Nursing Process

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Mr R. is a 72-year-old man who suffered a "stroke" at home two days ago. He was admitted to your unit from the emergency room after being discovered at home today by his daughter. His condition is stable but he has very limited movement in his extremities. He shows evidence of dehydration: decreased skin turgor, dry lips and mucous membranes, low urinary output. Height: 5" 10" Weight: 138 lbs He is on bedrest and IV fluids.

PA Nurse Practice Act and ANA defines nursing as the diagnosis and treatment of human responses to actual and potential health problems Nursing Process
5 steps

4 steps Assess Diagnose Plan Implement Evaluate

Assess
o

diagn

ose Plan Implement Evaluate

Step 1 Assessment

Initial step ongoing/ component of every step Collect data

Validate Communicate

Types of data

Subjective Objective

Subjective

"symptom" information apparent only to person experiencing it cannot be validated by someone else for example includes pts perception of his situation-human response Objective "sign" can be observed - seen, heard, felt smelled can compare to some standard e.g. increased temp pulse rate environment BUT. due to anxiety etc.

Sources of data

Primary o always the patient Secondary o family, S/O other health care personnel, medical records, lab reports, literature

For Mr. R: Subjective data primary secondary Objective data primary secondary

Data
should describe, not interpret be relevant Data collection should involve active participation by client (individual, family or community) and nurse

How do I get these data? Go through the process of assessment

Assessment

Initial assessment is the basis for the nursing care plan Include actual and potential health problems

Establish a data base 1. 2. 3. 4. nursing history physical examination review records and literature consultation

1. Components on Nursing History Biographical information reasons for seeking health care present illness, health concern (HPI) past health history (PMH) family history (genogram) environmental history psychosocial/cultural history review of systems (ROS) Most institutions have a nursing history or nursing admission form There is some organizing framework include pts perception of current health status and its meaning to pt and others

Use communication techniques to conduct interview, obtain nursing health history Examples Does the pt have the right to refuse to answer questions? Maintain cofidentiality 2. Physical Examination Explain get permission assure privacy

Height, weight, vital signs General survey - mental status - development

- nutritional status - gender, race - appearance - speech Systematic head-to-toe exam Diagnostic and laboratory data Techniques of Physical Assessment

Inspection Palpation Percussion Auscultation

And then remember the Dick-and-Jane books and the first word you learned - the biggest word of all -

Look
Inspection deliberate visual exam Palpation gather data with hands via sense of touch feel skin and underlying tissue to detect/describe: temp, texture, vibration, pulsation mass,size, consistency, tenderness Percussion tap body surfaces to produce vibration and sound Auscultation listen to sounds produced by body heart, lung , bowel sounds, BP

Validate data
support your findings integrate data from multiple sources review omissions check for inconsistencies

consult

OK - what is relevant, significant, meaningful??? Interpret/analyze/cluster data

look for patterns or cues

Pattern recognition is a characteristic of critical thinking! Organize/cluster data by:

Body systems Functional health patterns Nursing model

Problem List
Interpret Make judgment about meaning of data Do pt needs require nursing intervention List problems in your own words

Assessment Conclusions
1. No problem evident (WNL) - address risk factors - consider pt strengths and resources - possible health promotion activities 2. Collaborative problem - consult, refer 3. Problem which requires nursing intervention - problem list - Nursing Diagnosis >> actual, potential

Nursing Diagnosis
A statement that describes actual or potential health problems that can be prevented or resolved by independent nursing intervention

NANDA Definition: Nursing diagnosis is a clinical judgment about individual, family, or community responses to actual and potential health problems/life processes. Nursing diagnoses provide the basis for selection of nursing interventions to achieve outcomes for which the nurse is accountable. Form for writing Nursing Diagnosis P - problem diagnostic statement (NANDA) E - etiology/related to cause or contributing factor Characteristics of a Diagnostic Statement is clear and concise is specific and patient centered relates to one pt problem is accurate is based on reliable and relevant assessment data P: pain E: surgical trauma P: altered nutrition, less than body req. E: lack of knowledge of calorie content, lack of exercise P: high risk for injury E: effects of narcotics, weakness 20 bedrest

P: Problem statement (NANDA)

Goal Statement

E: Etiology/causative factors
Nursing actions P/Problem statement

identifies unhealthy response indicates what should change suggests pt goals (expectations for change)

E/Etiology

identifies causative or contributing factors

suggests nursing interventions

Let's develop some diagnostic statements for Mr. R.

