Nursing Process

Nursing Process

“To you, O Lord, I lift up my soul. In you, I trust , Oh my God.” Psalm 25:1

NURSING PROCESS • systematic, rational method of planning and providing individualized nursing care • Is a problem-solving framework for planning and delivering nursing care to patients and their families

NURSING PROCESS

NURSING PROCESS • A way of thinking as a nurse. • A framework of interrelated activities resulting in competent nursing care. • Dynamic and cyclical in nature. • A scientific, problem-oriented approach to patient care.

Assessing – collecting, organizing and communicating / recording client data

Purpose: to establish data base about the client’s response to health concerns or illness and the ability to manage health care needs

Assessment Activities: • Obtain health hx • Perform P.A. • Review records, e.g. lab records, other health care records • Interview support persons • Review literature • Validate assessment data

Nursing Process

Assessment

Assessment (Data Collection) = Observation + Interview + Examination

Observation

Interview

Examination

Data Collection – process of gathering information about the client’s health status TYPES OF DATA : • Subjective – symptoms or covert data e.g. – itching pain, feelings of worry • includes client’s sensations, feelings, values, beliefs, attitudes and perception of personal health status and life situations. Problem : Fever  subjective cue: “Mainit ang pakiramdam ko.”

Assessment “Let me look at that.” “Tell me about it.”

Types of Data • Objective data –signs or overt data; detectable by an observer or can be tested against an accepted standard • e.g. – discoloration of the skin • Problem: fever-objective cue : skin is warm to touch; temp. is 38.9 C/ax

Objective data Caput medusae

BP reading

SOURCES OF DATA: • Primary source client (best source of data)

SOURCES OF DATA: • Secondary sources – indirect sources e.g. – family members, -support people, -client records (medical records, records of therapies by other health professionals and laboratory records), -health care professionals,

METHODS OF DATA COLLECTION: • Observing  using the five senses; a conscious deliberate skill that is developed only through effort and with an organized approach

METHODS OF DATA COLLECTION • Interview  a planned communicati on or conversation with a purpose

Interview Interview

• b. • a. direct nondirective  interview  highly the nurse allows structured and the client to control elicit specific the purpose, information by subject matter and asking closed pacing questions that call for a specific Requirement: amount of data. RAPPORT - the 2 approaches:

understanding between two or more people.

Kinds of interview questions: • Closed • Open-ended questions  questions  restrictive and lead or invite generally clients to require only explore their short answers thoughts or giving specific feelings information; often begin with when, where, who, what, do, does, did

PLANNING THE INTERVIEW AND SETTING: • • • •

Time  need to be scheduled when the client is comfortable and free of pain Place  must have adequate privacy to promote communication Seating arrangement Distance  most people feel comfortable 3 to 4 ft apart during an interview

STAGES OF AN INTERVIEW: • Opening  sets the tone of the remainder of the interview. a.1. Establish rapport  process of creating good will and trust a.2 Orientation  explaining the purpose and nature of the interview • Body  client communicates what he or she thinks, feels, knows and perceives in response to questions from the nurse • Closing  important in facilitating future interactions.

ASSESSMENT TOOLS: GORDON’S FUNCTIONAL HEALTH PATTERN FRAMEWORK

• pattern -signifies a sequence of recurring behavior • dysfunctional as well as functional behavior • to discern emerging patterns.

TYPOLOGY OF 11 FUNCTIONAL HEALTH PATTERNS: 1.Health – perception – health – management – pattern: • describes client’s perceived pattern of health and well-being and how health is managed • How does the person describe her/ • his current health? • What does the person do to improve or maintain her/ his health?

1.Health – perception – health – management – pattern: • What does the person know about links between lifestyle choices and health? • How big a problem is financing health care for this person? • Can this person report the names of current medications she/he is taking and their purpose?

1.Health – perception – health – management – pattern: • If this person has allergies, what does s/he do to prevent problems? • What does this person know about medical problems in the family?

• Have there been any important illnesses or injuries in this person's life?

1.Health – perception – health – management – pattern: Nsg. Dx

• Ineffective health maintenance • Ineffective therapeutic regimen management • Ineffective family therapeutic regimen management • Ineffective community therapeutic regimen management

1.Health – perception – health – management – pattern:

Nsg. Dx

• Risk for infection • Risk for injury (trauma) • Risk for falls

TYPOLOGY OF 11 FUNCTIONAL HEALTH PATTERNS:

2.Nutritional – metabolic pattern: • pattern of food and fluid consumption relative to metabolic need and pattern indicators of local nutrient supply • Is the person well nourished? • How do the person's food choices compare with recommended food intake?

