NUR 101 UNIT 3: Nursing Process

What is Critical thinking?

the process of intentional higher level thinking to define a client's problem, examine the evidence-based practice in caring for the client, and make choices in the delivery of care

What is Critical reasoning ?

the cognitive process that uses thinking strategies to gather and analyze client information, evaluate the relevance of the information, and decide on possible nursing actions to improve the client's physiological and psychosocial outcomes.

What is the Nursing Process?

systematic, rational method of planning and providing individualized nursing care. It begins with assessment of the client and use of clinical reasoning to identify client problems.

What are the steps of the Nursing Process?

Collecting data/Assessment

Diagnosing (Problem Identification)/ Analysis

Planning

*Goal setting

*Planning interventions to achieve goal

Implementing the planned interventions

Evaluating the effectiveness of the interventions to help achieve the goal

In the nursing process what is Assessment?

Collecting, organizing, validating, and documenting client data

Example:

• Obtain a nursing health history.

• Conduct a physical assessment.

• Review client records.

• Review nursing literature.

• Consult support persons.

• Consult health professionals.

Update data as needed.

Organize data.

Validate data.

Communicate/document data.

In the nursing process what is Diagnosis ?

Analyzing and synthesizing data

To identify client strengths and health problems that can be prevented or resolved by collaborative and independent nursing interventions To develop a list of nursing and collaborative problems

Ex:

• Compare data against standards.

• Cluster or group data (generate tentative hypotheses).

• Identify gaps and inconsistencies.

Determine client's strengths, risks, and problems.

Formulate nursing diagnoses and collaborative problem statements.

Document nursing diagnoses on the care plan.

In the nursing process what is Planning?

Determining how to prevent, reduce, or resolve the identified priority client problems; how to support client strengths; and how to implement nursing interventions in an organized, individualized, and goal-directed manner

To develop an individualized care plan that specifies client goals/desired outcomes, and related nursing interventions

Set priorities and goals/outcomes in collaboration with client.

Write goals/desired outcomes.

Select nursing strategies/interventions.

Consult other health professionals.

Write nursing interventions and nursing care plan. Communicate care plan to relevant health care providers.

In the nursing process what is Implementing?

Carrying out and documenting the planned nursing interventions

To assist the client to meet desired goals/outcomes; promote wellness; prevent illness and disease; restore health; and facilitate coping with altered functioning

Reassess the client to update the database. Determine the nurse's need for assistance. Perform planned nursing interventions. Communicate what nursing actions were implemented:

• Document care and client responses to care.

• Give verbal reports as necessary.

In the nursing process what is EVALUATING ?

Measuring the degree to which goals/outcomes have been achieved and identifying factors that positively or negatively influence goal achievement

To determine whether to continue, modify, or terminate the plan of care

Collaborate with client and collect data related to desired outcomes.

Judge whether goals/outcomes have been achieved.

Relate nursing actions to client goals/outcomes. Make decisions about problem status.

Review and modify the care plan as indicated or terminate nursing care.

Document achievement of outcomes and modification of the care plan.

.

What is Objective data?

signs or overt data, detectable by an observer or can be measured or tested against an accepted standard. They can be seen, heard, felt, or smelled, and they are obtained by observation or physical examination. For example, a discoloration of the skin or a blood pressure reading is objective dat

What is Subjective data?

Symptoms data, apparent only to the person affected and can be described or verified only by that person. Itching, pain, and feelings of worry are examples of subjective data

When Validating Data what is a cue?

subjective or objective data that can be directly observed by the nurse; that is, what the client says or what the nurse can see, hear, feel, smell, or measure

When Validating Data what is a Inference?

the nurse's interpretation or conclusions made based on the cues (e.g., a nurse observes the cues that an incision is red, hot, and swollen; the nurse makes the inference that the incision is infected).

How is a nursing diagnosis formulated?

Analyze Data

Compare to standard

Cluster using framework(e.g, Gordon's Functional Health Patterns)

Formulate Nursing Diagnoses

Diagnostic Labels based on "Defining Characteristics" (if actual diagnoses)

Etiology based on "Related (or Contributing) Factors"

Identify Nursing Diagnosis to act upon

What are the Gordan Functional Health Patterns?

