Nursing Process Student Version-2
Chapter 16: Nursing Assessment
Key Elements of Nursing Assessment
Signature: Required by nurse to validate the process.
Date: Indicates when the assessment was made.
Model for Clinical Judgment
Evaluation: Look at outcomes to measure effectiveness.
Implementation: Recognize cues to take action based on the assessment.
Decision Making: Analyze clinical cues, generate solutions, and prioritize hypotheses for diagnosis.
Critical Thinking in Assessment
Two main steps:
Collection of data from primary (patient) and secondary sources (family, medical records).
Interpretation and validation of gathered data to ensure completeness and determine need for more data.
Types of Assessments
Patient-centered Interview: Conducted during nursing history.
Periodic Assessments: Conducted during ongoing patient interactions.
Assessment type can be either comprehensive or problem-focused.
Patient Data
Subjective Data: Information reported by the patient (e.g., symptoms).
Objective Data: Observable and measurable data (e.g., vital signs).
Sources: Involves family caregivers, healthcare team, and medical records to gather complete information.
Environment in Assessment
Factors Influencing Assessment:
Setting: Privacy and comfort levels.
Time pressure: Availability of adequate time for assessment.
Task complexity: Complexity of tasks affecting focus.
Interruptions: Minimizing distractions to improve assessment accuracy.
Example Case Study (Male Patient)
Patient Observations:
Lies still with arms along sides, appears tense.
States hasn’t turned for a long time; reports pain level of 7/10.
Inferences:
Indicates severe pain, limiting the patient's ability to move and reposition.
Chapter 17: Analysis and Nursing Diagnosis
Nursing Diagnoses
Definition: A clear label familiar to all healthcare providers that assists in understanding a patient’s needs.
Medical Diagnoses: Focus on disease.
Nursing Diagnoses: Focus on patient responses or needs.
Collaborative Problems: Require cooperative interventions.
Documentation and Informatics
After identifying nursing diagnoses, enter into the Electronic Health Record (EHR) of the agency.
The information system dictates how the diagnosis information will be communicated.
Structure of Nursing Diagnoses
3 Parts for Nursing Diagnoses:
Nursing Diagnosis: Taken from a care plan book; uses standard language.
Related Factors (R/T): Contributing factors taken from care plan resources.
Defining Characteristics (AEB): Based on abnormal assessment data.
Use commas to separate listed criteria.
2 Parts for At-Risk Nursing Diagnoses:
At risk nursing diagnosis: Identifies potential problems.
Related factors: No AEB since there is no abnormal assessment data.
Chapter 18: Planning and Outcomes Identification in Nursing Care
Establishing Priorities
Methods:
ABCs (Airway, Breathing, Circulation): Prioritizes physiological needs.
Maslow’s Hierarchy of Needs: Encourages consideration of the patient’s unique situation.
Avoiding strict classifications based on physiological needs alone.
Clinical Judgment in Outcomes Identification
Writing expected outcomes should meet the following criteria:
Specific
Measurable
Attainable
Realistic
Timed
Planning Nursing Interventions
Types of Interventions:
Direct Care Measures: Hands-on patient care.
Indirect Care Measures: Supportive actions for patient care.
Independent Nursing Interventions: Autonomously performed by the nurse.
Dependent Nursing Interventions: Require orders from a physician.
Chapter 19: Implementing Nursing Care
Standard Nursing Interventions
Foundation of Knowledge: Provides evidence-based guidelines on managing conditions.
Clinical Practice Guidelines: Recommendations on interventions to standardize care.
Protocols: Include preprinted medical orders.
Implementation Process
Key actions include:
Reviewing and Revising: Patient care plans based on ongoing assessments.
Reassessing: Continuously checking patient status.
Avoiding Adverse Events: Preventing complications during care.
Types of Direct Care Activities
Activities of Daily Living: Basic patient needs (e.g., hygiene).
Instrumental Activities of Daily Living: More complex activities (e.g., managing medications).
Physical Care Techniques: Includes interventions for comfort and safety.
Lifesaving Measures: Urgent interventions for critical conditions.
Counseling and Teaching: Patient education to support recovery.
Controlling for Adverse Reactions: Monitoring for side effects.
Preventative Interventions: Strategies to prevent further health issues.
Indirect Care Interventions
Actions performed away from the patient but supportive of their care, including:
Communicating Nursing Interventions: Ensuring continuity of care.
Delegating, Supervising, and Evaluating: Overseeing care provided by other staff members.
Chapter 20: Evaluation
The Evaluation Process
Recognizing errors or unmet goals is essential.
Corrective Actions Include:
Discontinuing ineffective care plans.
Redefining nursing diagnoses as needed.
Revising expected outcomes and interventions based on new data.
Continually revisiting the care plan to enhance effectiveness.