2.Nutritional – metabolic pattern: Nsg. Dx • Imbalanced nutrition: more than body requirements • Risk for imbalanced nutrition: more than body requirements • Imbalanced nutrition: less than body requirements

TYPOLOGY OF 11 FUNCTIONAL HEALTH PATTERNS:

3.Elimination – pattern: • describes pattern of excretory function ( bowel, bladder and skin) • Are the person's excretory functions within the normal range? • Does the person have any disease of the digestive system, urinary system or skin?

3.Elimination – pattern: Nsg. Dx • • • • • •

Constipation Diarrhea Risk for constipation Bowel incontinence Impaired urinary elimination Functional urinary incontinence

TYPOLOGY OF 11 FUNCTIONAL HEALTH PATTERNS:

Activity – exercise pattern :

4.

• describes pattern of exercise, activity, leisure and recreation • How does the person describe her/ his weekly pattern of activity and leisure, exercise and recreation? • Does the person have any disease that affects her/ his cardio-

• • • • •

4. Activity – exercise pattern : Nsg. Dx

Activity intolerance Risk for activity intolerance Fatigue Deficient diversonal activity Impaired physical mobility

TYPOLOGY OF 11 FUNCTIONAL HEALTH PATTERNS:

5.Cognitive – perceptual pattern : • describes sensory perceptual and cognitive pattern -make a quick neurological assessment

TYPOLOGY OF 11 FUNCTIONAL HEALTH PATTERNS:

6.Sleep – rest pattern:

• describes patterns of sleep, rest and relaxation • Descri bes person' s sle ep -wak e cycl e. • Does this person appear physically rested and relaxed?

6.Sleep – rest pattern: Nsg. Dx • Disturbed sleep pattern

7.Self – perception – self – concept – pattern: • describes self-concept pattern and perceptions of self (body comfort, body image, feeling state) • Is there anything unusual about this person's appearance? • Does this person seem comfortable with her/ his appearance?

• Describe person's feeling state

7.Self – perception – self – concept – pattern: • • • • • •

Nsg. Dx

Fear Anxiety Risk for loneliness Hopelessness Powerlessness Risk for powerlessness

• Situational low self-esteem • Risk for situational low selfesteem • Chronic low self-esteem • Body image disturbed • Disturbed personal identity • Risk for violence, selfdirected

TYPOLOGY OF 11 FUNCTIONAL HEALTH PATTERNS:

8.Role – relationship pattern :

• describes patterns of role engagements and relationships • How does this person describe her/ his various roles in life? • Has, or does this person now have positive role models for these roles?

8.Role – relationship pattern : • Which relationships are most important to this person at present? • Is this person currently going though any big changes in role or relationship? What are they?

8.Role – relationship pattern : Nsg. Dx

• Anticipatory grieving • Dysfunctional grieving • Risk for dysfunctional grieving • Ineffective role performance • Social isolation • Impaired social interaction • Relocation stress syndrome

TYPOLOGY OF 11 FUNCTIONAL HEALTH PATTERNS:

9.Sexuality – reproductive pattern: • describes client’s patterns of

satisfaction and dissatisfaction with sexuality; describes reproductive pattern

• Do you have regular menstruation?

• When was the last sexual intercourse? • Sexual activities?

9.Sexuality – reproductive pattern:

Nsg. Dx • Sexual dysfunction • Rape-trauma syndrome

TYPOLOGY OF 11 FUNCTIONAL HEALTH PATTERNS:

10.Coping – stress – tolerance – pattern:

• describes general coping pattern and effectiveness of the pattern in terms of stress tolerance • How does this person usually cope with problems? • Do these actions help or make things worse? • Has this person had any treatment for emotional distress?

10.Coping – stress – tolerance – pattern:

Nsg. Dx. • • • • • •

Ineffective coping Disabled family coping Ineffective community coping Post-trauma syndrome Risk for post-trauma syndrome Risk for suicide

TYPOLOGY OF 11 FUNCTIONAL HEALTH PATTERNS:

11. Value – belief pattern: • describes patterns of values, beliefs or goals that guide choices or decisions • E.g reads bible everyday

REVIEW OF SYSTEMS goal : to gather data from the client in each of the major body systems. • General Health. Weight loss, weakness, feelings of fatigue, mood changes, night sweats, or bleeding tendencies?

