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56 Cards in this Set

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Components of the Nursing Process: (Foundation)
*Systematic problem-solving approach toward giving individualized nursing care

*Provides a creative, organized structure and framework for the delivery of nursing care.

*Enables the nurse to:
1. identify a client's health care needs
2. determine priorities
3. establish goals and expected outcomes of care
4. establish and communicate a client centered plan of care
5. provide interventions
6. evaluate effectiveness of care
Components of the Nursing Process:(Foundation)

Characteristics
*Framework for prividing nursing care to indiv., families, and communities

*Orderly and systematic

*It is Interdependent

*It provides specific care for individuals, families & communities

*Client centered, utilizes client's strenghts

*Appropriate for use throughout lifespan

*May be used in all settings
Components of the Nursing Process:(Foundation)
Each Phase of the nursing process interacts with and is influences by other phases.

-example: nurse collects assessment information may implement some aspects of care at the same time

-As the nurse evaluates nusring care, he or she make and implements new plans

-During an emergency, a nurse may carry out all phases of the nursing process,
-- as the client's condition changes, the nurse gathers and incorporates new data into the plan of care
--Whe care is provided, evaluation of the client's responses may indicate a need for imediate revision of the plan or for the identification of new nursing process
Theorectical Foundations
Systems Theory
Problem-Solving Process
Decision-Making Process
Information-Processing Theory
Diagnostic Reasoning Process
Assessment
Systematic collection of subjective and objective data with the goal of amiing a clinical nursing judgment about an individual, family or community

-The nurse systematically analyzes, collects, communicates, organizes and verifies data about a client's present, past or potential problems to develop a complete database

-Date collection must be accurate, appropriate and relevant for the patient's situration, data collection takes place during every nurse-client interaction and from many other available sources.
Assessment is done for the following reasons
*To establish baseline information on the client
*To determine the client's normal function
*To determine the client's risk for dysfunction
*To determine the presence or absence of dysfunction
*To determine the client's strengths
*To provide data for the diagnosis phase
*To develop the nursing pllan of care
*Implement nursing interventions to support the client's adavptive responses
When is Assessment Done
Before development of a plan of care

Before implementation of nursing care

During implementation of nursing care

During evaluation of nursing care
Types of Assessments
Initial Assessment
Focus Assessment
Time Lapsed Reassessment
Emergency Assessment
Initial Assessment
-also known as admission assessment
*performed when client enters a facility
*purpose is to evaluate health status, to identify health patterns that are problemaic
*Establish a comprehensive in-depth database
*RN is responsifle for completing
-if a thoroguh assessment cannot be completed, it is finished at a later time
Focus Assessment
*Collect data about a problem that has already been identified

*Narrow scope and shorter time frame

*Ongoing process; integrated with nursing care
Time Lapsed Reassessment
*Comparison of client's current status to baseline (i.e. initial assessment) obtained previously
*Time-lapse reassessments are performed when substantial periods of time have elapsed between assessments (i.e., perioadic outpatient visits)
Emergency Assessment
Identification of life-threatening situation 9i.e, physiologic, psychological, or emotional crisis)
Assessment Skills (Observation)
-begins the moment the nurse meets the client
-invloves all senses: hearing, smell, touch, vision
Assessment Skills
(Interview)
*Involves effective communication techniques
-facilitators of communication
-barriers to comunication

**Four Phases
-Preparatory: occurs before the nurse meets the client)
-Introductory: orientation phase when the nurse & client meet
-Maintenance: working phase-nurse & client work toward achieving the specific task or goal
-Concluding: termination phase-focus is on reviewing goals or tasks attained and expressing concerns related to this phase to help ensure that the termination will be a positive experience for both participants
Assessment Skills
(Physical examination)
Four techniques:

*Inspection - Visual examination of the client carried out during the interview and subsequent physical examination (i.e., color, shape, symmetry, movement, pulsations)

*Palpation - uses the fingers and palms of the hand to determine the size, shape and configuration of underlying body structures

*Percussion - one or both hands are used to strike the body surface to produce a sound

*Ausculation - listening to body sounds with a stethoscope placed on the body surface to amplify normal and abnormal sounds
Assessment Skills
(Intuition)
Use of linsight, instincts, or clinical experience to make judgements aobut a client care 9i.e., common sense, gut feeling, or a sixtth sense)
Assessment Activities

(Types of Data Collection)
Subjective (covert=non-observable)
-only the patient can provide this information
-It is what the patient tells you and best recorded as direct quotations from the client, such as "Every time I move, I feel nauseated"

Objective (over=observable)
-Measuremnt devices or equipment
-Physical assessment data
--Inpection, palpation, percussion, auscultation
-Laboratory & diagnostic data
Assessment Activities

(Sources of Data Collection)
Primary Source
-client: considered to be the most reliable, unless circumstances sucha as LOC, acute illness, physical or mental condition that alter thinking, judgment or memory.