Health Perception-Health Management

Nutritional-Metabolic

Elimination

Activity-Exercise

Sleep-Rest

Cognitive - Perceptual

Self Perception - Self Concept

Role - Relationship

Sexuality - Reproductive

Coping - Stress Tolerance

Value - Belief

When planning goals for interventions what must they be?

SMART

S specific

M measurable

A achievable

R realistic

T time frame

What is an independent nursing intervention?

activities that nurses are licensed to initiate on the basis of their knowledge and skills.

Include physical care, ongoing assessment, emotional support and comfort, teaching, counseling, environmental management, and making referrals to other health care professionals

What is an dependent nursing intervention?

activities carried out under the orders or supervision of a licensed physician or other health care provider authorized to write orders to nurses.

such as provide medications, intravenous therapy, diagnostic tests, treatments, diet, and activity

What is Collaborative interventions?

actions the nurse carries out in collaboration with other health team members, such as physical therapists, social workers, dietitians, and primary care providers.

For example, the primary care provider might order physical therapy to teach the client crutch-walking. The nurse would be responsible for informing the physical therapy department and for coordinating the client's care to include the physical therapy sessions.

What is the nursing doing during the Implementation phase of the nursing process?

Carry out intervention

Delegate intervention

Doing, Delegating, Documenting

What is the nurse doing during the Evaluating phase of the nursing process?

Assessing patient response!

Determine:

Was the goal met? (partially or fully)

If not, why not?

Was the goal appropriate?

Was the diagnosis correct?

Is there data we missed?

Should plan be changed?

What is the hierarchy of evidence based interventions?

Most important to least

*Editorials/Expert Opinions

*Case series/Case Reports

*Case- Controlled Studies

*Cohort Studies

*Randomized Controlled Trials

*Systematic Reviews

What is body temperature?

reflects the balance between the heat produced and the heat lost from the body, and is measured in heat units called degrees

What is the physiologic regulation technique the body uses to regulate temperature when it drops? shivering, sweating, vasoconstriction

shivering, sweating, vasoconstriction (narrowing of blood vessels)

What are factors that effect temperature?

Age (Very young and Very old)

Circadian rhythms(time of day)

Exercise

Hormones

Stress (production of epinephrine and norepinephrine)

Environment

What is a normal body temp?

98.6° - Considered Afebrile

What is a high body temp?

Above normal: Fever, Pyrexia, Hyperpyrexia, Hyperthermia

What is a low body temp?

Hypothermia

What are the routes of measuring body temp?

Oral

Axillary

Rectal

Tympanic (ear)

Temporal

Scales

What is the ADVANTAGES OR DISADVANTAGES OF the oral ROUTE

cannot use with oral surgery

cannot use is mouth breather

cannot do right after eating or smoking

What is the ADVANTAGES OR DISADVANTAGES OF the rectal ROUTE

good b/c core

cannot do if rectal surgery

hemorrhoids may make more difficult or uncomfortable

What is the ADVANTAGES OR DISADVANTAGES OF the AXILLARY

ROUTE

takes long time; need to hold in place

poor reading on thin individuals

What is the ADVANTAGES OR DISADVANTAGES OF the Tympanic (ear) ROUTE

quick

wax interferes

What is the ADVANTAGES OR DISADVANTAGES OF the Temporal ROUTE

Sweating - need to also check temp behind ear

some equipment is expensive and delicate; may not be practical in hospital

What are some nursing diagnosis related to temperature?

Risk for imbalanced body temperature

Hyperthermia

Hypothermia

Ineffective thermoregulation

What is a Intermittent fever?

temperature alternates at regular intervals between periods of fever and periods of normal

What is a Remittent fever?

a wide range of temperature fluctuations (occurs over a 24-hour period, all of are above normal

What is a Constant fever?

body temperature fluctuates minimally but always remains above normat

What is a Relapsing fever?

goes away, maybe days, and then comes back - malaria is common for this:

Clinical manifestations of onset phase of a fever?

subjective: feel cold

objective: increased hr & rr and depth, shivering, goosebumps; pale, cold skin; cyanotic(blueish) nailbeds; decreased sweating