REVIEW OF SYSTEMS Skin. • Skin diseases such as eczema, psoriasis, • acne; change in pigmentation; • tendency toward bruising; • excessive dryness or moisture; jaundice; • itching, rashes, hives; • change in color or size of moles; • or open sores that are slow to heal? • Hair. Itchy scalp, loss of hair, excessive body hair? Does the client wear a wig?  Nails. color changes, biting, clubbing, splitting?

REVIEW OF SYSTEMS Head • Frequent or severe headaches, • fainting, • dizziness, • accident resulting in unconsciousness

REVIEW OF SYSTEMS

Eyes. Difficulty seeing, eye infection, eye pain, excessive tearing, double vision, blurring, sensitivity to light, cataracts, itching, spots in front of eyes? • Does the client wear glasses (for near or far vision) or contact lenses? • When was the client’s last eye examination?

REVIEW OF SYSTEMS Ears • Any infection, • loss of hearing, pain, discharge, ringing in the ears? • Does the client wear a hearing aid?  Nose. Frequent colds, nosebleeds, allergies, pain, tenderness, postnasal drip?

REVIEW OF SYSTEMS • Mouth and throat. • Sore gums; bleeding gums; sores, lumps or white spots on the mouth, lips or tongue; • toothaches, cavities, • difficulty swallowing; • voice change or hoarseness? • Does the client wear dentures (upper, lower, partial)? • When was the client’s last dental appointment?

REVIEW OF SYSTEMS

Neck. Pain, swelling, stiffness, limited movements, swollen glands? Breasts. Nipple discharge, Scaling or cracks around nipples, dimples, lumps, • pattern of self breast examination? • Last mammogram?

REVIEW OF SYSTEMS Respiratory system. • Chest pain; cough; shortness of breath; wheezing; coughing up blood; • lung disease such as tuberculosis, emphysema, asthma, bronchitis? • Has the client ever had a chest x-ray? When? Results?

REVIEW OF SYSTEMS Cardiovascular system. • • • • • •

Heart disease, palpitations, heart murmur, high blood pressure, anemia, varicose veins, leg swelling or ulcer?

REVIEW OF SYSTEMS

Gastrointestinal system.

• Nausea, vomiting, loss of appetite, indigestion, • heartburn, • bright blood in stools, • diarrhea, constipation, • abdominal pain; excessive gas, • hemorrhoids, rectal pain, • colostomy, ileostomy?

REVIEW OF SYSTEMS

Genitourinary system.

Frequency, dribbling, urgency, urination at night, difficulty starting stream, blood in urine, incontinence, pain or burning upon urination, urinary tract infection, sexually transmitted disease such as gonorrhea or syphilis?

REVIEW OF SYSTEMS Females: • Age of menarche, last menstrual period (LMP), • duration, amount of flow, regulatory of cycle? • Any problems with painful menstruation, bleeding within periods, • pain during intercourse, • vaginal discharge, vaginal itching, vaginal infection?

REVIEW OF SYSTEMS Males: • Penile discharge, • swelling, masses or lesions, • difficulty in sexual functioning?

REVIEW OF SYSTEMS Musculoskeletal system: • • • • • •

Muscular pain, swelling or weakness; joint swelling, soreness, or stiffness; leg cramps; bone defects?

REVIEW OF SYSTEMS Neurologic system: • • • • •

Difficulty of walking; unconsciousness; seizures; tremors; paralysis; numbness, tingling; or burning sensations in any body part; • weakness on one side of body; speech problems; unclear thinking; changes in emotional state?

REVIEW OF SYSTEMS • • • • • • •

Endocrine system: History of goiter; heat or cold; intolerance; diabetes; excessive thirst; excessive eating?

NURSING DIAGNOSIS : • statement of the client’s health status • clinical judgment about individual, family or community responses to actual and potential health problems / life processes. Purpose: Provides the basis for selections of nursing interventions to achieve outcomes for w/c the nurse is accountable

NURSING DIAGNOSIS : Eg. • Problem : Fever  nursing diagnosis : Alteration in thermoregulatory function: or hyperthermia related to inflammatory process

TYPES OF NURSING DIAGNOSES: • Actual Nursing Diagnosis  a judgment about the client’s response to a health problem w/c is present at the time of nursing assessment • Potential Nursing Diagnosis  a judgment that a client is more vulnerable to develop the problem in the same / similar situation

