A reasoning process used to reflect on and analyze thoughts, actions, and knowledge Requires a desire to grow intellectually Requires the use of nursing process to make nursing care decisions Chapter 16 Nursing Assessment Five-Step Nursing Process Nursing Process The nursing process is a variation of scientific reasoning. Practicing the five steps of the nursing process allows you to be organized and to conduct your practice in a systematic way. You learn to make inferences about the meaning of a patients response to a health problem or generalize about the patients functional state of health. Through assessment, a pattern begins to form. Case Study Ms. Carla Thompkins is being admitted to the medical- surgical unit as a postop patient. Ms. Thompkins, a 52- year-old schoolteacher, is recovering from a below-the- knee amputation (BKA) secondary to complications of type 2 diabetes. Ms. Thompkins is admitted to the unit not only so her recovery from the BKA may be monitored, but also because Ms. Thompkins is going to receive preliminary occupational and physical therapy to help her adapt to the amputation. Cues and Inferences Comprehensive Assessment Approaches Use of a structured database format, based on an accepted theoretical framework or practice standard Example: Gordons model of functional health patterns Problem-oriented approach Assessment moves from general to specific. Process of Assessment Collect data. Cluster cues, make inferences, and identify patterns and problem areas. Critically anticipate. Be sure to have supporting cues before making an inference. Knowing how to probe and frame questions is a skill that grows with experience. Interview Techniques Open-ended vs. closed-ended questions Back-channeling Probing ------------------------------------------- Because a patients report includes subjective information, validate data from the interview later with objective data. Obtain information (as appropriate) about a patients physical, developmental, emotional, intellectual, social, and spiritual dimensions. Case Study (contd) During the assessment, Ms. Thompkins complains of pain at the incision site. Ms. Thompkins report of pain is an example of what type of data?
Cultural Considerations To conduct an accurate and complete assessment, you need to consider a patients cultural background. When cultural differences exist between you and a patient, respect the unfamiliar and be sensitive to a patients uniqueness. If you are unsure about what a patient is saying, ask for clarification to prevent making the wrong diagnostic conclusion. Nursing Health History Biographical information Patient expectations Reason for seeking health care Present illness or health concerns Health history Family history Environmental history Psychosocial history Spiritual health Review of systems Documentation of findings Next Assessment Steps Physical examination = An investigation of the body to determine its state of health Observation of patient behavior (verbal vs. nonverbal) Diagnostic and laboratory data Interpreting and validating assessment data. Validation of assessment data consists of comparison of data with another source to determine accuracy of the data. Concept Mapping
A visual representation that allows nurses to graphically illustrate the connections between a patients health problems
Allows nurses to obtain a holistic perspective of health care needs
Chapter 17 Nursing Diagnosis Nursing Diagnosis 1. Medical diagnosis Identification of a disease condition based on specific evaluation of signs and symptoms 2. Nursing diagnosis Clinical judgment about the patient in response to an actual or potential health problem 3. Collaborative problem Actual or potential physiological complication that nurses monitor to detect a change in patient status History of Nursing Diagnosis First introduced in 1950 In 1953, Fry proposed the formulation of a nursing diagnosis. In 1973, the first national conference was held. In 1980 and 1995, the American Nurses Association (ANA) included diagnosis as a separate activity in its publication Nursing: a Social Policy Statement. In 1982, NANDA was founded. Case Study John is a first semester nursing student who is particularly interested in the cardiac system and specifically heart disease since his father died of a heart attack at age 48. John decided to go into nursing because of his fathers death, which prompted him to select a career that improves peoples lives. John is studying nursing diagnoses in his nursing fundamentals course and is learning the steps of the nursing diagnostic process. He knows this information will help him care for cardiac patients in the future. Nursing Diagnostic Process Assessment of patients health status: Patient, family, and health care resources constitute database. Nurse clarifies inconsistent or unclear information. Critical thinking guides and directs line of questioning and examination to reveal detailed and relevant database. Validate data with other sources. Are additional data needed? If so, reassess. If not, continue Nursing Diagnostic Process (contd) If no additional data are needed, proceed: Interpret and analyze meaning of data Data clustering Group signs and symptoms. Classify and organize. Look for defining characteristics and related factors. Identify patient needs. Formulate nursing diagnoses and collaborative problems. Data Clustering A data cluster is a set of signs or symptoms gathered during assessment that you group together in a logical way. Data clusters are patterns of data that contain defining characteristicsclinical criteria that are