Nursing Process II

• Process - It is a series of planned actions or operations directed towards a particular result or goal
• Nursing Process - It is a systematic, rational method of planning and providing individualized nursing
• Benefits of Using the Nursing Process

  • Continuity of Care
  • Prevention of Duplication
  • Individualized care
  • Standards of Care
  • Increased Client Participation
  • Collaboration of Care
• Assessment - The first step in the nursing process; It is a systematic and continuous collection, validation, and communication of patient data
• Data Characteristics(CFAR)

  • Complete
  • Factual
  • Accurate
  • Relevant
• 4 Phases of Nursing Interview

  • Preparatory Phase
  • Introduction
  • Working Phase
  • Termination
• Preparatory Phase - nurse collects background info from previous charts; ensure environment is conducive
• Phases of Nursing Interview

  Introduction

  • Setting the stage
  • Set an Agenda
  • Collect Assessment
  • Terminating the Interview
• Phases of Nursing Interview

  Working - Nurse gathers information for subjective data; Excellent communication skills are needed
• A cue is information that you obtain through use of the senses (directly observed by the nurse)
• An inference is your judgment or interpretation of these cues • (e.g., a nurse obsessively checking a patient’s vital signs)
• Diagnosis - Second step in the nursing process; Clinical judgment about individual, family, or community response to actual or potential health problems/life processes
• Medical Diagnosis - is a clinical judgment by the physician that identifies or determines a specific disease, condition, or pathological state; is the identification of a disease condition/process based on a specific evaluation of physical signs, symptoms, the patient’s medical history and the results of diagnostic tests and procedures
• Nursing diagnosis - is a clinical judgment about individual, family, or community responses to actual and potential health problems or life processes that the nurse is licensed and competent to treat
• Types of Nursing Diagnoses

  • Actual Nursing Diagnosis
  • Risk Nursing Diagnosis
  • Health Promotion Diagnosis
  • Syndrome Nursing Diagnosis
• Types of Nursing Diagnosis

  Actual nursing diagnosis–indicates that problem exists
• Types of Nursing Diagnosis

  Risk nursing diagnosis–indicates that specific risk factors are present
• TYPES OF NURSING DIAGNOSES

  Health Promotion diagnosis–clients’ preparedness to implement behaviors to improve their health condition.
• TYPES OF NURSING DIAGNOSE

  Syndrome nursing diagnosis–assigned by a nurse’s clinical judgment to describe a cluster of nursing diagnoses that have similar interventions
• Planning - Third step of the nursing process; Includes establishing guidelines for the proposed course of nursing action and developing the client’s plan of care.
• Types of Planning

  • Initial Planning
  • Ongoing Planning
  • Discharge Planning
• Types of Planning

  Initial planning–developing a preliminary plan of care.
• Types of Planning

  Ongoing planning–updating the client’s plan of care
• Types of Planning

  Discharge planning–anticipating and planning for the client’s needs after discharge.
• Planning Process

  • Setting Priorities
  • Establishing client goals/desired outcomes
  • Selecting nursing interventions
  • Writing individualized nursing interventions on care plans
• Setting Priorities - Establishing a preferential sequence for addressing nursing diagnoses and interventions.
• Setting Priorities

  • High-Priority
  • Medium-Priority
  • Low-Priority
• Setting Priorities

  High-Priority - pose the greatest threat to the client’s well being (Life-threatening) e.g. respiratory/cardiac problems.
• Setting Priorities

  Medium-Priority – non-life-threatening diagnoses (health threatening) e.g. decreased coping ability.
• Setting Priority

  Low-priority – not specifically related to the client’s current health problem (developmental needs).
• Guides in Prioritization

  1. Maslow's Hierarchy of Needs
  2. Patient Preference
  3. Anticipation of Future Problems
  4. Actual vs. Risk Diagnosis
• Guides in Prioritization

  Maslow’s Hierarchy of Needs - Thus nursing diagnoses such as Ineffective Airway Clearance and Impaired Gas Exchange would take priority over nursing diagnoses such as Anxiety or Ineffective Coping.
• Guides in Prioritization

  Patient Preference – it’s best to first meet the needs the patient thinks the most important, if this order does not interfere with other vital therapies
• Guides in Prioritization

  Anticipation of Future Problems – nurses must tap their knowledge base to consider the potential effects of different nursing actions.
• Cognitive Domain – increase in patient’s knowledge or intellectual behavior
• Affective Domain- changes in patient values, beliefs, and attitudes.
• Psychomotor Domain – pt’s achievement of new skills.
• Independent interventions - Those activities nurses are licensed to initiate (i.e., physical care, ongoing assessment), does not require doctor’s order
• Dependent interventions - Activities carried out under physician’s orders or supervision, or according to specified routines.
• Interdependent (Collaborative) interventions - Actions nurse carries out in collaboration with other health team members