Health Assessment: Nursing Process

Nursing Process

Common language for nurses to "think through" clinical problems

Critical thinking is at the base of nursing process.

Five stages of nursing process

1. Assessment

2. Diagnosis

3. Planning

4. Implementing

5. Evaluating

Critical Thinking and Diagnostic Process

The standards of practice in nursing is termed the NURSING PROCESS (it is ongoing)

Initial- Ongoing- Discharge Planning

- Initial

*Upon admission

*Comprehensive plan of care

- Ongoing

*Beginning of shift

- Discharge

*Anticipation for needs after discharge

*Begins with admission !!!!!!

Assessment will be subjective and objective and ongoing throughout their entire stay

Discharge begins at the admission!!!***

Do they even have a home.

Assessment

Point of Entry In an Ongoing Process

- Collection of data about the individual's health state

- Collecting and analyzing data

* subjective (what the person says)

* objective information (what you observe through: inspection, percussing, palpating, and auscultating)

* Patient's record/chart and lab values

Subjective then objective (what we can measure).

Subjective data would be patient stating they live alone and have no one to take care of them is subjective.

What we write during the assessment is creating a database.

Assessment

Point of Entry In an Ongoing Process : Database

DATABASE

- Clinical judgment or diagnosis about the individuals health, response to actual or risk problems, life processes, and higher levels of wellness

Diabetic blood sugar is out of control then we see the potential of being at risk. When blood sugar is out of control then we can identify other factors like amputation and kidney malfunction, so we need to teach the patient how to promote, prevent, or control the problem.

Assessment

Point of Entry In an Ongoing Process

It is Paramount that your assessment be factual and complete

We don't document "I think" you only document what you see, what they tell you, what you smell, and write ONLY factual assessment.

Assessment

The systematic and continuous

-collection

-organization

-validation

-documentation of information

Sources of Data (2)

Primary

- CLIENT

Secondary

-Family

-Health care providers

-Records

-Labs analysis

-Etc....

Client is best source of data if they're reliable. If the things aren't what the patient is quite telling you then you need to see for non-verbal communication because sometimes they just want to say what you want to hear. Also, you can use secondary sources.

How to Collect Data

*Observe

*Interview

-Closed questions

"yes" "no"

-Open -ended

Begin with "what" "how"

We observe, interview, and use closed or open ended question to bring about the narrative conversation.

Collection of Data: Subjective and Objective

Subjective:

*Symptoms

*Apparent only to person affected (Described By)

-Sensations

-Feelings

-Values & Beliefs

-Attitudes

-Perceptions

Objective:

*Signs

*(Detectable by) an observer

*Measured or tested

-Heard

-Felt

-Smelled

-Observed

-Examined

Subjective is symptoms and is only apparent to the client, objective is signs.

Physical Exam

*Tool Box

-Inspection (seeing)

-Palpation (touch)

-Percussion (touch/tapping)

-Auscultation (Listening)

Diagnostic Reasoning

Once data collection is complete, develop a preliminary list of signs and symptoms

Cluster the data in similar groups

Validate the data you collect for accuracy

Identify missing pieces of data (critical thinking)

Three area that it will fall under (Ex. Put all green or red separate together).

So if we have diabetic patient comes in and says my blood sugar runs a bit high, there is 3 P's in DM pt. polyphagia, polyuria, and polydipsia. This 3 things are signs of people having high blood sugar. Pt. states they drink a lot and can't have enough, then you see what the patient's blood sugar is and ask question if they urinate a lot. So, ask the next questions, identify the missing pieces and ask how their appetite is and critical think the missing pieces.

Diagnostic Reasoning

*The process of analyzing health data and drawing conclusions to identify diagnoses

*Hypothesis forming and Deductive reasoning

-Initial available cues

-Formulating a hypothesis about a diagnosis

-Gathering data relative to the tentative diagnosis

-Revaluating hypothesis with each new set of data to form a final diagnosis

Hypothesis their blood sugar is high.

Validate the Data

* The act of Double-checking

* Valid data

-Ensure a complete assessment has been performed

-Ensure data does not conflict

-Obtain additional information

-Identify Cues and make inferences

-Avoid jumping to conclusions

Don't jump to conclusion.

Diagnosing

The systematic and continuous

-Analyzing data

-Identifying health problems, risks and strengths

-Formulate diagnostic statements

Always ongoing. Always want to focus in patient's strength.

Nursing Diagnoses

"A clinical judgment about individual, family, or community responses to actual or potential health problems/life processes. A nursing diagnosis provides the basis for selection of nursing interventions to achieve outcomes for which the nurse is accountable"

Nursing diagnosis and medical diagnosis

nursing diagnosis is a clinical judgment about individual, family, or community responses to actual and/or potential health problems or life processes.

medical diagnosis is the identification of a disease based on its signs and symptoms.

Medicine is looking at the disease process.

Nursing Diagnosis (NANDA)

Nursing Diagnosis (NANDA) is the identification of human responses to health problems (Medical Diagnosis) and life processes. It is the basis for the nurses' decisions on how to best intervene to help people heal or improve their quality of life. With nursing diagnoses, emphasis is placed upon achievement of the client's maximum health potential. The nurse gathers the assessment data and from this data, identifies high-priority nursing diagnoses.

It's evidenced based practice (NANDA). The best way to intervene to help people heal and improve their quality of life.

Look at ABC (airway, breathing, and circulation).

Types of Nursing Diagnoses

* Actual (here and now)

-Diagnosis

Problem is present

-Related Factor (r/t)

Possible Causes (etiology)

-Defining Characteristics

Signs and Symptoms

As evidence by (aeb)

*Risk for (if we do not do something now)

-Diagnosis

Problem is potential

-Related Factor

Possible Causes (etiology)

*Wellness

-Diagnosis

Readiness for enhanced.

