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Steps of the Nursing Process
- Steps of the Nursing Process
- Assessment
- Diagnosis
- Outcome Identification
- & Planning-goals you wish patient to achieve, must be mutual
- Implementing-do it!
- Evaluating-were goals met
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Characteristics of the Nursing Process
- Systematic-assess before you identify a problem
- Dynamic-open to change at any given time
- Interpersonal-must communicate
- Outcome oriented-help patient achieve goals, good health and higher level of functioning
- Universal
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Nursing Process - Purpose
- Helps the nurse manage each client’s care
- ¡ Holistically
- ¡ Scientifically
- ¡ Creatively
Focus is on the human response!
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Problem Solving and the Nursing Process
- Trial and Error: tests solutions until one is found, not always efficient
- Scientific: appropriate for controlled lab settings, , ex: pedal pulse, use Doppler?
- Intuitive Thinking: problem solving based on experience, knowledge, or skill
- Critical Thinking: Intuitive, Logical or both
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Critical Thinking: A systematic way to form and shape one’s thinking.
- Solves problems creatively
- Thinking with a purpose-always a goal in mind
- Comprehensive-need data to make accurate assessment
- Well-reasoned
- Necessary for the nursing process!
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The Four Blended Skills are essential to nursing practice and critical thinking :
- Cognitive-thinking and reasoning
- Technical-psycho motor skills
- Interpersonal-applies to the way you work as a team
- Ethical/legal-act in best interest of your patient ANA code of ethics, state board of practice act and recognize our own inadquacies. Practice within our scope. Document in a legal and advisable manner. You didn't chart it, you didn't do it.
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Developing Cognitive Skills:
- Use scientific rationale when planning patient care-
- Identify the purpose or goal of your thinking-what do I want to accomplish?
- Determine if the knowledge is accurate, complete or relevant-collect good data
- Divert Potential Problems by basing decisions on sound reasoning-
- Identify self limitations and important resources for learning
- After drawing a conclusion, critique your decision-evaluate Taylor pg.218
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Developing Technical Skills:
- Includes the mastery of the manual skills essential to the nursing process-confidence comes with practice
- Practice new skills
- Learn new equipment, procedures and policies
- Seek help from technical experts
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Developing Interpersonal Skills:
- Caring behaviors are essential to nursing practice
- Promote the dignity and the respect of patients
- Communicate caring through patient interactions
- Enjoy the rewards of patient and staff respect for your care and interactions
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Developing Ethical/Legal Skills:
- Accept accountability for the care you delegate
- Voice your concerns over the unmet needs of your patients
- Document patient needs
- Report incompetent, unethical, or illegal practice
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Characteristics of Critical Thinkers:
- Independent thinker
- Fair minded
- Intellectually humble-never too proud to learn and help others
- Intellectually courageous
- Demonstrates good faith and integrity
- Possesses curiosity and perseverance
- Creative
- Disciplined
- Confident
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Blended Skills in Action
- Attend inservices
- Become a life-long learner
- Refrain from labeling patients
- Approach your patient as a person, not a disease
- Document appropriately
- Communicate and collaborate with the entire health care team
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Concept mapping
- A critical thinking approach to care planning
- An instructional strategy that links key concepts (problem, nursing intervention, patient response)
- A visual map of why relationships exist among patient problems
- Still the nursing process
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Nursing Assessment:
- First step of the nursing process-upon admissions and interviewing
- Nurse brings blended skills and experience to collecting data
- A patient data base is started or revised
- Accurate assessment is crucial to ensure needs are properly met
- Serves as the pool about which all other steps proceed
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Unique Focus of Nursing Assessment:
- Gathering information about the client upon admission
- Does not duplicate medical assessments
- Strives to determine the client’s RESPONSE to health problems or illness that lead the nurse to the development of the nursing diagnosis
- No other health professional does this for the client and family
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Types of Assessments:
- Initial-comprehensive, usually within 24 hours, follow protocol
- Focused-used to identify newer and overlooked problems
- Emergency-life may depend on it, life threatening
- Time Lapsed-compares current condition to baseline ex: wounds, hemoglobin,
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Assessment Priorities:
- Helps the nurse identify the type of data needed to develop a plan of care
- Focus on the patients reason for needing nursing assistance
- Includes the patients health orientation, developmental stage, need for nursing and practical considerations
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Assessment: The Data Base
- Data collection
- -Includes Objective data (includes the Physical Assessment and what you observe)
- -Subjective Data (the Nursing Health History and what the patient tells you)
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Types of data:
- Objective
- ¡ Can be observed by another person
- ¡ Can be verified
- ¡ Uses the senses
- Subjective
- ¡ Information perceived then communicated verbally by another
- ¡ Cannot objectively verify
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Objective
- Height 6’4”
- Weight 200 lbs
- Bruises on arms and face
- Facial grimacing
- BSG 107
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Subjective Data
- “I feel like I’m going to be sick”
- “I didn’t sleep well”
- “I don’t think I’ll ever get better”
- “My hip hurts”
- When documenting put in quotes
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Characteristics of Data:
- Data needs to be:
- Complete
- Factual and accurate
- Relevant
- Purposeful
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Data sources:
- Primary- most reliable
- ¡Client/Patient
- Secondary
- ¡ Family, significant other
- ¡ Health record
- ¢ Lab results
- ¢ Diagnostic procedures
- ¡ Health team members
- ¡ Literature/Internet
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Sources of Data: The Client Record
- Physicians orders
- History and physical
- Progress notes
- Diagnostic studies
- Lab reports
- Consultations
- Flow sheets, intake/output etc
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Client Record:
- Medical Admission records
- Treatment records
- Operative reports
- Other Health Care Professionals
- Computerized Medical Record
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Data Collection Methods:
- Observation
- ¡ Responses: what are they telling you?
