Funda Lec Module 2- Lesson 1- Nursing as a Sciene
Introduction
Nursing as a Science and its significance.
Page 1: Overview of Module
Topic: Problem Solving Process in Nursing
Focus: Nursing as a Science.
Page 2: What is a Science?
Requires systemized knowledge.
Derived from:
Observation
Critical thinking
Study and research.
A body of knowledge based on scientific research and analysis.
Page 3: Evolution of Nursing Science
Growth of scientific knowledge in nursing.
Nurses' awareness of basic principles leads to summarized procedures.
Nursing borrows from other disciplines.
Unique aspects of nursing lead to the development of nursing theories.
Page 4: Art and Science in Nursing Today
Major tasks for nursing:
Establish its scientific base separate from medicine.
Recognize nursing's scientific basis is behavioral systems.
Key Contributors:
Roy (1980): Behavioral subsystem.
Rogers (1970): Holistic science.
Watson: Humanistic science with caring.
Page 5: Conceptual Models for Nursing
Nursing practice based on:
Behavioral science
Holistic science
Caring science.
Nursing theories support the development of nursing science knowledge and practice.
1973: First National Conference on Nursing Diagnosis classification.
Page 6: Nursing Knowledge
Body of abstract knowledge from scientific research.
Focus on diagnosing and treating human responses to health problems.
Page 7: The Nursing Process
Overview of the nursing process as a systematic framework for professional nursing care.
Page 8: Definition of Nursing Process
Framework for providing professional nursing care across all settings.
Incorporates cognitive pieces such as critical thinking with nursing activities (assessing, planning, intervening, evaluating).
Page 9: Nursing Process Description
A systematic, rationale method of individualized nursing care.
Used for identifying, diagnosing, and treating health responses and concerns.
Page 10: Phases of the Nursing Process
Five overlapping phases:
Assessing
Diagnosing
Planning
Implementing
Evaluating
Page 11: Nursing Process Phases
Detailed steps in the nursing process: Assessment, Diagnosis, Planning, Implementation, Evaluation.
Page 12: Steps of Nursing Process
Assessment: Collection of patient health information.
Diagnosis: Identifying problems from collected data.
Planning: Setting care goals, identifying suitable nursing actions.
Implementation: Executing the care plan.
Evaluation: Assessing if goals are achieved.
Page 13: Characteristics of Nursing Process
System characteristics:
Open and flexible
Cyclic and dynamic
Client-centered
Planned and goal-directed.
Page 14: Interpersonal and Collaborative Nature
Emphasizes creativity in problem-solving with clients.
Feedback leads to re-assessment or care plan revision.
Universally applicable across different nursing settings.
Page 15: Assessment Overview
Continuous collection of data on patient health status.
Page 16: Purposes of Assessment
Establish a comprehensive database about the client:
Nursing health history
Physical assessment
Lab and diagnostic test results.
Page 17: Types of Assessment
Initial Comprehensive Assessment
Problem-Focused Assessment
Emergency Assessment
Time-Lapsed Assessment
Page 18: Initial Comprehensive Assessment
Conducted shortly after client's admission.
Evaluates health status and identifies functional health patterns.
Page 19: Problem-Focused Assessment
Collect data about identified problems.
Integrated with nursing care.
Page 20: Emergency Assessment
Conducted during life-threatening situations.
Involves physiological and psychological assessments.
Page 21: Time-Lapsed Assessment
Evaluates health & functional status changes months after initial assessment.
Page 22: Components of Assessment
Data Collection: Systematic and continuous.
Validation of Data: Checking accuracy with another source.
Organization of Data: Compiling into logical clusters.
Page 23: Data Collection Process
Gathering health status data via:
Physical factors
Psychological factors
Emotional influences.
Page 24: Types of Data in Assessment
Subjective Data: Symptoms reported by the patient.
Objective Data: Observable signs detected during assessments.
Page 25: Methods of Data Collection
Includes:
Interview
Observation
Physical assessment techniques (auscultation, palpation).
Page 26: Guidelines for Interviewing
Listen attentively and clarify points.
Maintain a logical question sequence.
Page 27: Interview Techniques
Ask one question at a time to facilitate patient responses.
Use non-verbal cues to convey respect and interest.
Page 28: Sources of Data
Primary Source: Patient data (interview and examination).
Secondary Source: Family, medical records, health team members.
Page 29: Different Data Sources
Examples include:
Client records
Family and support members.
Page 30: Data Organization
Organize data systematically for clarity and analysis.
Page 31: Validation of Data
Involves verification of collected data accuracy.
Page 32: Purpose of Validation
Ensure complete data collection and coherence between subjective and objective data.
Page 33: Steps in Data Validation
Evaluate if data requires validation and pursue inconsistencies.
