funds the nursing process and concept mapping

the nursing process

a systemic method that directs the nurse, with the pt’s participation, to accomplish the following: assess the pt. to determine the need for nursing care, determine nursing diagnoses for actual and potential health problems and needs, identify expected outcomes and plan care, implement the care, and evaluate the results

• provides a framework for nursing practice

• used to identify pt needs, priorities of care

• pt centered and goal oriented

• develops a holistic plan

concept map/care plan

• a diagram of pt. problems and interventions

• used to organize pt data, analyze the data, and provide a holistic view

  • collect pt problems and concerns on a list

  • connect and analyze the relationships

  • create a diagram demonstrating problem recognition, critical thinking, and nursing actions

  • keep in mind key concepts: the nursing process, holism, safety, and advocacy

the nursing process step 1: assessment

collection, validation, and communication of pt data

• systemically gathering data & establishing database

• sorting, organizing, & validating the data collected

• ongoing

• identifying cues and making inferences

• document the data

initial assessment

establishes a database for the pt

• performed shortly after the pt is admitted

• purpose is to establish a complete database for problem identification and care planning

• collects data about all aspects of the pts health

• usually in a hospital setting

• full head-to-toe assessment

focused assessment 

gathers data about the specific problem

• gathers data about a specific problem that has already been identified

• may be done at the initial assessment but is part of the ongoing data collection

• can identify new or overlooked problems

• use PQRST

emergency assessment 

identify life-threatening problems 

• identifies life-threatening problems

• ex: choking, stab wound pt, unresponsive pt, and a worker threatening violence

• ABC

time-lapsed assessment

compare pt’s current status to the baseline

• scheduled to compare a pt’s current status to the baseline obtained earlier 

  • ex: In one wk, go back to check on pt. to see any changes 

• can be comprehensive or focused 

triage assessment

identifies the extent and severity of their problems and recommends appropriate follow-up

• can be done in an internal medicine practice, specialized units or dr’s office, and emergency room

• nurses need highly specialized nursing knowledge and clinical reasoning and judgement skills 

collecting data

subjective data: information perceived only by the affected person; symptoms

objective data: observable and measurable data that can be seen, heard, felt, or measured by someone other than the person experiencing them 

• vitals, lung sounds, wound appearance

OLDCART

sources of data

• pt 

• family and significant others 

  • if pt speaks in a different language, have dementia/delirium, unresponsive 

• pt record 

  • shows exactly what treatments and meds being used 

• other healthcare professionals 

methods of data collection

observation: the use of the five senses to gather data

pt interview: planned communication w/ four phases 

• preparatory phase 

• introduction phase 

• working phase 

• termination 

physical assessment: examination of pt for objective data 

• review of systems or head to toe assessment 

• four methods include inspection, palpation, percussion, and auscultation 

patient interview

preparatory phase —> setting stage, make them comfortable

• “do you feel ok?” “how did you get here?” “are there any family members you could call?”

introduction phase —> planned communication

• “are you in any pain?, “where is the pain?”

working phase —> full assessment mode — actively getting 

termination —>end of interaction w/ the pt 

interview techniques

• use a mix of open-minded & close-minded questions

  • open-ended: make sure it is not a “yes” or “no” question

  • closed-minded: yes or no questions

• back-channeling —> nodding head, recall, eye-contact 

• probing —> makes them feel questioned

• because a pt’s report  includes subjective information, validate data from the interview later with objective data

• obtain information (as appropriate) about a pt’s physical, developmental, emotional, intellectual, social, and spiritual dimensions

• cultural considerations

nursing process step 2: diagnosis

actual or potential health problems that can be prevented or resolved by independent nursing intervention 

• provides the basis for selecting nursing interventions that will achieve optimal pt outcomes 

• interpret and analyze pt data 

• formulate and validate actual and potential health problems 

• develop a prioritized list of pt health problems 

• made by using clinical judgement and decisions

types of diagosis

medical traumatic or disease condition or syndrome validated by medical diagnostic studies

• correcting or preventing pathology of specific organs or body systems

  • how are we going to treat w/o anything going wrong w/ pt

2. nursing diagnosis: clinical judgement about individual, family, or community responses to health problems

• monitoring human responses to actual and potential health problems 

• ex: risk for aspiration caused by dysphagia 

significant data 

• standard = norm

• change in a pt’s usual health pattern that can’t be explained 

  • ex: vision loss —> can’t explain why 

• deviation form an appropriate population norm 

  • w/in that population: dependent on age, gender, religion, etc

    • ex: 16 yo complaining of chest pain that could be a heart attack —> is that normal 

