nursing Process

Page 1

Nursing process 5 steps, 5 characteristics

- Assessment, diagnosis, planning, implementation, evaluation (potter 201)

- universally applicable, outcome oriented, interpersonal/patient-centered, systematic, dynamic

The work of nursing: independent discipline, care delivered is unique, Nurses have universal problem solving and collaborating method (A.P.I.E. in '67, Nursing Process '73)

Nursing process: a systematic, client-centered, critical thinking, goal oriented model of delivering care

- benefits collaboration, enhanced client outcomes, patient- centered care

- organizes data

- formal statement of strategies

- efficient

- aids in the delivery of care that is: Holistic, goal oriented, individualized

Nursing process and critical thinking

- used thru out

- analyze data and cues

- identifies patterns

- adapts textbook knowledge

- requires some underlying skills (inference, evaluation, self-reflection, curiosity and perseverance

levels of critical thinking

- basic: counts on experts to know right answers

- complex: begin to separate themselves from the experts

- commitment: anticipate when to make choices without assistance

= be inquisitive and persistent

= develop confidence in your abilities

= learn through self reflection

= think independently

= be open minded

= take time to explore

= be creative

Page 2

Obstacles of critical thinking

- making assumptions

- personal biases

- habits and routines

- anxiety

- pressure and deadlines

- lack of confidence

- pride

Nursing assessment

- determine immediate needs and priorities

- identify strengths for solving problems

- focus on specific problem

- identify risks for complications

- recognize complications

- establish a database

Medical vs nursing assessment

- holistic picture vs. one diagnosis/problem

-Types

- initial: all meds, all Hx,

- focused: just one section

- emergency: prioritize in a case of emergency

- time-lapsed (ongoing): same tests over and over again. after surgeries especially.

Subjective data

- what the patient tells you

- uses patients own words

- "I feel dizzy"

Objective data

- observable and measurable

- verifiable by another person

- specific and non-judgmental (no terms like good normal average small large)

- ex: vomited 150 cc of undigested food 1/2 hour after breakfast

data characteristics:

-purposeful

-complete as possible

-factual and accurate

-relevant

Sources:

- client and family

- medical records

- colleagues/ health care team

- team meetings

- physician and nurse

- shift report

- nursing and other literature

assessment skills

- therapeutic communication

- cultural competence

- trust

- strong physical assessment skills

data collection

- Hx

- physical assessment

- data validation

- are subjective and objective data adhesive? does it make sense? does it connect?

- data communication

additional data

- knowledge base

- perception of health and illness

- family and psychosis Hx

- expectations of providers

- problem solving skills

Gordon's functional health patters

- organizes data into 11 functional health patters

- identifies nursing diagnoses

- unique to nursing

Cognitive/perceptual patter

- sensation perception and understanding; pain assessment

activity and exercise

- clients ability to be active

- many systems affect this including heart, lungs, muscles, bones, joints.

- endurance and pain, how much weight are they able to bear

nutritional and metabolic

- general appearance, well nourished, well developed, obese or too thin

- usual diet and fluid intake

- oral and dental condition

- hydration markers

- disease that affect dietary intake or swallowing

Elimination

- bowel and bladder habits

- usual habits or unusual occurrences

- related to nutritional metabolic pattern, GI, kidneys and bladder function.

Sleep and rest pattern

- needs for individuals vary

- problems with inadequate rest and sleep lead to other emotional and physical problems

sexuality/ reproductive pattern

- often confused with sex

- present from birth to death, caries by age, culture, beliefs, health, life circumstances, and social norms

- important to self esteem and role function

values/beliefs pattern

- philosophical position guides choices or decisions

- influences health perception and practices

- spirituality is an important component of this pattern

Health perception/ maintenance

- personal view of health and quest to be healthy

- focuses on health behaviors and risk factors

coping and stress

- stress is everyday occurrence

- high stress levels can cause problems

- persistent stress levels can cause problems

- coping is a learned skill

- support offers a way of coping

self perception

- assess thru active listening and observations

- tell me about yourself

- how do you feel about being in the hospital? about your illness?

- listen for negative self talk, lack of confidence

role/relationship

- roles are the parts played in one's life

- how we relate to others

- isolation, loneliness, abuse

Assessment is the deliberate and systematic collection of information about a patient to determine the patient's current and past health and functional status and his or her present and past coping patterns The purpose is to gather information for health problem identification

diagnostic process Mental steps (data clustering and analysis, problem identification) that follow assessment and lead directly to the formulation of a diagnosis.

planning Process of designing interventions to achieve the goals and outcomes of health care delivery.

implementation Initiation and completion of the nursing actions necessary to help the patient achieve health care goals

evaluation Determination of the extent to which established patient goals have been achieved

A ____[answer]__ is the identification of a disease condition based upon medical history and the results of diagnostic tests and procedures