Page 34: Documentation Purposes
Chronological record of assessments that inform care strategies.
Page 35: Documentation Guidelines
Document clearly, accurately, objectively, avoiding redundant language.
Page 36: Examples of Subjective & Objective Data
Subjective: "I am having vomiting."
Objective: Physical findings of the patient.
Page 37: Diagnosis in Nursing Process
Second phase where interpretation of assessment data occurs.
Page 38: Definition of Nursing Diagnosis
Clinical judgment about responses to actual or potential health issues.
Page 39: Nursing Diagnosis Process
Involves:
Analyzing data
Identifying health issues
Formulating diagnostic statements.
Page 40: Types of Nursing Diagnosis
Five types:
Actual Diagnosis
Risk Nursing Diagnosis
Possible Nursing Diagnosis
Syndrome Diagnosis
Wellness Diagnosis.
Page 41: Actual Diagnosis
Present client problems identified during assessment.
Page 42: Risk Nursing Diagnosis
Clinical judgment that a problem may develop based on risk factors.
Page 43: Possible Nursing Diagnosis
Evidence is incomplete or unclear regarding health issues.
Page 44: Syndrome Diagnosis
Related to a cluster of other nursing diagnoses.
Page 45: Wellness Diagnosis
Indicates a healthy response where patients strive for higher wellness levels.
Page 46: Components of Nursing Diagnosis
Consists of three components:
Problem (diagnostic label)
Etiology (related factors)
Defining characteristics.
Page 47: Problem or Diagnostic Label
Descriptive of patient responses or problems.
Page 48: Etiology or Risk Factors
Factors influencing responses to health issues.
Page 49: Defining Characteristics
Signs and symptoms indicating presence of a diagnostic label.
Page 50: Diagnostic Process Explanation
Critical thinking skills applied in analyzing and synthesizing data.
Page 51: Analyzing Data Steps
Compare data against established standards and cluster cues.
Page 52: Identifying Health Problems
Collaborative decision-making process to spotlight client strengths and concerns.
Page 53: Formulating Diagnostic Statements
Structured in two-part or three-part formats (e.g., Problem related to Etiology).
Page 54: Basic Three-Part Statements
Example: Problem related to Etiology as evidenced by Signs and Symptoms.
Page 55: Planning in Nursing Process
Focusing on setting goals and developing nursing strategies.
Page 56: Difference Between Nursing and Medical Diagnosis
Nursing diagnosis prompted by a nurse’s judgment, while medical diagnosis by a physician.
Page 57: Characteristics of Nursing vs Medical Diagnosis
Nursing diagnoses change with individual responses, while medical diagnoses remain more static.
Page 58: Definition of Nursing Planning
Third phase in which nurses and clients collaborate on goals and interventions.
Page 59: Planning Overview
An essential category of nursing behaviors where client-centered goals are agreed upon.
Page 60: Types of Nursing Planning
Initial Planning
Ongoing Planning
Discharge Planning.
Page 61: Initial Planning
Started as soon after initial assessment.
Page 62: Ongoing Planning
Occurs during the start of a shift, planning care for that day.
Page 63: Discharge Planning
Begins during initial patient contact for comprehensive assessment of ongoing needs.
Page 64: Developing Nursing Care Plans
End product of the planning phase is the care plan.
Page 65: Informal Care Plan
Exists in the nurse's mind as a mental plan of action.
Page 66: Standardized Care Plan
Specifies nursing care for groups of clients with similar needs.
Page 67: Individualized Care Plan
Tailored to meet the specific needs of individual patients.
Page 68: Kardex Care Plan
Centralized information including client care instructions.
Page 69: Formats for Nursing Care Plan
Organized into:
Nursing Diagnosis
Goals/Desired Outcomes
Nursing Orders/Planning
Evaluation.
Page 70: Categories of Care Plan
Varies in student plans, computerized plans.
Page 71: Student Care Plan
More detailed and structured than regular care plans with added rationale.
Page 72: Example of Student Care Plan
Key Components:
Assessment
Nursing Diagnosis
Goals/Desired Outcomes
Interventions
Rationale
Implementation
Evaluation.
Page 73: Computerized Care Plan
Generates standardized and individualized care plans from centralized systems.
Page 74: Process of Planning
Stages:
Setting priorities
Establishing client goals
Choosing nursing strategies
Writing nursing orders.
Page 75: Setting Priorities
Establishes a preferential order for nursing diagnosis and interventions.
Page 76: Establishing Client Goals
Client goals reflect the highest level of wellness and independence.
Page 77: Types of Goals
Short-term goals: Achievable within less than a week.
Long-term goals: To be achieved over weeks or months.