• behavior that is nonproductive in the whole-person context 

• behavior that indicates a developmental lag 

  • ex: if i have a 40 yo down syndrome pt. would i treat them the same as another 40 yo pt?

data clustering

a set of signs or symptoms gathered during assessment that you can group together in a logical way —> presentation of pt 

• patterns of data that contain defining characteristics — clinical criteria that are observable and verifiable 

• each clinical criterion is an objective or subjective sign, symptom, or risk factor that, when analyzed w/ other criteria, leads to a diagnostic conclusion

interpretation

• it is critical to select the correct diagnostic label for a pt’s need 

• from assessment to diagnosis, move from general information to specific 

• think of the problem identification phase in assessment as a general health care problem and the formulation of the nursing diagnosis as the specific health problem

• the absence of certain defining characteristics suggests that you reject a diagnosis under consideration

  • ex: do all stroke pts have paralysis? —> no, reject

reaching conclusions

• no nursing response needed; reinforce health habits and patterns, initiate health promotion

• possible problem — collect more data 

  • potential problem ex: missing meds, smoke cigars

• actual or potential nursing diagnosis — begin planning, implementing and evaluating care to reduce or resolve the problem

• clinical problem other than nursing diagnosis - consult w. appropriate health care professional 

• they could report 1 symptom and it can lead to many symptoms that could lead to a diagnsis

• ex: frequent urination —> UTI? diabetes? —> ask more questions 

guidelines for writing nursing diagnosis

• not a medical diagnosis

• phrase it as an actual or potential diagnosis, problem, or issue

• make sure that the pt/ problem precedes the etiology

• use-nonjudgmental language

• problem statement indicate what is unhealthy about the pt

• ex: risk of dysphagia due to stroke 

nursing process step 3: outcome identification and planning

nurses work in partnership w/ the pt and family 

• want to establish priorities, identify and write expected pt outcomes, select evidence- based nursing interventions, and communicate the nursing plan of care 

patient outcome: an expected conclusion to a pt health problem

expected outcome: specific, measurable criteria used to evaluate the extent to which a goal has been met 

initial planning

• performed by the nurse with the admission nursing history and the physical assessment 

• this will address each problem listed in the prioritized nursing diagnosis 

• identifies appropriate pt goals and the related nursing care

• what we need to take care of 

ongoing planning

• carried out by any nurse who interacts w/ the pt

• chief purpose is to keep the plan of care up to date to facilitate the resolution

• new data will be collected and analyzed to enhance the plan and make it more effective 

• can change and get more specific as time goes on

• prioritize the care

• can be a lot more targeted

discharge planning

• best if its done by the nurse who was w/ the pt the longest

• begins at admission

• effective teaching and counseling is a must —> explains S&S

• may involve a social worker or a case manager

  • if client has unstable housing or not safe at home

  • financial issues

  • assistive devices

• discharge planning must begin during admission

writing pt-centered outcomes

subject: patient

verb: define, prepare, identify, list, verbalize, explain, apply

conditions: particular circumstances by which the outcome is to be achieved —> describe 

performance criteria: expected pt behavior described in observable, measurable terms 

target time: pt is expected to be able to achieve the outcome 

SMART

ensuring quality outcomes

aims to be met by healthcare systems w/ regard to the quality of care: 

1. safe 

2. effective 

3. pt centered 

4. timely 

5. efficient 

6. equitable 

ex:

• IV morphine —> 15-30 mins

  • pt outcome: “w/in 15-30 mins, the pt will report little to no pain”

nurse-initiated interventions

an autonomous action based on scientific rationale that a nurse executes to benefit the pt in a predictable way related to the nursing diagnosis and projected outcomes 

• does not need an order 

• it is the cause of the problem that dictates nursing interventions 

• effective nursing select nursing interventions that address factors that cause a pt’s problem

• not the same for every pt 

nurse-initiated interventions

1. monitor pt health and response to treatment

2. reduce risks 

   1. ex: elevate HOB, aseptic technique, call bell on bed, changing positions,

3. resolve, prevent, or manage a problem 

4. promote independence w/ ADL’s

5. promote optimum sense of physical, psychological, and spiritual well-being 

6. educate pts and help them make informed decisions and be independent 

guidelines for selecting nursing interventions

• valued by the pt and family

• appropriate to the pt’s problems

• consistent w/ research findings and standard of care available to the nurse and pt

