Unit A

Nursing Process

A systematic rational method of planning & providing nursing care.

$          Assessment

-THE PRIMARY PURPOSE OF ASSESSMENT IS TO ESTABLISH A DATABASE

                        -collecting, validating, organizing data.

-resources include: family/significant other, nursing/medical records, verbal/written consultations w/other health care teams, records of Dx studies, relevant literature

                                    -data that can be accurately measured can be accepted as factual

                                    -data that someone else observes may/not be factual

                                    -validate questionable data!

                                    -organize data into categories

-always review assessment to fill in gaps/save time early in process

                        -identifying patterns, reporting & recording

                             -report assessment ASAP, report anything you suspect is abnormal

                             -record the specific behavior, NOT your opinion about the behavior

$          Diagnosis (Analysis)

                        -finish “putting it all together”

-proficiency is formatting nursing Dx is dependant on accurate assessment & knowledge of nursing & clinical experience

                        -errors in Dx may lead to:

-starting interventions that may aggravate the problem, omitting interventions that are essential, problems may exist or progress w/o detection, interventions may be harmless but waste time, influencing other caregivers to believe that problems exist when they don’t, danger of legal liability

Nursing Diagnosis - clinical judgements about responses to actual or potential health problems/life processes

-they provide the basis for selection of nursing interventions to achieve outcomes for which the nurse is accountable

-don’t state dx in medical terminology, don’t state as a medical dx, don’t state 2 problems at the same time, don’t write the nursing dx in a legally incriminating way, don’t rename medical problem to try to make it a nursing dx, don’t write it based on value judgements, don’t write dx in terms of needs, don’t write dx in terms that you can do nothing about

                                    -NANDA - North American Nursing Diagnosis Association

-Actual Dx - 3 parts: problem (comes from list of NANDA diagnoses), etiology (related to), signs/symptoms (as evidenced by)

Ex: Knowledge, deficient: self administration of insulin r/t information misinterpretation a/e/b pt verbalizing “I get so confused about the steps for drawing up my insulin.”

                                    -Risk Dx - 2 parts: problem, etiology

                                         Ex: Risk for disturbed body image r/t perceived threat to self concept

Medical Dx - require the expertise of a physician, usually refer to problems w/organs or systems

                        Collaborative Dx - pt problems that can be helped by both medical & nursing interventions

                                    -usually start w/ “Potential complication...”

                                    -post-op: “potential complication of hemorrhage or shock”

$          Planning                                                                                                       

-setting priorities, establishing expected outcomes/goals, determining nursing interventions, recording the plan of care

                        -expected outcomes/goals are many times used interchangeably

-expected outcomes are specific, measurable steps to achieve the broad goals of treatment derived directly from the nursing dx, should agree w/problem statement which is further specified by the evidence, they should be mutually set w/the pt.

                        -goals are broad guidelines indicating the overall desired response

                        -short term goals - can be met quickly, usually met in less than a week

-long term goals - can take weeks/months, can be ongoing, can be things that are to be accomplished every day

-outcomes/goals must be realistic/achievable, specific & measurable, pt centered

                        -5 components: subject, verb (action verbs), conditions, criteria, time frame

-action verbs: apply, assemble, breathe, choose, compare, define, demonstrate, describe, differentiate, discuss, drink, explain, help, identify, inject, list, move, name, prepare, report, select, share, sit, sleep, state, talk, transfer, turn, verbalize

                        -Classification of outcomes:

-cognitive - outcomes associated w/acquiring knowledge or intellectual abilities (pt will list 3 signs/symptoms of wound infection w/in 48 hrs)

-psychomotor - outcomes that deal w/developing motor skills (pt will demonstrate self-administration of insulin w/in 48 hrs)

-affective - outcomes associated w/change in attitude, feelings, or values. Somewhat difficult to write & evaluate (pt will express that eating habits need to change prior to discharge)                       

-nursing interventions are specific nursing actions that a nurse must perform to prevent complications, provide for comfort, & promote, maintain, & restore health

-nursing interventions must be realistic in terms of abilities, time, & resources available to pt & nurse