Planning

Patient-centered goals are established Strategies are designed to meet goals

1. Set priorities 2. Determine goals 3. Develop expected outcomes 4. Design nursing interventions 5. Write Nursing Care Plan 6. Record and modify Write Goals Expected Outcomes Nursing orders (i.e. develop the nursing care plan) Goals could be considered Long Term Expected Outcomes " Short Term Nursing diagnosis guides the type of goal oriented toward: health restoration health maintenance health promotion Nursing care plan written guideline for client care coordinates/communicates care promotes continuity lists outcomes/criteria to be evaluated Nursing care plans vary depending on pt population, setting Institutional care plans may be

3 column: Problem Goal Nursing action

4 column: NDx Goal Nursing Eval action

5 column: Assessment NDx Goal Nursing Eval action

Standardized care plans include generalized NDx Goals Nursing actions Eval/Outcome criteria

Student care plans include NDx Goals Nursing actions Scientific Rationale Eval

Goals/Expected outcomes Anticipated patient responses specific statements of pt behavior or response that nurse anticipates from nursing care formulated for each diagnosis Tips for writing goals Write a goal for each nsg dx Write step-by-step expected outcomes for each goal helps to:

guide nursing actions evaluate goal achievement

Guidelines for writing goals and Expected Outcomes Client-centered singular observable measurable time-limited mutual realistic Formula for Writing Goals/Outcomes Goal statement (long or short term) = patient behavior + criteria + time + conditions (if needed) 1. Subject - patient 2. Verb - action/behavior which pt performs 3. Criteria - acceptable performance How well How far How long How much 4. Within specified time period 5. Condition (if needed) circumstances under which behavior performed Example: The patient (1) will walk (2) the length of the hall (3) with a walker (5) by the end of the shift (4). P: high risk for impaired skin integrity E: immobility, dehydration Goal: TPW maintain intact skin. P: high risk for impaired skin integrity E: immobility, dehydration Goal: TPW maintain intact skin. Expected Outcomes: The pt will 1. change position every 2 hours 2. avoid pressure on bony prominences 3. maintain clean, well-hydrated skin 4. Drink 1000 cc liquid/24 hours

7 - 3 500 cc 3 - 11 400 cc 11- 7 100 cc Nursing orders May be called Implementation or Intervention Actions designed to help pt achieve established goals Developed according to standard of care Examine alternative possible strategies Choose based on assessment and REASON for action Scientific Rationale Explains WHY the nurse planned that action to help pt achieve goal researched data obtained from texts, journals, etc. Appears on student care plans, not in "real life" SAMPLE Mouth Care for the Unconscious Patient Nursing Orders 1. Assess for gag reflex. 2. Cleanse mouth with H2O2 2. Dilute solution of H2O2 (1:1) hydrogen peroxide acts 3. Apply thin layer of petroleum as an antiinfective and loosens debris. (Perry, 1996, p.77) jelly to lips. 3. Lubricates lips to prevent drying and cracking.(Taylor & Perry, 1998, p. 348) Implementation Continue to assess pt Modify care plan Implement nursing orders Communicate nursing interventions Evaluation Compare ongoing assessment data with expected outcomes Scientific Rationale 1. Intact gag reflex prevents aspiration. (Potter, 1999, p.121)

1. Were goals, expected outcomes met 2. Did pt exhibit expected physiological response or behaviors And 3. Quality assurance - evaluation of nursing and health care services based on legal guidelines and professional standards Sample: Evaluation of Goal Achievement Goal Client Response Evaluation Pt administered Pt will self-administer Pt will demo selfaccurate dosage Goal was met. insulin by 9/23. injection by 9/23. correctly on 9/23. Pt will be able to Pt reports R-sided Pt will verbalize pain perform ADLs w/o abdominal pain at of 3 on 10-point scale Goal not met. discomfort in 3 days 5/10 while bathing on within 3 days (9/22). (9/22). 9/22. Mr R. is a 72-year-old man who suffered a "stroke" at home two days ago. He was admitted to your unit from the emergency room after being discovered at home today by his daughter. His condition is stable but he has very limited movement in his extremities. He shows evidence of dehydration: decreased skin turgor, dry lips and mucous membranes, low urinary output. Height: 5" 10" Weight: 138 lbs He is on bedrest and IV fluids. ExpOut

P: high risk for impaired skin integrity E: immobility, dehydration Goal: TPW maintain intact skin. Expected Outcomes: The pt will 1. change position every 2 hours 2. avoid pressure on bony prominences 3. maintain clean, well-hydrated skin 4. Drink 1000 cc liquid/24 hours 7 - 3 500 cc 3 - 11 400 cc

11- 7 100 cc Nursing Orders 1.TNW 2. 3. 4.