• compatible w/ the pt’s values, beliefs, and cultural and psychosocial backgroud 

• compatible w/ other planned therapies 

  • pt, ot, dietary, psych 

physician-initiated & collaborative interventions 

• an intervention is initiated by a physician in response to a medical diagnosis but is carried out by a nurse in response to a doctor’s order

• the nurse who performs these interventions is implementing physician-initiated interventions

• both the physician and nurse are legally responsible for these interventions 

• nurses also carry out treatments initiated by pharmacists, respiratory therapists, or PA — collaborative interventions 

  • ex: can give nebulizer, even though that’s a respiratory interventions

nursing process step 4: implementation

• evidence-based nursing actions planned in the previous step are carried out 

• purpose is to help the pt achieve health outcomes, promote health, prevent disease, store health, and facilitate coping w/ altered functioning 

• carry out the plan 

• continue data collection and modify the plan as needed

• document care 

direct care intervention

• treatment performed through interaction w/ the pt 

• includes physiologic and psychological nursing care 

  • medication administration

  • wound care 

  • counseling during a time of grief

indirect care intervention

• treatment performed away from the pt but on behalf of a pt 

• aims at management of the pt care environment and interdisciplinary collaboration 

• supports the effectiveness of direct care intervention 

  • infection control 

  • advocacy teams  

nursing process step 5: evaluation

• the nurse and pt together measure how well the pt has achieved the outcomes specified in the care plan 

• depending on the pt’s response to the plan of care, the nurse will decide to:

  • terminate the plan of care 

  • modify the plan of care 

    • positive or negative? —> switch gears if needed

• continue the plan of care 

• measure how well the pt has achieved desired outcomes

• identify factors contributing to the pt’s success or failure 

• interpret and summarize findings 

• document findings 

factors that can lead to lack of goal achievements

• an incomplete database 

• unrealistic client outcomes 

• nonspecific nursing interventions 

• inadequate time for the client to achieve the outcomes 

a nurse if caring for a client who is 2 days post-operative and has not achieved satisfactory pain relief. according to the nursing process, what action should the nurse take first?

check the client to determine the reason for inadequate pain relief

concept mapping

• an instructional strategy in which learners identify, graphically display in a diagram or drawing, and identify interrelationships between core concepts 

• it promotes critical thinking and self-directed learning 

• allows for the recognition of relationships and connecting between data, and the application of this knowledge to pt care

step 1 of concept mapping

• collect pt problems and concerns on a list 

  • can be a symptom, lab value, test results, and treatment 

  • can be obtained from an assessment, medical record, and the interdisciplinary team 

• all problems and concerns based on diagnosis

step 2 of concept mapping

• connect and analyze the relationships

  • differentiate between groupings of main and related problems

  • compare, contrast, and group your data 

    • not every lab problem is a concern

step 3 of concept mapping

• create a diagram 

  • problem recognition and nursing actions 

  • use shapes and connective lines to emphasize nursing actions related to the care plan

step 4 of concept mapping 

• keep in mind key concepts

  • the nursing process

  • holism 

  • safety

  • advocacy

identify goals, outcomes and nursing interventions

• on a separate piece of paper, write goals/outcomes for each nursing diagnosis

• goals are broad statements (e.g., the patient maintains optimal mobility)

• outcomes should be SMART; usually written in future tense (e.g., the patient will ambulate in hallway for 10 feet, three times a day on the day of care)

  • can be broad statements

• list nursing interventions (not medical) to attain the goal/outcome. include what you are supposed to be carefully monitoring - assessment, treatments, medications, patient education. be complete and think “what am I doing this day for this client/patient?”

• provide a scientific rationale for the interventions proposed

evaluate the patient’s response

• as you complete a nursing intervention, write down the pt’s response

• evaluate the goal: was the goal met or not? do the nursing interventions need to be revised?

• involves writing your clinical impressions & inferences regarding your pt’s progress toward expected goals/outcomes and the effectiveness of your interventions to bring these goals/outcomes 

OLDCART

onset, location, duration, characteristics, alleviating and aggravating factors, relieving factors, treatments, severity 

SMART

S - specific 

M - measurable 

A - attainable 

• w/in realistic reach —> “drink 3-60 mL w/in 2 hrs while awake”

R - realistic

T - time-bound