- ¡ Need for nursing care: what level of help is needed?
- ¡ Immediate environment: what do you see?
- ¡ Larger environment: where are they?
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Nursing History
- Should be obtained as soon as possible after admission
- Will be combined with the physical assessment
- Focus should be getting to know the person
- Should capture the uniqueness of the person
- Information gained helps nurse identify patient strengths and weaknesses
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The Interview:
- Purpose
- ¡ Obtain a health history that contains information about the client’s health status
- Needed
- ¡ Strong interview skills
- ¡ Active listening skills
- ¡ Nonjudgmental non-verbal communication skills-eye level, takes about 20 minutes, private, face the patient, within 3-4 feet.
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Phases of the Interview:
- Preparatory
- Introduction
- Working
- Termination
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Preparatory Phase
- Nurse may review information in the medical record
- Approach client with open mind
- Be sensitive to human needs
- Use a non-judgmental approach- I accept you for who you are
- Ensure privacy (family presence only if patient approves)
- Conduct interview at opportune time
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Introduction
- State purpose-lead in question
- ¡ All information is for one purpose- to help nursing staff plan and provide care
- Introduce self
- Clarify roles
- ensure privacy but let them know you may have to share info
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Working Phase
- Focus on the patient
- Use therapeutic communication skills, closed and open questions, use terms they will understand
- Gather information
- Accuracy, completeness and relevance depends largely upon nurse’s interviewing skills
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Termination:
- Conclude carefully, not abruptly,
- Encourage client/family to give nurse additional information in order to help nursing staff to plan care
- “Is there anything else you think we need to know?”
- Thank them for answering the questions
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Problems Related to Data Collection
- Inappropriate organization of the data base
- Omission of data
- Inclusion of irrelevant data
- Failure to establish rapport
- Failure to observe appropriate behavior
- Failure to update the data base
- Failure to document accurately, clearly & timely
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Validation of Data
- Confirm or verify discrepancies
- ¢ Between objective and subjective data
- ¢ Between sources, client and family or record
- Explore data which lacks objectivity
- ¢ Suspicions or conflicting data
- ¢ Intuition that information is not accurate
- ¢ Use cues and inferences to assist in validation
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Cues and Inferences:
- Cues -- pieces of information obtained through assessment;
- --an indication that something may be wrong
- --can be objective or subjective
- ojective + subjective = inference
- Inference -- assignment of a meaning to the cue
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Inferencing:
- *Temp 102F *Temp 102F
- *Scattered rhonchi *Decreased turgor
- *Thick green mucous *Dry tongue
- *Shortness of breath *Urine output--200 cc/8hr, &
- concentrated
- *Problem: Pneumonia *Problem -Dehydration
- *Nursing DX: *Nursing DX:
- -Ineffective Airway -Deficient Fluid Volume
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Inferencing:
- *Always thirsty
- *Urinates 8-12 x’s/day
- *Weight 224 pounds
- *Height 5’1”
- *Having blurred vision
- *Tires easily
- Problem: Diabetes Mellitus
- Inference: Unstable blood glucose
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Use Critical Thinking to Identify the Problem:
- 72 year old man
- Blind
- Lives alone
- States: “I am always bumping myself”
- States: “I get around by using my cane”
- Has visible bumps and bruises on his head and arms
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Identification of Patient Problem:
- After data collection is complete, the nurse clusters data (cues) to form inferences.
- Inferences lead the nurse to identification of the patients problem
- Nursing Diagnosis becomes the clinical judgment product of critical thinking
- Complete Health Assessment
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Identification of Patient Problem:
- After data collection is complete, the nurse clusters data (cues) to form inferences.
