Nursing process

Standardized nursing language

• defines nursing’s contribution and impact in healthcare, defines what nurses do

• gives nurses more EB outcomes and interventions

• easily integrated into EMR

• standardizes knowledge for nursing curriculum

• promotes nursing research

• individualizes patient care

NGN clinical judgement measurement model

• recognize cues

• analyze cues

• prioritize hypotheses

• generate solutions

• take actions

• evaluate outcomes

Alignment of the clinical judgement model (CJM)

• getting the information

• making meaning of the information

• determine actions to take

• take action

• evaluate outcomes and your thinking

Alignment of the nursing process

• assessment

• diagnosis

• planning

• implementing

• evaluating

ADPIE nursing process: planning

• patient outcomes

• nursing interventions

A nursing care plan allows the nurse to

• individualize care that maximizes outcome achievement

• set priorities

• facilitate communication among nursing personnel and colleagues

• evaluate patient response to nursing care

• create a record used for evaluation, research, reimbursement, and legal reasons

Characteristics of nursing assessment

• prioritized

• complete

• systematic

• accurate

Types of assessment

• initial

• focused

Types of assessment: initial

• admission

• shift 

Sources of data for assessment

• patient

• family and significant other 

• patient record

• other healthcare professionals

Types of assessment data

• subjective

  • what the patient feels or says

• objective

  • measurable and observable

How the phases of assessment set the stage for diagnosis: assessment

• collecting data

• identifying cues and making inferences

• validating data

• clustering related data and identifying patters

• reporting and recording data

How the phases of assessment set the stage for diagnosis: clinical reasoning

• analyzing

• synthesizing

• reflecting

• making judgments

• drawing conclusions

Diagnosis: nursing diagnosis

a clinical judgement about an individual’s responses to actual or potential health problems

• provides the basis for selection of patient outcomes and the nursing interventions to achieve the set outcomes

Nursing diagnosis

• no problem

• problem focused diagnosis ***

• risk diagnosis ***

• health promotion diagnosis

• syndrome diagnosis

***types of NSG DX used in the first semester

Actual nursing diagnosis - 3 part statement

• problem (related to, outcomes)

• etiology (cause, nursing interventions)

• defining characteristics 

At risk nursing diagnosis

a clinical judgement concerning the vulnerability of an individual for developing an undesirable human response to health conditions or life processes

• 2 part diagnosis

• problem statement AEB risk factors

Examples of nursing diagnosis

• ineffective airway clearance

• distrubed body image

• risk for unstable blood glucose

• impaired urinary elimination

• self-care deficit: dressing

Examples of medical diagnosis

• pneumonia

• amputation

• type 2 diabetes mellitus

• post-op prostatectomy

• cerebrovascular accident

Planning

• goals to measure your care

  • problem statement drives the patient outcomes

• interventions

  • traditional, EBP

  • etiology drives the nursing interventions

Goal of planning step

• establish priorities

• identify and write expected patient outcomes

• select evidence-based nursing interventions

• communicate the plan of care

1st part of the nursing diagnosis

problem statement

• identifies the unhealthy response

• indicates what should change

• suggests patient goals/outcomes (expectations for change)

2nd part of the nursing diagnosis

etiology

• identifies factors causing or contributing to the undesirable response and preventing desired change

• suggests nursing interventions

Four types of outcomes smart goals: cognitive

increase in patient knowledge

Four types of outcomes smart goals: psychomotor

patients achievement of new skills

Four types of outcomes smart goals: affective

changes in patient values, beliefs, and attitudes

Four types of outcomes smart goals: physiologic

physical changes in the patient

Smart goals pneumonic

S = specific

M = measurable

A = attainable

R = realistic

T = time bound

Interventions

• realistic

• evidenced based

• nurse initiated verses physician initiated and collaborative

Clinical judgment and evaluation

• identify evaluation criteria

• collect data to determine whether these criteria and standards are met

• interpret the findings

• document your findings

Actions based on patient response to plan of care in the evaluation phase

• direct future care

• terminate

• modify

• continue

Actions based on patient response to plan of care in the evaluation phase: terminate

the plan of care when each expected outcome is achieved

Actions based on patient response to plan of care in the evaluation phase: modify

the plan of care if there are difficulties achieving the outcomes

Actions based on patient response to plan of care in the evaluation phase: continue

the plan of care if more time is needed to achieve the outcomes

Narrative evaluation of outcomes: 3 elements to evaluate the smart goal (outcome)

• has the smart goal been met or unmet?

• present data to support your decision

  • the smart goal has not been met because of this objective proof

• CRITICAL THINKING

  • what would you need to specifically and measurably see for you to say that this problem has been resolved. speak to the smart goal and the overall resolution of the problem

Using the nursing process to formulate a nursing care plan: the nursing process

• assessment

• diagnosis

• planning

• implementation

• evaluation

Using the nursing process to formulate a nursing care plan: nursing care plan

• assessment data clustered

• NANDA diagnosis

  • actual 3 part

  • high risk 2 part

• identify outcomes (planning)

• select traditional interventions

• not actually implemented

• evaluation

  • evaluate achievement of the outcomes

  • revision of plan

  • guide future interventions