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What is a process?
It is a series of steps or components leading to achievement of a goal.
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Characteristics of a process:
- Purpose
- Organization
- Creativity
- Interaction
- Scientific
- Tools
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A process is a continuous progression from one point to another to ahcieve a specific goal.
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A system is made of separate parts or elements. The parts rely on one another and are interrelated have a common purpose and together form a whole.
Systems Theory
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A system has a specific goal.
The content is the product and info obtained from the system.
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3 Components of a System:
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Which type of system:
Interacts with it's environment
Exchange of info between the system and the environment
Open system
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Which type of system:
Does not interact with the environment
No exchange of info
Closed system
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Nursing Process as a system:
- Purpose - provide systematic, individualized and appropriate care to client
- Process - 5 components of the Nursing Process
- Content - Info is obtained and used from each component
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The Nursing Process is a ___ system.
Open.
Because it interacts with it's environment continually changing as the client's needs change.
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Nursing Process as a system:
- Input - assessment and from nursing interventions
- Output - evaluation component
- Feedback - evaluation component returned and reassessment occurs on basis of client's health care needs.
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Theoretical approach to the Nursing Process:
Problem solving method
- Foundation for the nursing process
- A specific method for obtaining a solution to a problem
- Is a 6 step process
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6 Step Problem Solving Method:
- 1.) Encountering a problem
- 2.) Collecting data
- 3.) Identifying exact nature of the problem
- 4.) Determining a plan of action
- 5.) Carrying out the plan
- 6.) Evaluating the plan and the new situation
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What does the Nursing Process provide us with?
- Organized framework
- Goal
- Tool
- Independent nursing action
- Promotion
- Focus
- Creativity
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A method for organizing and delivering nursing care.
Provides the organizational structure and framework for nursing care, yet it is creative and flexible enough to be used in a variety of settings.
Nursing Process
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Is an organized systematic method of giving individualized nursing care that focuses upon identifying and treating unique responses of individuals or groups to actual or potential alteration in health.
Nursing Process
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Purpose of the Nursing Process:
- Identifies problems
- Establishes line of communication and establishes a database
- Delivers method to give nursing care and provides continuity of nursing care
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The Nursing Process organization has 5 components that are interrelated.
*These 5 components are:
- 1.) Assessment
- 2.) Nursing diagnosis
- 3.) Planning
- 4.) Implementation
- 5.) Evaluation
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Purpose:
To gather, verify and communicate data.
Establish the data base
Assessment
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Steps:
Collecting nursing health history
Perform physical exam
Collect lab data
Assessment
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Purpose:
To identify health care problems and needs of the client.
To formulate nursing diagnostic statement.
Nursing diagnosis
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Steps:
Interpret, cluster and validate data
Formulate nursing diagnostic statement
Nursing Diagnosis
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Purpose:
Identify client goals
Determine priorities
Design nursing strategies
Determine outcome criteria
Planning
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Steps:
Identify client goals
Select nursing actions
Delegate actions
Consult
Write NCP (nursing care plan)
Planning
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Purpose:
Complete nursing actions necessary for accomplishing plan
Implementation
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Steps:
Perform nursing actions
Reassess
Review and modify existing care plan
Implementation
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Purpose:
Determine the extent to which goal of care has been accomplished
Evaluation
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Steps:
Evaluate according to the established evaluation criteria
Compare client response to criteria
Analyze reasons for results and conclusions
Evaluation
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Goals of Nursing:
- Promote, maintain or restore health
- Enable individuals to manage their own health
- Provide nursing care
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History of Nursing Process:
- Introduced in 1950, was a 3 step process:
- assessment
- planning
- evaluation
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History of Nursing Process:
- 1976 - 5 step process
- Classification of nursing diagnoses
- Advanced the profession
- Focus of nursing care is established through the nursing care plan
- Specific nursing responsibility defined
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Nursing autonomy and accountability are enhanced through the identification of health care problems within the domain of nursing practice.
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Assessment
Data collection and Data organization
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What the client actually SAYS
May not be validated
May not be factual
Subjective Data
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Based on what you see, hear, smell and feel.
Objective Data
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Initial assessment
Includes objective and subjective data
- Screening Assessment
- Baseline assessment
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Assessment on a specific area
Focused assessment
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Subjective statements and objective data
Family
Something you see or hear
Cues
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Always subjective
Influenced by nurses knowledge
Inferences
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Assessment is an on-going continuous process it occurs throughout each phase of the nursing process.