observable and verifiable. Each clinical criterion is an objective or subjective sign, symptom, or risk factor that, when analyzed with other criteria, leads to a diagnostic conclusion. Case Study (contd) Because of Johns interest in cardiac nursing, he is familiar with the clinical criteria for heart disease. Which of the following is an example of a clinical criterion? (Select all that apply.) Hypertension Fatigue Food preference High cholesterol Types of Nursing Diagnoses Actual Nursing Diagnosis Describes human responses to health conditions or life processes Risk Nursing Diagnosis Describes human responses to health conditions/life processes that may develop Health Promotion Nursing Diagnosis A clinical judgment of motivation, desire, and readiness to enhance well-being and actualize human health potential Components of a Nursing Diagnosis Diagnostic Label (NANDA-I) Definition Related Factors/Etiology: Treatment-related Pathophysiological (biological or psychological) Maturational Situational (environmental or personal) PES Format: Problem Etiology Symptoms (or defining characteristics) Case Study (contd) John learns the four types of nursing diagnoses. Which of the following are the four types of nursing diagnoses? (Select all that apply.) Actual diagnoses Risk diagnoses Wellness diagnoses Health promotion diagnoses Disease prevention diagnoses Cultural Relevance of Nursing Diagnoses Consider patients cultural diversity when selecting a nursing diagnosis. Ask questions such as: How has this health problem affected you and your family? What do you believe will help or fix the problem? What worries you most about the problem? Which practices within your culture are important to you? Cultural awareness and sensitivity improve your accuracy in making nursing diagnoses. Case Study (contd) John knows that a ______________ diagnosis is applied to vulnerable populations. Concept Mapping Nursing Diagnosis
A visual representation of a patients nursing diagnoses and their relationships with one another Concept maps promote problem solving and critical thinking skills by organizing complex patient data, analyzing concept relationships, and identifying interventions. Diagnostic Statement Guidelines
1. Identify the patients response, not the medical diagnosis. 2. Identify a NANDA-I diagnostic statement rather than the symptom. 3. Identify a treatable cause or risk factor rather than a clinical sign or chronic problem that is not treatable through nursing intervention. 4. Identify the problem caused by the treatment or diagnostic study rather than the treatment or study itself. 5. Identify the patient response to the equipment rather than the equipment itself. Diagnostic Statement Guidelines (contd)
6. Identify the patients problems rather than your problems with nursing care. 7. Identify the patient problem rather than the nursing intervention. 8. Identify the patient problem rather than the goal of care. 9. Make professional rather than prejudicial judgments. 10. Avoid legally inadvisable statements. 11. Identify the problem and its cause to avoid a circular statement. 12. Identify only one patient problem in the diagnostic statement. Nursing Diagnosis: Application to Care Planning By learning to make accurate nursing diagnoses, your care plan will help communicate the patients health care problems to other professionals. A nursing diagnosis will ensure that you select relevant and appropriate nursing interventions. Chapter 19 Implementing Nursing Care Nursing Intervention A nursing intervention is any treatment based on clinical judgment and knowledge that a nurse performs to enhance patient outcomes. Interventions include direct and indirect care measures aimed at individuals, families, and/or the community. Case Study Miranda is a nursing student who is assigned to Mr. Bagley. Mr. Bagley is a 52 y/o Asian male admitted to the medical-surgical unit for management of tuberculosis. Mr. Bagley travels internationally because of his executive position with a global company and most likely contracted tuberculosis during his travels. Mr. Bagleys current symptoms are shortness of breath, night sweats, muscle pain, fatigue, and a productive cough. Miranda reviews Mr. Bagleys plan of care to determine which interventions are to be implemented first. Critical Thinking in Implementation Review the set of all possible nursing interventions. Review all possible consequences associated with each possible nursing action. Determine the probability of all possible consequences. Make a judgment of the value of that consequence to the patient. Standard Nursing Interventions Clinical practice guidelines and protocols Standing orders NIC interventions ANA Standards of Professional Practice Protocols and Standing Orders Guidelines and Protocols
