Unit 3A The Nursing Process

Problem Solving

1. Identify the problem

2. Look for causes

3. Identify possible methods to solve (Plan)

4. Consider each

   a. Advantages / disadvantages

5. Select

6. Carry out the plan (implement)

7. Consider the effectiveness or the ineffectiveness; revise as needed (evaluate)

ADPIE:

• Assessment

• Diagnosing

• Planning

• Intervention

• Evaluation

Nursing Judgment

• Critical Thinking

• Clinical Reasoning

• Nursing Judgment

• Integration of best evidence into practice

Don’t take data for face value: investigate deeper, reason through data, and develop inferences.

Nursing Process (Methodical Process)

“problem-solving, critical thinking approach to patient care” or “solving problems in a systematic, patient-centered way”

• Collecting data- Assessment — clutter data — Assessment

• Diagnosing (problem identification) — Always based on Assessment

• Planning

  • Goal setting (planning care) — Develop a plan for the best outcome

  • Planning interventions to achieve goal (must anticipate what will happen)

• Implementing the planned interventions — Will change a patients outcome

• Evaluating the effectiveness of the interventions to help achieve the goal- “Did our actions work”?

Characteristics of Nursing Process

• Core and essence of nursing

• Patient-centered, humanistic, holistic

• Collaborative

• Structured, yet flexible; useful in any setting

• Organized, systematic, deliberate — Fluid and makes sense

• Continuous

• Dynamic

The steps are cyclical and interrelated: A constant cycle of evaluating and reassessing, modify the plan because the nursing process is always changing

• Diagnosis may be actual or at risk for (potential diagnosis)

  • Ex; risk for falls

Collecting Data

Types

• Subjective (statement)- Something that the patients can feel

  • Ex; patient is nervous

  • Ex; patient states they are in pain

• Objective- What we can see

  • Ex; patient bp is 120/80

  • Ex; patient has a 4×6 cm lesion

• Cues- A clear fact observable directly/verifying

  • Ex; patient is receiving O2 via nasal cannula

  • Ex; patient’s pulse is 102, regular, and bounding

• Inferences- A small “hop” (assumption) conclusion

  • Ex; patient is in pain

  • Ex; patient’s family is aggravating

Three Steps of the nursing process:

• Observing

• Interviewing

• Assessing

  Assessment will never change a patient’s outcome

Sources

• Patient (primary source)

• Documents (secondary)

  • Chart/EMR (Electronic Medical/Health Record)

    • H&P (Medical History & Physical)

    • Admission Nursing Assessment

    • PCP orders (Primary care provider)

    • Progress Notes

    • Diagnostic test results

    • MAR (Medication Administration Records)

  • Concept cap/Kardex

• Family and Interdisciplinary team members

Diagnosing- (Analyzing)

• Analyze Data

  • Compare to standard- Comparing the data to the standard

  • Cluster using framework (Gordon’s Functional Health Patterns)

  • Formulate Nursing Diagnoses

    • Diagnostic labels based on “defining characters” (if actual diagnosis) — Defining characteristics that can lead to the problem

      • Ex; Activity Intolerance

        • R/T: compromised O2 supply

        • Secondary to: CHF (cognitive heart failure)- Underlying cause

    • Etiology based on “Related (or contributing factors)

• Identify Nursing Diagnosis to act upon

Functional Health Pattern

• Health perception-Health Management

• Nutritional — Metabolic

• Elimination

• Activity — Exercise

• Sleep — Rest

• Cognitive — Perceptual

• Self-Perception — Self Concept

• Role — Relationship

• Sexuality — Reproductive

• Coping — Stress Tolerance

• Value — Belief

These are Gordon’s Functional Health Patterns (Carpenito Nursing Handbook)- Used too organize Nursing Diagnosis

Nursing Interventions: “Are evidence based”

Planning / Implementing

• Set patient centered SMART goals:

  • S - specific

    • Can’t set ambiguous goals

  • M - measurable

  • A - achievable

    • Don’t have sky-high goals

  • R - realistic

    • Ex; you can’t expect a patient to have 100% O2 saturation if they have a history of COPD

  • T - time frame

    • WIMC (while in my care — your shift! — short term goals)

• Nursing care plans should be evidence based

  • Systematic reviews, randomized controlled trials, cohort studies, case-control studies, case series/case reports, editorials/expert opinion

• Types of Interventions

  • Independent (without MD orders)

    • Ex; vitals, patient teaching

  • Dependent (MD orders needed)

    • Medication

      • Use nursing judgment » when medication has parameters

      • Ex; hold if BP is..

  • Collaborative / Interdependent

    • Working with physicians » must be patient advocate » help make decisions, make suggestions for patient care

• Implementation

  • Carry out intervention » Doing, Delegating, Documenting

  • Delegate Intervention

Evaluating

• Final Step (assessing patient’s response)

• Determine:

  • Was the goal met? (partially or fully)- what can we modify? (REVIEW THE PLAN)

  • If not, why not?

    • Was the goal SMART

• Should the plan be changed?

Documenting/Reporting- Always Document and report their findings

• Requirements

  • Prompt

  • Care and response

  • Objective

  • Complete, yet concise- make sure data is complete

  • Relevant

  • If on paper — clear, legible, black ink

  • Corrected properly

  • Data, time, signature