• Problem Statement  describes the client’s health problem or response for which nursing therapy is given • Qualifiers  added words to give additional meaning to the diagnostic statement • Altered  change from baseline • Impaired  made worse, weakened, damaged • Decreased  smaller in size, amount or degree • Ineffective  not producing the desired effect • Acute  severe or of short duration • Chronic  lasting a long time

COMMON ERRORS IN FORMULATING NURSING DIAGNOSES

1.Using medical diagnosis –INCORRECT: Self-care deficit related to stroke –CORRECT: Self-care deficit related to neuromuscular impairment 2.Relating the problem to an unchangeable situation

COMMON ERRORS IN FORMULATING NURSING DIAGNOSES

1. Confusing the etiology or signs/symptoms for the problem – INCORRECT: Post-operative lung congestion related to bed rest – CORRECT: Ineffective airway clearance related to general weakness and immobility

COMMON ERRORS IN FORMULATING NURSING DIAGNOSES

1. Use of a procedure instead of a human response – INCORRECT: Catheterization related to urinary retention – CORRECT: Urinary retention related to perineal swelling

COMMON ERRORS IN FORMULATING NURSING DIAGNOSES

1. Lack of specificity • INCORRECT: Constipation related to nutritional intake • CORRECT: Constipation related to inadequate dietary bulk and fluid intake

COMMON ERRORS IN FORMULATING NURSING DIAGNOSES

1. Combining two nursing diagnosis • INCORRECT: Anxiety and fear related to separation from parents • CORRECT: Anxiety related to change in environment and unmet needs

COMMON ERRORS IN FORMULATING NURSING DIAGNOSES

1. Relating one nursing diagnosis to another • INCORRECT: Coping, individual ineffective related to anxiety • CORRECT: Anxiety, severe related to change in role functioning and socio-economic status

COMMON ERRORS IN FORMULATING NURSING DIAGNOSES

• Use of judgmental/value-laden language • Ineffective airway clearance related to bad habit

COMMON ERRORS IN FORMULATING NURSING DIAGNOSES

• Making assumptions • INCORRECT: Risk for altered parenting related to inexperience • CORRECT: Deficient knowledge regarding child care issues related to lack of previous experience, unfamiliarity with resources

1. Writing a Legally Inadvisable Statement • INCORRECT: Skin integrity related to not being turned every 2 hours • CORRECT: Impaired skin integrity related to pressure and altered circulation

A Nursing Diagnosis • Is – A statement of a patient problem – Actual or potential – Within the scope of nursing practice – Directive of nursing

• Is Not – A medical diagnosis – A nursing action – A physician order – A therapeutic treatment

Medical Dx vs.Nursing Diagnosis • Myocardial infarction

• Fear r/t possible recurrence of uncertain outcome • Chronic ulcerative colitis • Diarrhea r/t dis. process • Alteration in nutrition: less than body requirements r/t • Chronic ulcerative colitis altered GI absorptions • Risk for(Potential) body image disturbance if • Cancer of the breast mastectomy is required • Cerebral vascular accident

• Self-care deficit: dressing & grooming r/t right sided flaccidity

Etiology (Related/ Risk Factors)  the

probable cause of the health problem; may include client’s behavior, environmental factors or the interaction of the two; NANDA-“ related to” to describe the etiology or likely cause Example: • Activity intolerance related to decreased cardiac output. • Ineffective breast-feeding related to firsttime experience • Altered bowel elimination; constipation related to insufficient fluid intake.

• Medical Diagnosis  made by a physician refers to a pathophysiologic responses that are fairly uniform from one client to another. • Nursing Diagnosis  describes the clients’ physical, sociocultural, psychologic and spiritual responses to an illness or potential health problems; vary among individuals.

Nursing diagnosis Actual nursing diagnoses PES approach = Problem + Etiology + S/S • Impaired verbal communication r/t cultural differences as manifested by inability to speak English

Nursing diagnosis Potential nursing diagnosis

PRF approach (risk factor) • Potential skin breakdown r/t physical immobilization in total body cast • Potential fluid volume deficit r/t diarrhea, age 3 yrs., low oral intake, elevated temperature

PLANNING

• involves decision making and problem solving Planning process includes: A.Setting priorities  establishing a preferential order for nursing strategies ; the nurse must consider a variety of factors : 1.Client’s health values and beliefs  a client may believe that being home with children is more urgent than a health problem. 2.Client’s priorities  involving the client enhances cooperation between nurse and client 3.Urgency of health problems  ABC’s of life (airway, breathing, circulation) 4.Medical treatment plan  must be congruent with treatment of other health care professionals

PLANNING should be S-M-A-R-T (specific, measurable, attainable, realistic and time-bound) • Example: • Problem : Fever  subjective cues : “Mainit ang pakiramdam ko.” • objective cues : skin is warm to touch; temp. is 38.9 C •  nursing diagnosis : Alteration in thermoregulatory function: hyperthermia related to inflammatory process •  plan : After 4 hours of continuous nursing intervention, patient’s temperature will decrease from 38.9 C to 37.5C/ ax.