Secondary Source
-Family, health team members, diagnostic and laboratory tests, written & verbal reports, reviewing literature
Nursing Diagnosis
"clinical judgement about individual, family or community responses to actual or ptential health/life processes that the nurse is licensed and comptetent to treat. It provides the basis for selection of nursing interventions to achieve outcomes for which the nurse is accountable"
Nursing Diagnosis (2)
This is the 2nd phasse of the nursing process that enables the nurse to individualize care for the client.

Includes:
-Analyzing and interpreting the data
-Identifying client needs, strengths, and functional level
-Formulatioon of nursing diagnoses
The Nursing Diagnosis Statement
The etiology of the nursing diagnosis must be within the domain of nursing practice an a condition that responds to nursing interventions

It is not a medical diagnosis

The goal of the diagnosis statement is to diret a plan of care to assist clients and their families to adapt to their illness and to resolve health care problems
Medical Diagnosis vs. Nursing Diagnosis
Nursing diagnosis
-Main focus is on monitoring human responses to actual and potential health problems
-Nurse identifies and validates independently that problem exists and can be treated legally by nursing staff
-Nurse legally initiates action for treatment

Medical Diagnosis:
-Main focus is on monitoring for pathophysiologic response of body organs or systems
-Nurse may identify problem but required to refer to physician for validation that problem exist
-Nurse may not be qualified to diagnose exact nature of problem but refers abnormal data to physician
-Nurse collaborates with physician to initiate interventions for treatments
Components of a Nursing Diagnosis
**Diagnostic label (definition)
-Is the name of the nursing diagnosis as listed in the taxonomy. It describes the essence of the problem. i.e. Anxiety, Caregiver Role strain

**Descriptors (Defining Characteristics)
-words used to give additonal meaning to a nursing diagnosis. They describe changes in condition, state of the client. i.e., Delayed: to postpone , impede and retard.

**Related Factors (Etiology)
-describes the conditions, circumstances, or etiologies that contribute to the problem. Terms that can be used are associated with, relatted to, contributing to used are associated with, related to, contributing to. i.e,, caregive role strain, increase, related to

**Risk Factors
-environmental factors and physiological, psychological, genetic, or chemical elements that increase the vulnerability of an individual, family or community to an unhealthful event. i.e., caregiver role strain, increased, relatio to discharge of family member w/ significant healthcare needs, economic instability, lack of respite care availablitility
Types of Nursing Diagnosis

(Actual Nursing diagnosis)
Describres a human respon to a health problem that is being manifested.


3 Part Statement
-diagnostic label
-related factors
-defining characteristics
Types of Nursing Diagnosis

(Risk Nursing Diagnosis)
Describes human responses to health conditions/life processes tht may develop in a vulnerable individual, or community

2 Part statement
-diagnostic label
-risk factors that contribute to increased vulnerability
-
Types of Nursing Diagnosis

(Wellness nursing diagnosis)
Diagnostic statement that describes the human responses to levels of wellness.

1 Part Statement
-diagnostic label
Types of Nursing Diagnosis

(Possible nursing diagnosis)
Made when not enough evidence supports the presence of the problem

2 Part Statement
-Diagnositc label
-Related factors (unknown)
Outcome Identification
Refers to formulating and documenting measurable, realistic, client-focused, goals and expected outcomes and nursing interventions are selected to achieve the goals and outcomes of care
Outcome Identification seves the following purposes
-providing individualized care
-promoting client participation
-planning care that is realisic and measurable
-allowing for involvement of support
-establish priorities
-establish client goals and outcome criteria
Outcome Identification Activities

(Establish Priorities)
Priority selection is the method the nurse and client use to mutually rank th diagnoses in order of importance based on the client's desires, needs and safety

*priorities are classified as high, intermediate or low
Outcome Identification Activities

High Priority
-life threatening situations
-something needing immediate attention
-something of great importance to the client
Outcome Identification Activities

Medium Priority
-problems that might result in unhealthy consequences but are not life threatening i.e. dysfunctional grieving fatigue, stress incontinence
Outcome Identification Activities

Low Priority
-problems that can be resolved easily with minimal intervention

-problems that have little potential to cause significant dysfunction ie. washing a client's hair to promote self esteem
Client Outcome & Outcome Criteria
- a client outcome is an eduated guesss, about what the client's state will be after the nursing intervention is carried out

-outcomes may be short term or long term
-

-goals need to be revised if the client's situation or medial conditon changes

-outcome criteria are specific, measurable, realistic statements of goal attainment

-Outcome criteria answer the questions who, what actions, under what circumstances, how well and when.
Planning
The nursing plan of care is a written summary of the care that a client is to receive and JCAHO requires a written plan of care for each client

