sex, marital status, religion, occupation, education

    ž Biographical data may be available from the admitting information obtained from the Admissions office.
  44. Subjective interview:
    • Reason for seeking healthcare
    • ž Use the patients exact words; “place words in quotes”.
    • ž Ask: “What brings you here?”
    • Patients opinion of own general health
    • ž What is your opinion of your health?
    • ž If “10” is the best health, how do you rate your health?

    • Activities of Daily Living:
    • ž Ask questions specific to the patients functional status.
    • ž Do you need assistance with any of the activities of daily living?
    • ž Describe a typical day for you?
    • · Pattern of Nutrition
  45. Subjective interview continued:
    • How many meals do you eat each day?
    • ž Do you follow a special diet?
    • ž Have you lost or gained weight within the last 2 weeks?
    • ž Who cooks and buys groceries for you?
    • · Elimination
    • ž How often do you move your bowels?
    • ž When was your last Bowel movement?
    • · Activity/exercise
    • ž Do you follow any special exercise program? If yes, explore the frequency, intensity, and duration of the exercise.
    • ž Does your health put any limits on your ability to exercise?
    • · Rest/sleep
    • ž How long do you sleep at night?
    • ž Do you have any trouble going to sleep?
    • ž Do you take a sleeping pill to help you sleep?
    • · Safety
    • ž Do you wear glasses, hearing aids, or use any assistive devices?
    • ž Do you feel safe in your home? *(patient must be alone when you screen for domestic violence)
    • ž When do you not feel safe?
  46. Subjective interview:
    • Previous illnesses (major) & hospitalizations
    • ž Have you ever been hospitalized before? Can you tell me why?
    • Surgeries:
    • ž Have you had any previous surgeries?
    • ž Can you describe them?
    • ALLERGIES:
    • ž Do you have any allergies?
    • ž Are you allergic to any medications?
    • ž Are you allergic to latex? (balloons and kiwi)
    • Wellness Practices:
    • ž What do you do for exercise? How often do you exercise?
    • ž Do you smoke cigarettes?
    • ž How many alcoholic drinks do you have in a day? (ask what type)
    • ž Are there any religious beliefs or cultural practices that may affect your care?
    • Medications
    • ž Can you tell the name of all of the medications you are currently taking?
    • *(include herbal meds, OTC meds, illegal or street meds)
  47. Subjective interview:
    • Family History: (role in family, significant relationships)
    • ž Do you have a family? How do you support your family?
    • ž What do you do to earn a living?
    • ž Who is the most important person to you in your life right now?
    • ž Who is available to help you at home after you are discharged?
    • Family Support:
    • ž From whom do you get the most support?
    • ž Tell me about the emotional support you receive from your family/friends.
    • Psychosocial History: (substance abuse, sources of stress/coping)
    • ž How have you coped with medical or emotional crisis in the past?
    • ž Has your life changed recently?
    • ž Do you sniff, snort, or inject any substances?
    • Review of Systems
  48. Subjective interview continued:
    • Skin and Respiratory
    • ž Do you bruise easily?
    • ž Do you have any open sores, wounds or lesions?
    • ž Do you get short of breath when you climb the stairs, or walk?
    • ž Do you have a cough?
    • Cardiovascular and Axillae/breasts
    • ž Do you experience chest pains, palpitations, irregular heart beat, shortness of breath, or cough?
    • ž Do you perform monthly breast self exams?
    • GI and Reproductive
    • ž Do you experience nausea, vomiting, decreased appetite, bloating, increased gas, constipation, or heartburn?
    • ž Female pt: Can you tell me the date of your LMP, # of pregnancies, #births, birth control, last Pap smear?Male pt: Can you tell me the date of your last testicular or prostate exam
  49. Subjective interview:
    • Urinary and Peripheral-vascular circulation
    • ž Do you experience burning, incontinence, frequency, urgency, or decreased flow when urinating?
    • ž Do you experience cold extremities (hands and feet)?
    • ž Have you ever been diagnosed with anemia?

    • Musculoskeletal and Neurologic
    • ž Do you experience swelling, soreness, or stiffness in your joints?
    • ž Do you get headaches?
    • ž When was your last eye exam?
    • Endocrine
    • ž Do you feel unusually tired?
    • ž Have you experienced a recent weight loss or gain in the last 2 weeks to one month?
    • ž Have you experienced increased thirst?
    • ž Do you take hormones?

    • Anything else the patient would like you to know?
    • ž Is there anything else you would like me to know?
  50. Summary
    • ž The Nursing Process is a 5 step process that is used to determine the need for nursing care.
    • ž The Nursing Process requires the integration of critical thinking skills.
    • ž Assessment is the first step of the Nursing Process.
    • ž Data collection both subjective and objective is used to develop the data base which is needed to determine patient strengths and weaknesses.

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