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

  1. Initial Comprehensive Assessment

  2. Problem-Focused Assessment

  3. Emergency Assessment

  4. 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:

    1. Actual Diagnosis

    2. Risk Nursing Diagnosis

    3. Possible Nursing Diagnosis

    4. Syndrome Diagnosis

    5. 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

  1. Initial Planning

  2. Ongoing Planning

  3. 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

  1. Independent Interventions

  2. Dependent Interventions

  3. 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

  1. Ongoing

  2. Intermittent

  3. 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.