Standing Orders Systematically developed set of statements that helps nurses, physicians, and other health care providers make decisions about appropriate health care for specific clinical situations A preprinted document containing orders for the conduct of routine therapies, monitoring guidelines, and/or diagnostic procedures for specific patients with identified clinical problems Implementation Process Reassessing the patient Reviewing and revising the existing nursing care plan Organizing resources and care delivery Anticipating and preventing complications Anticipate and Prevent Complications Identify risks to the patient. Adapt interventions to the situation. Evaluate the relative benefit of a treatment vs. the risk. Initiate risk prevention measures. Modification of an Existing Written Care Plan Revise data assessment. Revise the nursing diagnoses. Revise specific interventions. Determine how to evaluate whether you have achieved outcomes. Quick Quiz! 1. Nurse-initiated interventions are A. Determined by state Nurse Practice Acts. B. Supervised by the entire health care team. C. Made in concert with the plan of care initiated by the physician. D. Developed after interventions for the recent medical diagnoses are evaluated. Implementation Skills Cognitive skills Application of critical thinking in the nursing process Interpersonal skills Developing a trusting relationship, expressing a level of caring, and communicating clearly with a patient and his or her family Psychomotor skills Integration of cognitive and motor activities Direct Care vs. Indirect Care Direct Care Indirect Care Treatments performed through interactions with patients
Examples: -Medication administration -Insertion of an intravenous (IV) infusion -Counseling during a time of grief Treatments performed away from the patient but on behalf of the patient or group of patients
-Managing the patients environment (e.g., safety and infection control) -Documentation -Interdisciplinary collaboration Direct Care Activities of Daily Living (ADLs) Instrumental Activities of Daily Living (IADLs) Physical care techniques Lifesaving measures Direct Care (contd) Counseling Teaching Controlling for adverse reactions
Preventive measures Case Study (contd) Mr. Bagleys plan of care calls for oxygen therapy to improve his respiratory status. A preprinted document that contains orders for the conduct of routine therapies, such as oxygen therapy, is referred to as a __________ _____________. Quick Quiz! 2. You are writing a care plan for a newly admitted patient. Which one of these outcome statements is written correctly? A. The patient will eat 80% of all meals. B. The nursing assistant will set the patient up for a bath every day. C. The patient will have improved airway clearance by June 5. D. The patient will identify the need to increase dietary intake of fiber by June 5. Indirect Care Communicating nursing interventions Written or oral Delegating, supervising, and evaluating the work of other health care team members Case Study (contd) Mr. Bagley is placed on Isolation Precautions. Isolation Precautions as a treatment intervention are an example of which type of care? A. Direct B. Indirect C. Prevention D. Safety Achieving Patient Goals Nurses implement care to meet patient goals. At times, multiple interventions may be needed. Priorities help nurses to anticipate and sequence nursing interventions. Patient adherence means that patients and families invest time in carrying out required treatments. Chapter 18 Planning Nursing Care Establishing Priorities Ordering of nursing diagnoses or patient problems uses determinations of urgency and/or importance to establish a preferential order for nursing actions. Helps nurses anticipate and sequence nursing interventions Classification of priorities: HighEmergent Intermediate LowAffect patients future well-being Establishing Priorities (contd) The order of priorities changes as a patients condition changes. Priority setting begins at a holistic level when you identify and prioritize a patients main diagnoses or problems. Patient-centered care requires you to know a patients preferences, values, and expressed needs. Ethical care is a part of priority setting. Priorities in Practice Case Study Fulmala is a first semester nursing student who is assigned to Ms. Nadine Skyfall, a 35 y/o American Indian patient diagnosed with severe anemia secondary to a bleeding peptic ulcer. Ms. Skyfall experiences pain because of the ulcer and weakness and fatigue resulting from the anemia. Fulmala develops Ms. Skyfalls plan of care, which addresses pain, weakness, and fatigue. Fulmala includes nutrition and patient safety as part of the plan of care. Critical Thinking in Setting Goals and Expected Outcomes Goal A broad statement that describes the desired change in a patients condition or behavior An aim, intent, or end Expected outcome Measurable criteria to evaluate goal achievement Goals of Care
Patient-centered goal: A specific and measurable behavior or response that reflects a patients highest possible level of wellness and independence in function Short-term goal: An objective behavior or response expected within hours to a week Long-term goal: An objective behavior or response expected within days, weeks, or months Goals of Care (contd) Always partner with patients when setting their individualized goals. For patients to participate in goal setting, they need to be alert and must have some degree of independence in completing activities of daily living, problem solving, and decision making. Patients need to understand and see the value of nursing therapies, even though they are often totally dependent on you as the nurse. Expected Outcomes An objective criterion for goal achievement A specific, measurable change in a patients status that you expect in response to nursing care Direct nursing care Determine when a specific, patient-centered goal has been met Are written sequentially, with time frames Usually, several are developed for each nursing diagnosis and goal. Nursing Outcomes Classification A nursing-sensitive patient outcome is a measurable patient, family, or community state, behavior, or perception largely influenced by and sensitive to nursing interventions. The Iowa Intervention Project published the Nursing Outcomes Classification (NOC) and linked the outcomes to NANDA International nursing diagnoses. NOC outcomes provide a