The Nursing Process (FOUNDATION SOF NURSING #2)

The Nursing Process

• A systematic guide to patient-centered care with 5 sequential steps that utilizes critical thinking:assesment, diagnosis, planning outcomes, implementation, evaluation

assessment

• First phase: Gather data through interviews and physical assessment

• Gather the data, systematically, categorize and record

• Assessment: systematic gathering of information related to the physical, mental, spiritual, socioeconomic, & cultural status of an individual, group, or community

Diagnosis

Second phase: Identify patient’s health needs

List by priority, identify patterns, draw conclusions

planning outcomes

• Decide goals & outcomes to achieve through nursing activities

• Choose interventions to achieve stated goals

• Create the care plan

implementation

Action phase: Carry out or delegate actions planned

evaluation

Final phase: Judge actions; have they treated, attained or prevented the patient’s health problems

relation to other steps: diagnosis

Data is used to identify actual or potential health problems and strengths

relation to other steps: planning outcomes and interventions

• Data about the patient’s motivation, family, & available resources help to formulate realistic goals

• Assessment data helps to choose the most effective interventions for the patient

relation to other steps: implementation & evaluation

Gather data: observe patient responses to interventions

• Assess patient responses to interventions

• Reassessment provides the basis for changes in the care plan

medical assesments vs nursing assessments

• Medical assessments focus on disease and pathology (Medical Diagnosis)

• Nursing assessments focus on patient’s responses to illness (Nursing Diagnosis)

how is data used?

• By other disciplines (care collaboration)

• To plan nursing care

• To ensure patient receives:

  • Appropriate interventions / care

  • Promotes safety

  • Qualified individuals are providing care

  • Care is provided at the time it is needed

Professional Standards & Assessment

• Assessment is an essential skill endorsed by:

  • American Nurses Association (ANA)

  • National Council of State Boards of Nursing (NCSBN)

  • CMS (Medicare) / The Joint Commission (TJC)

• A professional nurse must perform all aspects of the  nursing process

• Nurse aides, other nursing assistive personnel (NAP) and licensed practical nurses (LPNs) collect information such as vital signs, pain reports, & fingerstick blood glucose levels (Data)

• The professional nurse assigns those tasks, validate the data collected, conduct the interview, & complete a physical assessment

delegating

• The ANA and NCSBN’s Joint Statement on Delegation (updated 2019) states the “The decision of whether or not to delegate or assign is based upon the RN’s judgement concerning the condition of the patient, the competence of all members of the nursing team and the degree of supervision that will be required of the RN if a task is delegated”.

types of data

subjective

objective

primaray

secondary

subjective data

What the patient (or caregiver) states in response to questions

objective data

• What the nurse observes or measures when assessing the patient (care giver)

primaray data

• Obtained directly from the patient

secoundary data

• Obtained secondhand through the medical record review or another person (family)

Nursing Assessment Skills

• Observation (what do you see?)

• Physical assessment

  • Inspection(visual)

  • Palpation (touch)

  • Percussion (touch/hearing)

  • Auscultation (stethoscope)

• Interviewing (conversation/questions)

types of assessments

initial

ongoing

comprehensive

focused

assement: initial

The initial contact with the patient (i.e. on admission)

assement: ongoing

Repeated reassessment at specified intervals

assesment: comprehensive

Review data based on collection of information from multiple sources; H&P, lab data, medical records, transfer documents, etc.

assessment: focused

• 
  

• Generally conducted for a specific issue /problem (body part, topic, or functional ability)

• Special needs: Type of focused assessment that is more in-depth related  issue (Nutrition, Pain, Cultural, Spiritual, Psychosocial)

Special Needs Assessment

nutrtion assesment

pain assesment

cultural assesment

spiritiral health

psychosocial assement

wellness assesment

family/community assesment

functional ability

nutrtion assesment

if warranted because of malnutrition, new diagnosis of diabetes, economic issues, etc.

pain assesment

• A though pain is assessment is required on all patients (per regulation)

cultural assesment

• cultural influences or requirements may play an important role in the care of the patient

spirital health

• The patient’s spiritual health may play an important part in  health & well-being

Psychosocial Assessment

To include family, lifestyle and coping strategies

Wellness Assessment:

• Overall physical and psychosocial wellbeing & strategies to maintain

• Family / Community Assessment

• Are there resources available to support the patient

functional ability

• Ability to carry out ADL’s & will rehab be needed?