Maslow said we need to first met (physiological needs) this needs, then if its all met, then go to the next level. You can't advance the hierarchy until you mastered the lower level. Risk for is what need to be look out for so patient teaching is effective to prevent and promote the "Risk for".

Ackley book has wellness nursing diagnoses.

Planning

The systematic and continuous

Prioritizing problems / diagnosing

Formulate goals / desired outcomes

Select nursing interventions

Write nursing interventions

and desired outcome is what patient is going to do.

→ Intervention is what we do to help them reach the goal. So it is important to know what their goal is to help identify the intervention so we can help or teach clients so they can reach their goals or outcomes.

The Planning

* A deliberative, systematic phase of the nursing process that involves decision making and problem solving.

* In planning the nurse refers to Assessment Data and specifically to the Diagnostic Statement.

Setting Priorities

Process of establishing a sequence for addressing nursing diagnoses and interventions.

need to set what is our priority, and look at Maslow's hierarchy and follow ABC.

Maslow's

* Physiological needs:

Water, food, sleep, sex, and breathing.

* Safety needs:

Security of resources, employment, family, and health.

Factors to Consider While Creating a Care Plan

-Client's health values and beliefs

-Client's priorities

-Available resources

-Urgency

-Medical treatment plan

Establishing Goals & Outcomes

S = Specific to the client

Start with "Client will:"

Positive restatement of the nursing Dx.

M = Measurable

Specifically what are we looking for?

A = Appropriate

Is the goal appropriate for the client?

R = Realistic

Can the client actually achieve the goal?

T = Time sensitive

Exactly when will this goal be evaluated?

Goals is what client is going to do and " client will" is client specific.

It needs to be measurable.

→ Appropriate for their condition because certain patient can't gain their mobility back, so need to be appropriate to the patient.

→ Need to be realistic time for patient's condition.

→ Time needs to be realistic to the patient's condition.

→ Impaired skin integrity: GOAL patient will have intact skin integrity. Measurable part list two or three things that there is no open area no lesion. If you see redness in the toxic area then you didn't meet your goal. Then we reevaluate the goal and try to see what can we do to reduce the redness.

Establishing Goals & Outcomes:

* Goals

-Broad statements

* Outcomes

- Specific

-Provide direction for planning interventions

-Criteria for evaluating progress

-Enables nurse and patient to see if resolved

-Motivates the client to have a goal

outcome is specific that we have met our goals or not.

Skin integrity our outcome is less than 7 diameter in the red area of coccyx. Then I am going to do this to help get rid off the redness. So, monitoring urine output doesn't help reduce the redness, so the outcome/ goal need to be condition specific.

Implementation

* The systematic and continuous

- Reassess client

- Implement nursing interventions

- Supervise delegated tasks

- Document nursing activities

We identify the problem, we set our goals, and intervention, then we're going to implement it (We're going to take action and do it). Intervention is reposition the patient, then it needs to be implemented when you state you will do it.

Implementing

- The action phase in which the nurse performs the nursing intervention.

- Doing and Documenting

Writing Interventions

Verb + condition + modifier + time

- Assess, Teach, Explain, Apply

- What makes it specific?

- How much, How often, When?

S = smart

M = measurable

A = attainable

R = realistic

T = time-framed

Goal then intervention.

Types of Interventions

Independent:

Activities that nurses are licensed to initiate

- Physical care

- Ongoing assessment

- Emotional support

- Teaching

- Environmental management

- Referrals

Dependent:

Activities carried out under the orders or supervision of a licensed health care provider authorized to write orders.

- Provide Medications

- IV therapy

- Diagnostic test

- Diet

- Treatments

Collaborative: With other health team members

Administer pain medication then this is not independent intervention because you need to get an order from the doctor so in this case it's collaborative intervention. Physical activity to improve their gait mobility is collaborative intervention. I am going to monitor affects of the medication is independent intervention.

Choosing Interventions

- Congruent with client's values, belief, and culture

- Work with medical therapies

- Based on nursing knowledge

- Achievable

- Within standards of care

- Safe & Appropriate

Up hold the standards of care. If we don't reposition the patient, then its substandard care and we're liable for it.

Evaluation

The systematic and continuous

-Collect related to outcomes

-Compare data and outcomes

-Relate nursing actions to goal and outcomes

-Draw conclusions

-Continue, modify, terminate plan of care

Evaluating

Planned ongoing, purposeful activity in which clients and health care professionals determine the client's progress toward a goal and the effectiveness of the nursing care plan.

Evaluation is continuous!!

Evaluation:

Goal/Outcome Met

- Client response is same as outcome

Goal/Outcome Not Met

- Client response is not same as

outcome

Goal/Outcome Partially Met

- Client did not completely achieve goal

The Nursing Care Plan

- End Product of Planning Phase

- Standardized Care Plan

- Individualized Care Plan

- Planning Process

→ Set Priorities

→ Establish client Goal/desired Outcomes

→ Select Nursing Interventions

→ Write Individualized Nursing Interventions

→ Implement

→ evaluate

→ Always date and sign the documentation. (Ex: skin without redness) needs to be factual and brief.

Guidelines for Care Plans

→ Date and sign the plan

→ Use key words

→ Be Specific

→ Refer to sources of information

→ Tailor the plan to the client

→ Ensure ongoing assessment

→ Include collaborative & coordinated activities

→ Include discharge needs

→→ Monitor blood pressure q4hr/ its realistic and specific.