Page 78: Short-Term Goal Example
Expectation: Client to achieve comfort within 24 hours post-surgery.
Page 79: Long-Term Goal Example
Expectation: Client to adhere to activity restrictions for one month.
Page 80: Goal Components
Example: Client to raise right arm post-surgery.
Page 81: Meaning of Goals
Goal: Broad term; Desired Outcomes: Specific actions to achieve.
Page 82: Example of Desired Outcomes
Problem: Ineffective airway clearance.
Desired outcome: Lungs to clear as prescribed.
Page 83: Nursing Outcome Classification (NOC)
Provides a framework similar to goals.
Page 84: Purposes of Goals and Desired Outcomes
Guide nursing interventions, assess client progress.
Page 85: Components of Desired Outcomes
Includes:
Subject
Verb
Conditions/Modifiers
Criterion for performance.
Page 86: Subject
Primary focus of goals—the patient or their attributes.
Page 87: Verb
Specifies the action clients are to take.
Page 88: Action Verb Examples
Examples include: apply, assist, identify, demonstrate.
Page 89: Conditions or Modifiers
Details circumstances under which behaviors should be performed.
Page 90: Criterion of Desired Performance
Standards against which performance is evaluated.
Page 91: Guidelines for Writing Goals
Construct goals focusing on patient behaviors and responses.
Page 92: Realistic Goals
Goals should consider client capabilities and limitations.
Page 93: Compatibility of Goals
Ensure therapeutic alignment with other professionals' treatments.
Page 94: Singular Goal Focus
Each goal should stem from one nursing diagnosis.
Page 95: Observable Outcomes
Use measurable terms; avoid vague language.
Page 96: Selecting Nursing Interventions
Actions taken to achieve client goals and improve health outcomes.
Page 97: Types of Nursing Interventions
Independent Interventions
Dependent Interventions
Collaborative Interventions.
Page 98: Independent Interventions
Actions navigated by nurse's judgement and expertise.
Page 99: Dependent Interventions
Tasks performed under physician orders or supervision.
Page 100: Collaborative Interventions
Actions performed in collaboration with other members of health teams.
Page 101: Components of Nursing Orders
Should include:
Signature
Date
Action verb
Time element
Content area.
Page 102: Date in Nursing Orders
Essential for periodic review and documentation accuracy.
Page 103: Action Verb Examples
Verbs must precisely initiate the nursing orders.
Page 104: Content Area
Specifies what actions will be taken and where.
Page 105: Time Element
Indicates frequency and duration of nursing actions.
Page 106: Signature Importance
Nurse's signature indicates accountability and legal responsibility.
Page 107: Example of Nursing Order
Showcases completion details for clarity.
Page 108: Implementation Overview
Execution phase of the nursing process.
Page 109: Categories of Nursing Interventions
Include assessment, treatments, administrative tasks.
Page 110: Implementation Skills
Required skills include cognitive, interpersonal, and technical competencies.
Page 111: Cognitive Skills in Nursing
Refers to knowledge-based skills such as problem-solving and critical thinking.
Page 112: Interpersonal Skills Overview
Essential for effective communication with patients and peers.
Page 113: Technical Skills Definition
Skills related to hands-on patient care and equipment management.
Page 114: Process of Implementation
Involves reassessing, communicating actions, and delegating tasks.
Page 115: Reassessing the Client
Ensuring interventions are still appropriate based on clients' current condition.
Page 116: Determining Nurse's Need for Assistance
Identifying situations requiring support during patient care.
Page 117: Implementing Nursing Orders
Execution of care plans with clear communication to patients about actions taken.
Page 118: Documentation of Nursing Actions
Continuation of the nursing process, recording care provided and responses.
Page 119: Evaluation in Nursing Process
Final phase assessing progress towards established goals.
Page 120: Types of Evaluation
Ongoing
Intermittent
Terminal.
Page 121: Ongoing Evaluation
Conducted during or right after the implementation of nursing orders.
Page 122: Intermittent Evaluation
Scheduled assessments that show client progress or the need to modify care plans.
Page 123: Terminal Evaluation
Assessment during discharge to evaluate client status and care needs.
Page 124: Evaluation Process
Steps include identifying desired outcomes, collecting data, and modifying care plans as needed.
Page 125: Data Collection in Evaluation
Gathering subjective and objective data to assess goal achievement.
Page 126: Comparing Data with Outcomes
Determining if goals were met, partially met, or unmet based on data gathered.
Page 127: Relating Actions to Outcomes
Assessing the impact of nursing actions on achieving client goals.
Page 128: Drawing Conclusions
Evaluating nursing care effectiveness in meeting client needs.
Page 129: Modifying the Care Plan
Adjusting care plans based on evaluation outcomes to enhance care efficiency.