The Nursing Interview

• Purposeful & structured communication

• Involves questioning the patient (per assessment document)

• Purpose: gather subjective data for the nursing health history

• The EMR will prompt questions by system

Preparing for the Interview

• Know purpose of the interview & how data will be used

• Read patient’s medical record

• Form some goals & opening questions

• Schedule uninterrupted time

• Have EMR (forms) & equipment ready

• Compose yourself before entering the room

• Introduce yourself and tell them your role and purpose of the visit

Validating Data

• When to validate

  • Subjective/objective data do not agree or make sense

  • Patient statements differ at different times in the interview

  • Data is far outside normal range

  • Factors present that interfere with accurate measurement

Guidelines for Documenting Data

• Document

  • as soon as possible (during the interview & assessment if possible)

  • electronically (or write neatly, legibly, and in black ink or record data)

• Use proper spelling & grammar

• Use acronyms sparingly (only approved to use)

• Write patient’s own words (in quotations), when possible

• Record only the most important patient words

• Use concrete, specific information

• Record cues, not inferences

Additional Tools to Record Assessment Data

• Graphic flow sheet

• Intake and output (I & O) sheet

• Nursing admission assessment (form)

• Nursing discharge summary

• Special-purpose forms

• Electronic documentation

Reflect on the Assessment

• Is data complete, accurate, and validated?

• Record data, not conclusions?

• Follow up with special needs assessment if indicated?

• Think about patient interview; Was anything important missed?

• Review physical assessment, observation, and examination (from health assessment lab)

Analysis & Nursing Diagnosis

• A critical step: links assessment with all subsequent steps in Nursing process

• Use critical thinking skills to identify patterns in data and draw conclusions about the patient’s health status

• Include strengths, health problems, & factors contributing to the problems

• It is NOT a medical diagnosis:

  • Focus on nursing issues (ex; pain management, prevent infection, patient/family education)

  • Basis for planning patient centered goals and interventions

Nursing Diagnosis

• States health problem the nurse identifies, prevents, or treats independently

• Written in terms of human response

• NANDA officially defines nursing diagnosis

  • “a clinical judgment concerning a human response to health conditions/life processes, or a vulnerability for that response, by an individual, family, group or community”.

Medical Diagnosis

• Describes a disease, illness, or injury

  • NOTE: Except for Advanced Practice Nurses, Nurses cannot legally diagnose or treat medical problems

Diagnostic Reasoning

• Use critical thinking to

  • Analyze & interpret data

  • Draw conclusions on health status

  • Verify problems

  • Prioritize problems

  • Record diagnostic statements

Analyzing Data

• Identify significant data (prominent issues)

• Cluster cues

• Identify data gaps & inconsistencies (is additional exploration needed?)

• Draw conclusions about health status

• Make inferences (based on cues)

• Identify problem etiologies (immobility, poor nutrition, noncompliance with medications, incontinence, etc.)

• Verify problems with the patient

Prioritize Problems

• Place problems in order of importance

• Does not mean you must resolve one problem before attending to another

• Determined by theoretical framework you use

• Maslow’s Hierarchy of Needs

  • Often used to prioritize nursing problems

Problem Urgency

• High priority

• Medium priority

• Low priority

• Patient Preference

high priotiry

life threatinig

md priotiry

Not a direct threat to life, but may cause destructive physical or emotional changes

low priority

Requires minimal supportive nursing intervention

patient preference

Assign high priority to problems the patient thinks are the most important if they do not conflict with basic needs or medical treatment

Diagnostic Reasoning

1. What beliefs, values, & experiences affect your thinking and may be misleading?

2. Are there stereotypes / biases that influence your thinking?

3. Are you relying heavily on any past experiences (by using stereotyping)?

4. Have you relied heavily on the medical diagnosis, care setting, or what others have said about the patient (can bias your thinking)?

Diagnositic Label NANDA-I Nursing Diagnosis: Componenets

a word or phrase to represent a pattern of related cues and describes a problem or wellness response to seek

diagnositic label definition

explains the meaning of the label and distinguishes it from similar nursing diagnoses

nursing diagnosis components: defining characteristics

cues (S&S) allow you to identify a problem or wellness diagnosis

nursing diagnosis: components: related factors

cues, conditions, or circumstances that cause, precede, influence, contribute to, or are in some way associated with the problem (label)

nursing diagnosis: componenets: risk factors

Events, circumstances, or conditions that increase the vulnerability of a person or group to a health problem

diagnostic statements origniates from

problem and its etiology e.g activity intolarence

diagnostic statements: related factors

general weakness, sedentary lifestyle, bedrest / immobility, anemia

diagnostic statement subjective data:

Reports fatigue, generalized weakness, exertional discomfort, dyspnea

diagnostic statements: objective data

Abnormal HR and BP response to activity, EKG changes (arrythmia, conduction abnormality, ischemia)

Define functional level based on patient feedback  - actual observations

diagnostic statments: desired outcomes goals

activity tolerance, energy conservation, endurance and psychomotor energy (improved desire to maintain ADL’s)

Define how this will be met – what steps will need to occur and when to expect improvement?

diagnostic statements actions and interventions

Activity prescription, Energy management, exercise promotion