FUNDA LEC

• Nursing as a profession

  It is more of systematic and logical (with basis and evidence)
• Identifying the problem


  Recognition and definition, that could be addressed
• Analyzing the problem


  Gathering of information, assessment, critical thinking skills
• Formulating possible solutions


  Brainstorming, possible solutions
• Determine the best course of action

  Prioritize, choose the most effective solution by considering needs, resources, and organization policies
• Implementing the solutions


  Carry out the chosen solutions, allocate resources, provide support
• Evaluating the outcomes


  Reflect on the results, assess effectiveness
• The nursing process is the cornerstone of the nursing profession, without it nurses are not in the profession
• Nurses must obtain skills and utilize the nursing process
• Characteristics of the nursing process

  • Patient-centered (care respectfully and patient is the priority)
  • Interpersonal (communicate therapeutically with patients)
  • Collaborative (cannot be done alone, involves referrals)
  • Dynamic and cyclical (different phases influence each other)
  • Requires critical thinking (to analyze patient problems and achieve optimal wellness)

  
• Purpose of the nursing process

  • Identify client's health status
  • Establish plans
  • Identify needs
  • Deliver specific nursing interventions
  • Establish data base
  • Protect nurses against legal problems
  • Systematically organize practice

  
• Nursing diagnosis


  Implemented when American Nurses Association innovated the nursing process, involves identifying different nursing diagnoses

  
• Assessment


  1. Collecting, validating, organizing and recording data about the client's health status (individual, family or community)

  2. Includes subjective and objective data

  3. Methods: interview, observation, physical assessment

  4. Sources: primary, secondary and tertiary
• Nursing diagnosis


  • Clinical act of identifying problems
  • Potential or actual alteration of health status
  • Includes problem, related factors, signs and symptoms

  
• Correct nursing diagnosis


  • Risk for injury related to sensory and interrogative dysfunction as manifested by altered mobility
  • Increased bowel motility related to presence of amoeba as manifested by watery stools
• Incorrect nursing diagnosis


  • Ineffective airway clearance related to pneumonia

  Correct: Ineffective airway clearance related to thick, copious, mucous secretion
• Outcome identification


  1. Establish priorities: life threatening situations, ABCD principle, Maslow's hierarchy of needs, important to patient

  2. Short term (less than 1 week) and long term (several weeks/months) goals
• Examples of priority outcomes

  • Hemorrhage, difficulty breathing, suicidal tendencies
• Planning


  1. Strategies or course of actions before implementation of nursing care

  2. Identify client goals and appropriate nursing interventions

  3. SMART goals: Specific, Measurable, Achievable, Relevant, Time-bound

  
• Types of nursing care plans

  Initial plan, ongoing plan, discharge plan, formal nursing care plan

  
• Implementation


  1. Carry out planned nursing interventions to help client attain goals and achieve optimal health

  2. Nursing interventions classified by: cognitive, technical, interpersonal skills

  
• Fields of nursing interventions

  Behavioral, community, family, health system, physiological, safety
• Evaluation


  1. Appraise the extent to which goals and outcome criteria of nursing care have been achieved

  2. Assess client response and effectiveness of interventions

  
• Types of outcomes


  Goal met, goal partially met, goal not met