PLANNING Planning = setting priorities + establishing goals + planning interventions

PLANNING B. Establish Goals Components of a goal statement Goal statement = pt behavior + criteria of performance + Time + conditions (if needed)

Components of a goal statement • PATIENT BEHAVIOR - an observable activity that the patient will demonstrate – (the patient) will void – Decrease in ( the patient’s) BP – (the patient) will ambulate – (the patient) will report – (the patient) will drink

Components of a goal statement • TIME FRAME - a designated time or date when the patient should be able to achieve the behavior – Within the next hour – By discharge – At the end of this shift – By Dec. 25 – In 2 months

Components of a goal statement • CONDITIONS - specific aides which will facilitate the patient performing a behavior at the level in the criteria and within the specified time frame

– With the help of a walker – With the use of a wheelchair – With the help of the family – With the use of medication – Using oral analgesics q3-4 hrs – Using IM Demerol q3-4 hrs

Planning Process C. Planning Interventions • render continuous tepid sponge bath • loosen tight and thick clothing • increase fluid intake • keep room well ventilated • administer antipyretics as indicated/ordered

IMPLEM EN TATIO N / INTERVEN TI ON  implement the interventions identified in the plan of care. • Cognitive/Intellectual Skills  include problem solving, decision making, critical thinking and creative thinking

IM PL EME NT ATIO N / INT ER VENT ION

• Interpersonal skills  activities use when communicating directly with one another; include verbal and nonverbal activities; necessary for caring, comforting, referring, counseling and supporting clients;

IM PL EME NT ATIO N / INT ER VENT ION

• Technical /psychomotor skills  ‘hands-on’ skills such as manipulating equipment, giving injections and bandaging, moving, lifting, and repositioning clients; require knowledge and frequently manual dexterity.

The process of implementing: 1.Reassessing the client  reassess whether the intervention is still needed Note: even though an order is written on the care plan, the situation or the client’s condition may have changed.

The process of implementing: 2.Determining the need for nursing assistance  the nurse maybe unable to implement the nursing strategies safely alone

The process of implementing: 3.Implementing nursing strategies  nursing activities include caring, communicating, helping, teaching, counseling, acting as a client advocate and change agent, leading and managing.

The process of implementing 4.Communicating nursing actions  recording the interventions along with the client responses in the nursing progress notes.

TYPES OF NURSING ACTIONS: • Independent Nursing Actions  an activity that the nurse initiates as a result of the nurse’s own knowledge and skills • Dependent nursing actions  activities carried out on the order of the physician, under the physician’s supervision or according to specified routines • Collaborative nursing actions  activities performed either jointly with another member of the health care team or as a result of a joint decision by the nurse and another health care team member

• Problem : Fever  subjective cues : “Mainit ang pakiramdam ko.” • objective cues : skin is warm to touch; temp. is 38.9 C  nursing diagnosis : Alteration in thermoregulatory function: hyperthermia related to inflammatory process  plan : After 4 hours of continuous nursing intervention, patient’s temperature will decrease from 38.9 C to 37.5C.

Intervention • continuous tepid sponge bath rendered • tight and thick clothing loosened • fluid intake increased • room kept well ventilated • antipyretics as indicated/ordered administered

EVALUATION • The evaluation process has 6 components: • Identifying the expected outcomes that the nurse will use to measure client goal achievement • Collecting data related to the expected outcomes • Comparing the data with the expected outcomes and judging whether the goals have been achieved • Relating nursing actions to client outcomes • Drawing conclusions about problem status • Reviewing and modifying the client’s care plan • determine client’s progress toward goal achievement and the effectiveness of NCP

• EVALUATION STATEMENT consist of 2 parts : a conclusion and a supporting data • Example : Goal met : After 4 hours of continuous nursing intervention, temperature decreased from 38.9 to 37.4 C/ax