Nursing_Process

Nursing Process Overview

  • Course Info: VNSG 1204 by C. Graves, MSN, RN, CEN.

What is the Nursing Process?

  • Definition: An organized sequence to assess patient needs and how to meet those needs.

    • Also known as clinical pathways.

    • Directs patient care for specific conditions.

    • A method to manage client health problems and organize data.

    • Acts as a blueprint or map for patient care.

Steps to Nursing Process

  • Assessment: Identify patient needs.

  • Analysis: Evaluate data to understand problems.

  • Planning: Develop a care plan with goals.

  • Implementation: Execute the plan of care.

  • Evaluation: Assess effectiveness of the interventions.

Characteristics of Nursing Process

  • Seven distinct characteristics:

    • Within the legal scope of nursing.

    • Based on knowledge and evidence-based practice.

    • Planned and systematic.

    • Client-centered focus.

    • Goal-directed approach.

    • Prioritized based on patient needs.

    • Dynamic, adaptable to the patient's condition.

Role of the LVN

  • Focuses on predictable outcomes and patient data collection.

  • Documents and reports abnormal findings.

  • Collaborates with RNs and follows the established plan of care.

Assessment

  • Objectives:

    • Collect data to determine abnormal functions and risk factors systematically.

    • Organize data into subjective and objective categories.

  • Types of Data:

    • Subjective Data: Patient's symptoms (ex: "I don’t feel good").

    • Objective Data: Observable signs (ex: dark amber urine).

  • Assessment is crucial: it's a foundational nursing skill that enhances expertise.

Where to Collect Data

  • Sources include:

    • Patient assessments.

    • Laboratory results.

    • Diagnostic tests.

    • Family members and caregivers.

Objective Data Examples

  • Patient observations:

    • Well-groomed appearance.

    • Gait abnormalities (ex: dragging right leg).

    • Physical signs (ex: tremors, specific urine characteristics).

Subjective Data Examples

  • Patient complaints:

    • Expressions of discomfort or anxiety about health conditions.

    • Concerns or fears regarding medical procedures.

Conclusions and Judgements

  • Judgments about patient attitudes and states:

    • Emotional states (hostility, anxiety, confusion).

    • Assessments of pain tolerance and potential conditions (ex: headaches, tachycardia).

    • Conclusions drawn from observations (ex: low pain tolerance).

Analyzing Data

  • Problem Analysis:

    • Identify problems by analyzing abnormal findings from assessments.

    • Prioritize problems using Maslow’s Hierarchy of Needs.

Prioritization of Needs

  • Use Maslow's hierarchy to determine immediate needs:

    1. Basic Needs: Such as ineffective breathing patterns.

    2. Safety and Security: Including risks for injury.

    3. Love and Belonging: Focus on social support needs.

    4. Esteem Needs: Address feelings of powerlessness.

    5. Self-Actualization: Considering spiritual and developmental needs.

Planning in Nursing Process

  • Setting Priorities: Establish clear goals and nursing interventions.

  • Goals Must:

    • Be patient-centered and measurable.

    • Include specific outcomes and a time frame.

Goals Definition

  • A goal is a specific, measurable expected outcome based on identified problems.

    • Goals provide direction for both the client and nurse in care planning.

SMART Goals Framework

  1. Specific: Clearly define who, what, where, when, why, and which.

  2. Measurable: Determine how progress will be tracked.

  3. Attainable: Ensure goals are realistic and achievable.

  4. Relevant: Align with the patient's needs and other established goals.

  5. Timely: Set a time limit for goal achievement to instill urgency.

Outcome Statements

  • Structure of an Outcome Statement:

    • Format: Patient behavior + criteria of performance + time frame.

    • Ex: "The patient will have a bowel movement in 2 days."

Outcome Practice Examples

  • Practical application of outcome statements in nursing:

    • Improvement in hydration.

    • Reduction of anxiety levels.

    • Patient education on specific care topics.

Interventions

  • Types of Interventions:

    • Independent: Actions taken by the nurse without a physician's order.

    • Dependent: Actions based on physician orders or protocols.

Implementations

  • Actions required to achieve expected nursing outcomes:

    • Reassessing the client.

    • Documenting interventions and patient responses.

Evaluation Process

  • Assess effectiveness of nursing interventions:

    • Determine if goals were met and discuss next steps if needed.

    • Adjust care plans based on patient responses.

Care Plan Essentials

  • Key Components:

    • Priority problems and admitting diagnoses.

    • Essential assessment findings and lab tests needed.

    • Relevant medication management and required treatments.

    • Setting SMART outcomes with identified nursing interventions.

    • Patient education as a critical aspect of care planning.