                        -also called nursing actions, nursing orders

-must be specific - leave no room for error or misinterpretation (“avoid skin breakdown” is too vague - “turn & position every 2 hrs on the even hour” is more specific & leaves little room for error)

-interventions may include assessing, teaching, counseling, direct care or indirect care such as monitoring labs

                        -interventions are derived from the “related to” part of the nursing dx

                          -document the nursing care plan: the care plan is the final product of the planning portion of the nursing process, it promotes communication between caregivers, directs care & documentation, creates a record for evaluation, research & legal reasons, & is necessary for insurance reimbursement

$          Interventions (Implementation)

- act of “getting it done,” includes actual nursing care, is when we carry out what we’ve planned in the planning phase

- includes: continuing assessment, setting daily priorities, performing nursing actions, documenting nursing care, giving verbal nursing reports (to other shifts, other floors, etc.)

- independent nursing action or nurse-initiated interventions: activity the nurse initiates as a result of her own knowledge & skills

- dependent nursing action or physician-initiated interventions: requires a physician’s order, physician’s supervision, or is based on protocol or policy developed by the facility in conjunction w/the medical staff

- collaborative or interdependent nursing action: performed either jointly w/another member of the health care team or as a result of a joint decision by the nurse & another health care team member (except physician)           

- Health Teaching: specific form of intervention, approach systematically as w/nursing process, specific nursing dx associated w/health teaching (knowledge, deficient r/t...), health teaching may also be implemented w/other nursing dx

- assessment of the learner: previous education & experience, physiologic status, vocabulary level, anxiety level, motivation, learning style, support system, culture & values, age & developmental level

                               - external influences: physical environment, privacy, timing, teacher’s vocabulary

- documentation of teaching process is important - document goal, interventions, any referrals to community agencies, etc.

                        - documentation of nursing care:

                                                            - documentation is important for communication, financial billing, educational resources, research, & legal implications

                                    - if it’s not charted, it was not done!

                                    - each facility has specific guidelines

                                    - confidentiality is very important

- use ink (black, maybe blue), be legible, do not use erasable ink or white out, write notes ASAP after giving care so that recall is optimal

                                    - document interventions & pt response to interventions

- document interventions that are held & why, or if pt refuses interventions & what action was taken

- NEVER leave a blank space or an empty line - draw a line through any unused spaces before & after signature, be concise but descriptive (you don’t need complete sentences)

- nursing process can be a guide for charting: document assessment, intervention & evaluation in nurse’s notes

- if you document something abnormal in your assessment, be sure to document how you intervened!

- document status of invasive lines/treatment, begin each entry w/time/date & end entry w/signature & title

                                    - correct errors properly, according to facility policy

- if physician is called for clarification of an order or w/test results or changes in pt condition, document the call in the nurse’s notes

$          Evaluation

                        - determines how well the care plan worked & allows for revisions

                        - involves a complete reassessment of the entire plan of care, should be ongoing

                        - criteria for evaluation will be the outcomes established during the planning phase

                        - should include pt when possible

                        - 3 possible results:

                                    1. Outcome has been met - d/c nursing actions r/t that outcome

2. Outcome has been partially met & progress toward the outcome is seen - continue nursing actions

3. Outcome has not been met & there is no progress toward it - modify care plan as necessary - may require change in interventions, change in outcome, etc.

- Summary: nurse determines how well the goals of nursing care are being met, nurse seeks the opinion of the pt/family/significant others & members of the health care team, & results of evaluation are used to make changes as needed

                        - Standards of Practice (ANA)

                                    Standard 1. Assessment : the nurse collects pt health care data

                                    Standard 2. Dx: nurse analyzes the assessment date in determining dx

Standard 3. Planning: outcome identification: nurse identifies expected outcomes individualized to the pt

Standard 4. Planning: nurse develops a plan of care that prescribes interventions to attain expected outcomes

Standard 5. Implementation: nurse implements interventions identified in the plan of care

Standard 6. Evaluation: nurse evaluates the pt’s progress toward attainment of outcomes