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Data Organization:
Analysis:
- Maslow's Heirarchy
- Nursing Diagnosis
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Nursing Diagnosis
States the actual or possible problems.
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Three Steps in the area:
- 1.) Analysis
- 2.) Identification (actual or risk diagnosis)
- 3.) Statements
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Problems identified are those the nurse is licensed and competent to treat.
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Identification of a disease based on physical signs, symptoms, history, lab tests and procedures.
Medical diagnosis
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Derived from the physiological psychological sociocultural developmental and spiritual dimensions.
Medical diagnosis
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Goals are to identify and cure the disease.
The focus is curative.
Medical diagnosis
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Identifies health are needs.
Present level of health
Response to a disease
Nursing diagnosis
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Goals and objectives are to identify health problems and develop a plan of care.
Focus is to help the client reach a maximal level of wellness.
Nursing diagnosis
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Advantage of Nursing Diagnosis:
- Facilitates communication
- Focus for quality assurance and peer review.
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Limitation of Nursing Diagnosis:
Incomplete Taxonomy
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NANDA (North American Nursing Dx Associates) does what:
Approve nursing diagnosis
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Statement of actual or possible problem that requires nursing intervention to resolve or less or prevent.
Nursing diagnosis
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PES format includes:
- Problem
- Etiology
- Signs and symptoms
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Ask yourself three questions when making a nursing diagnosis:
- What is the problem?
- What is causing the problem?
- How do you know the problem exists?
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Problem = nursing diagnosis
Etiology = what is causing the problem?
Signs & Symptoms = always supports the nursing diagnosis it NEVER supports the etiology
Avoid using medical diagnosis as etiology.
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Do not use for a newly diagnosed paraplegic
no: impaired walking
yes: impaired mobility
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Nursing diagnosis should be simple, brie, specific and based on collected data.
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Nursing diagnosis statement:
- Actual problem
- related to
- Contributing Factors (etiology)
- as shown by
- Defining characteristics
- as manifested by
Do not say "due to"
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May use "of unknown etiology"
Acute pain of unknown etiology...
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Example
Impaired walking (nursing diagnosis
Related to post op status (etiology)
As shown by requiring physical support during ambulation (signs and symptoms)
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Example:
Acute pain related to fractures, trauma and immobility as manifested by client reporting pain of 6 on a pain scale. BP 120/76, P 100, R 30 & moaning.
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Basic needs
Psychological and Physiological
HIGH priority
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Intermediate and Non life threatening
Medium priority
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Not directly related to specific illness or disease process
Low priority
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Acute pain related to surgical incision as manifested by client stating the incision hurts.
- Etiology? surgical incision
- Problem? acute pain
- Supporting evidence? client states incision hurts
- Priority? 1 week - medium; 6 hr post op - high
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Two part statement
Risk of problem developing and probable cause or etiology
There are NO signs and symptoms!
Risk diagnosis
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Incorrect statements of the nursing diagnosis:
- Nursing diagnosis stated as a medical diagnosis - such as an MI
- Use of medical terminology to describe the cause (decrease cardiac output r/t MI)
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Common Errors in writing nursing diagnosis:
- Statement may legally inadvisable and may show implications of blame
- Problem and etiology say the same thing
- Environmental problems are put into the problem statement
- Identified problem is not necessarily unhealthy
- Identified problem cannot be changed
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Common errors:
- Omission
- Incomplete data
- Incorrect clustering
- Incorrect interpretation
- Commission
- Diagnosing of non existent problems
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Goals to lessen, prevent or resolve the problem
A category to develop nursing behaviors/nursing interventions
3rd step in nursing process.
Planning
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In planning:
- Goals are determined
- Priorities are established
- Outcomes -something that the client can accomplish that you can measure
- Nursing care plan
- Consulting
- Modifiying care
- Documentation - document what the outcomes and interventions are
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Goals must be specific to patient.
- Goals must be important to client.
- What is important to them may not be important to you.
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Nursing care plan:
- Problems
- Goals for every problem
- Nursing actions for every goal
- Projected outcomes
- Evaluation - how do you know you have accomplished the goal
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Purpose of nursing care plan:
- Documentation - of what is impt to the client
- Coordination of care
- Promotion of health and wellness
- Criteria for evaluation
- Communication
- Lower risk of inaccurate care
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Nursing care plans also:
- Identify problems
- Cost effective (may decrease length of hospital stay)
- Organization of information
- Discharge planning
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3 types of Nursing Care Plans:
- Institutional
- Standardized
- Student
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Institutionalized care plan:
Everyone is treated the same, similar medical problems
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Standardized care plan:
Associated with specific medical disease (ex: MI has same basic needs)
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Student care plan:
More specific to the patient, includes all of the patient's problems.