common nursing language for continuity of care and measuring the success of nursing interventions. Seven Guidelines for Writing Goals Patient centered Singular goal or outcome Observable Measurable Time limited Mutual factors Realistic Quick Quiz! 1. A patient is suffering from shortness of breath. The correct goal statement would be written as A. The patient will be comfortable by the morning. B. The patient will breath unlabored at 14 to 18 breaths per minute by the end of the shift. C. The patient will not complain of breathing problems within the next 8 hours. D. The patient will have a respiratory rate of 14 to 18 breaths per minute. Critical Thinking in Planning Care Nursing interventions are treatments or actions based on clinical judgment and knowledge that nurses perform to meet patient outcomes. Nurses need to: Know the scientific rationale for the intervention Possess the necessary psychomotor and interpersonal skills Be able to function within a setting to use health care resources effectively
Types of Interventions Nurse initiated IndependentActions that a nurse initiates Physician initiated DependentRequire an order from a physician or other health care professional Collaborative InterdependentRequire combined knowledge, skill, and expertise of multiple health care professionals
Clarifying an Order When preparing for physician-initiated or collaborative interventions, do not automatically implement the therapy, but determine whether it is appropriate for the patient. The ability to recognize incorrect therapies is particularly important when administering medications or implementing procedures. Selection of Interventions Six factors to consider: Characteristics of nursing diagnosis Goals and expected outcomes Evidence base for interventions Feasibility of the interventions Acceptability to the patient Nurses competency Nursing Interventions Classification (NIC) The Iowa Intervention Project developed a set of nursing interventions that provides a level of standardization to enhance communication of nursing care across health care settings and to compare outcomes. The NIC model includes three levels: domains, classes, and interventions for ease of use. NIC interventions are linked with NANDA International nursing diagnoses. Systems for Planning Nursing Care Nursing care plan = Nursing diagnoses, goals and expected outcomes, and nursing interventions, and a section for evaluation findings so any nurse is able to quickly identify a patients clinical needs and situation Reduces the risk for incomplete, incorrect, or inaccurate care Changes as the patients problems and status change Interdisciplinary care plan = Contributions from all disciplines involved in patient care. Change of Shift A critical time, when nurses collaborate and share important information that ensures the continuity of care for a patient and prevents errors or delays in providing nursing interventions Change-of-shift report: Communicates information from offgoing to oncoming patient care personnel = Nurse handoff Focus your reports on the nursing care, treatments, and expected outcomes documented in the care plans. Student Care Plans A student care plan Helps you apply knowledge gained from the nursing and medical literature and the classroom to a practice situation Is more elaborate than a care plan used in a hospital or community agency because its purpose is to teach the process of planning care Planning care for patients in community- based settings involves Educating the patient/family about care Guiding them to assume more of the care over time Critical Pathways Critical pathways are patient care plans that provide the multidisciplinary health care team with activities and tasks to be put into practice sequentially. The main purpose of critical pathways is to deliver timely care at each phase of the care process for a specific type of patient. Concept Maps Provide a visually graphic way to show the relationship between patients nursing diagnoses and interventions Group and categorize nursing concepts to give you a holistic view of your patients health care needs and help you make better clinical decisions in planning care Help you learn the interrelationships among nursing diagnoses to create a unique meaning and organization of information Case Study (contd) What are some examples of independent nursing interventions that Fulmala may develop for Ms. Skyfall? (Select all that apply.) A. Medication administration B. Medication teaching C. Patient positioning D. Family teaching Consulting Other Health Care Professionals Planning involves consultation with members of the health care team. Consultation is a process by which you seek the expertise of a specialist such as your nursing instructor, a physician, or a clinical nurse educator to identify ways to handle problems in patient management or in planning and implementation of therapies. Consultation occurs at any step in the nursing process, most often during planning and implementation. When and How to Consult When: The exact problem remains unclear How: Begin with your understanding of the patients clinical problem. Direct the consultation to the right professional. Provide the consultant with relevant information about the problem area: Summary, methods used to date, and outcomes Do not influence consultants. Be available to discuss the consultants findings. Incorporate the suggestions. Case Study (contd) Fumala works with the nutritionist to develop a meal plan for Ms. Skyfall. True or False: Collaborative interventions are therapies that involve multiple health care professionals.