Clinical manifestations of course(plateau) phase of a fever?

subjective: neither hot nor cold; thirsty; dec appetite; malaise(discomfort); weak; achey

objective:

warm skin; inc p & rr; dehydrated; drowsy; restless, delirious, depending on severity; glassy eyes

Clinical manifestations of abatement phase of a fever?

subjective: feel better

objective: flushed, warm skin; sweating; dec shivering; possible dehydration

Clinical Manifestations of Hypothermia?

dec temp, pulse, rr, bp

shiver

pale, cool, waxy skin; frostbite

dec urine

dec muscle coordination

disorientation

drowsiness to coma

What are Interventions for Clients with Fever (Hyperthermia)?

• Monitor vital signs.

• Assess skin color and temperature.

•skin color and warmth

• fluid balance

• lab tests (WBC, C & S)

•Blankets

•Fluids

•Medications: "antipyretics"

•Tepid bathing (slightly warm)

• Provide oral hygiene to keep the mucous membranes moist

• Dry clothing, linens

What are Interventions for Clients with hypothermia?

Blankets

Warm environment

Dry clothing

Cover head

Warm fluids

Position

What is a pulse?

reflection of heart beat per minute

Whats the normal pulse reading for an adult?

60-100

full, strong

What are somethings that effect pulse?

age- dec the older you get

metabolism

size/sex

activity

anxiety

physical condition emotion/stress

fever: incr.

pain

medications

position change

deep breath

disease-heart conditions or those that impair oxygenation

what is Tachycardia ?

an abnormally rapid pulse rate; greater than 100 beats per minute

what is Bradycardia?

abnormally slow pulse rate, less than 60 beats per minute

What is a thready pulse?

weak

what is a bounding pulse?

High volume pulse

What is Dysrhythmia

irregular pulse

What is inspiration ?

refers to the intake of air into the lungs

What is expiration?

refers to breathing out or the movement of gases from the lungs to the atmosphere.

What is Respiration is controlled by?

(a) respiratory centers in the medulla oblongata and the pons of the brain and (

b) chemoreceptors located centrally in the medulla and peripherally in the carotid and aortic bodies. These centers and receptors respond to changes in the concentrations of oxygen (O2), carbon dioxide (CO2), and hydrogen (H+) in the arterial blood.

What are Factors that affect respirations?

HEAD TRAUMA

MUSCLE PARALYSIS OR WEAKNESS

AGE

OBESITY

ASCITESAIRWAY OBSTRUCTION

EMOTION (ANXIETY)

PAIN

TEMPERATURE (FEVER, HYPOTHERMIA)

DRUGS

EXERCISE

What is Tachypnea?

quick, shallow breaths

What is Bradypnea?

abnormally slow breathing

What is Apnea?

stop breathing

What is Hyperventilation?

overexpansion of the lungs characterized by rapid and deep breath

What is Hypoventilation?

underexpansion of the lungs, characterized by shallow respirations

What is Dyspnea?

difficult and labored breathing during which the individual has a persistent, unsatisfied need for air and feels distressed

what is orthopnea

ability to breathe only in upright sitting or standing positions

What is Oxygen Saturation?

the percent of all hemoglobin binding sites that are occupied by oxygen.normal is 90 to 100%.. less than 70%

What are some Nursing Interventions poor respiration

Activity restrictions

Positioning

Breathing exercises

Administration of supplemental oxygen

Modification of contributing factors

What

Blood Pressure?

pressure created when heart contracts and relaxes

What is normal blood pressure for an adult?

Systolic ≤120

Diastolic ≤80

What are Factors affecting blood pressure?

stress (GAS), age, exercise, race, sex, medications, circadian rhythm, dehydration, hemorrhage, pain

What is Orthostatic Hypotension ?

blood pressure that decreases when the client sits or stands

Diagnostic Tests

White Blood Cells

Hemoglobin, Hematocrit, Red Blood Cells

Electrolytes: Sodium, Potassium

Chemistry: Glucose, BUN, Creatinine, Albumin

Coagulation: INR, PT, APTT, Platelets

Culture and Sensitivity

Urine analysis (UA)

Imaging (X-rays, MRI, CT scan)

EKG