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Planning Defined:
- Setting Priorities
- Writing goals/objective/outcomes
- Planning nursing actions must be specific to goals/objectives.
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Determining goals:
- Achievement of maximal level of wellness
- Involve client, family, SO
- (ex: wife will learn how to prepare low fat meals)
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Projected outcomes of planning:
- Determination if goal has been met or not
- Measurable behaviors
- Criteria used for evaluation
- Realistic
- Time frame
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Components of Goal Statement:
- Subject/Noun (who)
- Verb (will do)
- Criteria/Task (what)
- Condition (when)
Who will do what when?
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Intellectual knowledge
Cognitive domain
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Client will verbalize understanding of decreased caloric intake.
Cognitive domain
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Manipulation and motor skills
Psychomotor domain
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Client will walk 10 feet without assistance.
Psychomotor domain
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Value, judgements, and emotion.
Affective domain
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Client will express feelings about lonliness.
Affective domain
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Pain at cellular level; pain at incision site
Psychomotor domain
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Pain due to grief or emotions
Affective domain
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Objective/Goal states:
- What the client will accomplish
- Outcome criteria
- Realistic time frame to accomplish the objective
- Realist for the nurse's level of skill
- Congruent with and supportive of medical regime
- Important and valued b the client, nurses and physicians.
- Must be written behaviorally.
- (client will do something specific themselves: state something, perform a task)
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3 Goals/Objective Categories:
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Prevents problem from occurring
Prevention
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Prevents the problem
Rehab
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Teaches the patient about the problem.
Education
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Nursing diagnosis:
Impaired skin integrity related to prolonged bed rest and immobility as evident by a 3 x 2stage II decub ulcer on right buttocks.
HIGH priority
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Planning:
The client's decubitus ulcer on right buttock will decrease to 2 cm x 1 cm by 2/28/2012.
- psychomotor (cellular level)
- rehab
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The client will understand the importance of repositioning self to prevent further skin breakdown by 2/28/2012 as evident by verbalization
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Client's decubitus ulcer on right buttocks will be completely healed as evidenced by no redness, drainage or bread in epidermal layer by 2/28/2012
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Client will experience no additional skin break down by 2/28/12
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Evaluation Outcome Criteria (EOC):
When you have a BROAD goal statement EOC's may be needed for measurement.
Example:
Client will experience decreased pain experience by 2/28/12 as evidence by:
1. Decreased requests for pain med, requests for pain med at 8 hour intervals instead of 6 hour intervals.
2. Correct use of muscle relaxation techniques
3. Verbalization of decreased pain on a pain scale of 1-10 with 10 being the most severe pain.
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Client will perform quad exercises every 1 hour while awake.
Correct
- psychomotor
- rehab/prevention
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Client will appreciate the need to ambulate.
- Incorrect
Client will verbalize the need to ambulate.
- affective
- education/prevention/rehab
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Mother will be instructed on proper infant care.
Incorrect this is an nursing intervention.
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Wife will list 10 foods high in Na by the end of the week.
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Weight reduction group will attend classes weekly.
Correct
- psychomotor
- education/rehab/prevention
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Client will understand major purpose of his meds 2 days prior to expected discharge by 2/28/12
- Incorrect, you cannot measure "understand"
- Client will verbalize, instead.
Cognitive
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Client will ambulate by 2/28/12.
Correct.
psychomotor
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Client will write his menu for a week by 2/28/12
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Common Mistakes in writing Goals/Objectives:
- Written in terms of nursing actions rather than client actions.
- Cannot be observed or measured through one of the senses.
- Task not specific to the individual client.
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Improve & more specific goal statements:
Client will state 1 major purpose for each of his four meds 2 days prior to expected discharge of 2/28/12
Client will walk without assistance from this room to the nurses station by 2/28/12
Client will select one food from each of the four basic food groups for his dinner by 2/28/12
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Planning nursing actions:
Nursing strategies are developed to achieve a client goal.
- Based upon client center goals
- Determine priorities
- Specify nursing actions
- Use collaborative approach
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