-A plan of care is developed to direct nursing care activities related to the person for whom the goals and outcome criteria were developed
Purposes of planning include the following
-direct client care activities
-promote continuity of care
-focus charting requirements
-allow for delegation of specific activities
-writing the plan of care on the client record formally recognizes what the nurse planned and accomplished to assist the client
-the plan of care remains a permanent part of the record, and once the plan of care is written, it must ve implemented on the client's behalf
Planning nursing interventions
-actions designed to assist the client in moving from the present level of health to that which is describled in the goal and measured in the outcome
-the plan of care ususally contains three key elements: the nursing diagnosis, client goals, nursing interventions
-To initiate the intervention the nurse must be competent: know scientific rationale, possess the phychomotor and interpersonal skills, and be able to function in a particualr setting
Implementation
*Category of nursing behaviors in which actions necessary for achieving the goals and expected outcomes of nursing care are initiated and completed.
-nursing actions are goal-directed, assisting the lcient to reach maximun functional health

*Includes intervention for assisting, directing, or performamce of activities of daily living, counseling and teaching the client or family.
Implementation Includes
-providing direct care to achieve cleint centered goals
-delegating, supervising and evaluating work of others
-recording and exchanging information relevant to the clients condition
-any action taken by the nurse that helps the client move toward an expected outcome
Implementation skills
*Intellectual skills
- problem soving, decision making, and teaching

*Interpersonal skills
- communication skills - verbal/nonverbal

*Techinical Skills
-used to carry out treatments and procedures, being able to use equipment, machines, and supplies
Implementation Activities
*Reassessment
*Set priorities
-the client's condition
-new information from reassessment
-time and resources available for nursing interventions
-the nurse's experience in assessing situations and setting priorities
*Performing nursing interventions
*Evaluation of the response
*Recording of Action taken
-client's health record
Implementation Types
Dependent
-requires a physician order

Independent
-autonomous action

Protocols
-written plan specifying the procedure to be followed with a specific clinical situation

Standing order
-guideline for conduct of routine therapies for clients wih specified conditions
Implementation of Nursing Intervention
*Nurse initiated:
-Independent response of the nurse
-autonomous actions based on scientific rationale
-Executed to benefit the client in a predicted way related to the nursing diganosis and goals
-require no supervision from others
-require no physician order
Cognitive Interventions
Education (demonstrating, teaching, observing returen demonstrations)

Supervisory (overseeing a client's overall care)

**RN cannot delegate "nursing activities that include the core of the nursing process
Interpersonal Interventions
Coordinating (Involves acting as a client advocate, making referrals for folloup care, collaborating with other healthcare team members)

Psychosocial Interventions (focus on resolving emotional, psychological or social problems)

Supportive (communication skills, relief of spiritual distress, and caring behaviors)
Technical Interventions
Maintence (retain a certain state of health, preventing deterioration of physical or psychological functiong and preserving independence)

Psychomotor (technical expertise - inserting, removing , changing, applying, administering, cleansing, or activity that requires a pyschomotor action)

Surveillance (detrecting changes from baseline data and recognizing abnormal responses)
Physician Initiated Intervention
Based on physician's response to a medical diagnosis

Nurse carries out doctor's orders

Require specific nursing responsibilites and knowledge

Collaborative
-require knowledge, skill and expertise of multiple health care professionals
Evaluation
Step in the nursing process that measures the client's response to nursing actions and the client's progress toward achieving goals

-although evaluation is a separate and distince phase, it also ia n ongoing and continuous process performed throughtout all p hases of the nursing process

Evaluate the goals after comparing evaluative finding with all expected outcomes
Types of Evaluation
Structure Evaluation

Process Evaluation

Outcome Evaluation
Structue Evaluation
Focuses on the atttrivutes of the setting or surrounding where healthcare is provided
Process Evaluation
Focuses on the nurses' performance and whether the nursing care provided was appropriate and competent
Outcome Evaluation
Determins the extent to which the client's behavioral response to nursing interventions reflects the desired client goal and outcoem criteria i.e standards of care
Types of Interventions
Cognitive, Interpersonal, Technical, Physician Initiated
Purposes for carrying out Evaluation
-To examine the client's behavioral resonses to nursing interventions

-Compare establish outcome criteria with behavior or responses

-To approaise the extent to which client goals were attained or problems resolved

-To appraise involvement and collaboration of the lcient, family members, nurses and healthcare team

-To monitor quality of nursing care and its effect on the client's health status
Evaluation Activities
-Review client goals and outcome criteria
-Collect Dats (subjective and objective)
-Measure Goal/Oucome Achievement (state if goal was completely met, partially met or completely unment)
-Record jusgment or measurement of goal attainment
-Revise or modify the nursing plan of care
Evaluation Skills
-Knowlege of standard of care
-Knowledge of normal client responses (ie. obtained through basic nursing education, standards of care)
-Knowledge of conceptual models and theories
-The ability to monitor the effectiveness of nursing interventions (ie. intervieng techniques and physical assessment skills)
-Awareness of clinical research