- Inferences lead the nurse to identification of the patients problem
- Nursing Diagnosis becomes the clinical judgment product of critical thinking
- Complete Health Assessment
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Two components
¡ Nursing history
¡ Physical assessment
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Guide to Collecting the Nursing History
Collection of subjective data
- If the patient cannot give you accurate information, ask for the name of a friend or relative who can provide the information
- Biographical Data
Patient initials, age, sex, marital status, religion, occupation, education
Biographical data may be available from the admitting information obtained from the Admissions office.
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Subjective interview:
- Reason for seeking healthcare
- Use the patients exact words; “place words in quotes”.
- Ask: “What brings you here?”
- Patients opinion of own general health
- What is your opinion of your health?
- If “10” is the best health, how do you rate your health?
- Activities of Daily Living:
- Ask questions specific to the patients functional status.
- Do you need assistance with any of the activities of daily living?
- Describe a typical day for you?
- · Pattern of Nutrition
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Subjective interview continued:
- How many meals do you eat each day?
- Do you follow a special diet?
- Have you lost or gained weight within the last 2 weeks?
- Who cooks and buys groceries for you?
- · Elimination
- How often do you move your bowels?
- When was your last Bowel movement?
- · Activity/exercise
- Do you follow any special exercise program? If yes, explore the frequency, intensity, and duration of the exercise.
- Does your health put any limits on your ability to exercise?
- · Rest/sleep
- How long do you sleep at night?
- Do you have any trouble going to sleep?
- Do you take a sleeping pill to help you sleep?
- · Safety
- Do you wear glasses, hearing aids, or use any assistive devices?
- Do you feel safe in your home? *(patient must be alone when you screen for domestic violence)
- When do you not feel safe?
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Subjective interview:
- Previous illnesses (major) & hospitalizations
- Have you ever been hospitalized before? Can you tell me why?
- Surgeries:
- Have you had any previous surgeries?
- Can you describe them?
- ALLERGIES:
- Do you have any allergies?
- Are you allergic to any medications?
- Are you allergic to latex? (balloons and kiwi)
- Wellness Practices:
- What do you do for exercise? How often do you exercise?
- Do you smoke cigarettes?
- How many alcoholic drinks do you have in a day? (ask what type)
- Are there any religious beliefs or cultural practices that may affect your care?
- Medications
- Can you tell the name of all of the medications you are currently taking?
- *(include herbal meds, OTC meds, illegal or street meds)
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Subjective interview:
- Family History: (role in family, significant relationships)
- Do you have a family? How do you support your family?
- What do you do to earn a living?
- Who is the most important person to you in your life right now?
- Who is available to help you at home after you are discharged?
- Family Support:
- From whom do you get the most support?
- Tell me about the emotional support you receive from your family/friends.
- Psychosocial History: (substance abuse, sources of stress/coping)
- How have you coped with medical or emotional crisis in the past?
- Has your life changed recently?
- Do you sniff, snort, or inject any substances?
- Review of Systems
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Subjective interview continued:
- Skin and Respiratory
- Do you bruise easily?
- Do you have any open sores, wounds or lesions?
- Do you get short of breath when you climb the stairs, or walk?
- Do you have a cough?
- Cardiovascular and Axillae/breasts
- Do you experience chest pains, palpitations, irregular heart beat, shortness of breath, or cough?
- Do you perform monthly breast self exams?
- GI and Reproductive
- Do you experience nausea, vomiting, decreased appetite, bloating, increased gas, constipation, or heartburn?
- Female pt: Can you tell me the date of your LMP, # of pregnancies, #births, birth control, last Pap smear?Male pt: Can you tell me the date of your last testicular or prostate exam
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Subjective interview:
- Urinary and Peripheral-vascular circulation
- Do you experience burning, incontinence, frequency, urgency, or decreased flow when urinating?
- Do you experience cold extremities (hands and feet)?
- Have you ever been diagnosed with anemia?
- Musculoskeletal and Neurologic
- Do you experience swelling, soreness, or stiffness in your joints?
- Do you get headaches?
- When was your last eye exam?
- Endocrine
- Do you feel unusually tired?
- Have you experienced a recent weight loss or gain in the last 2 weeks to one month?
- Have you experienced increased thirst?
- Do you take hormones?
- Anything else the patient would like you to know?
- Is there anything else you would like me to know?
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Summary
- The Nursing Process is a 5 step process that is used to determine the need for nursing care.
- The Nursing Process requires the integration of critical thinking skills.
- Assessment is the first step of the Nursing Process.
- Data collection both subjective and objective is used to develop the data base which is needed to determine patient strengths and weaknesses.
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