1- Nursing process steps : assessment diagnosis planning intervention evaluation .pptx

fundamental of nursing

1. Nursing Process

2. LEARNING OBJECTIVES On completion of this chapter, the students will: Identify component of nursing process. Identify four sources for assessment data. Differentiate between a data base assessment and a focus assessment. Distinguish between a nursing diagnosis and a collaborative problem . List three parts of a nursing diagnostic statement. Describe the rationale for setting priorities . Discuss appropriate circumstances for short-term and long-term goals. Discuss three outcomes that result from evaluation.

3. Component of nursing process The steps of the nursing process: 1. Assessment 2. Diagnosis 3. Planning 4. Implementation 5. Evaluation

4. Elements of Nursing process

5. 1- Assessment Definitions: Assessment; is the systematic and continuous collection, organization, validation, and documentation of data (information). Assessment; is the first step in the nursing process, is the systematic collection of facts, or data.

6. Assessments vary according to their - Purpose - Timing, time available, - Client status. The registered nurse is responsible for the collection of comprehensive data, including physical, functional, psychosocial, emotional, cognitive, sexual, cultural, age-related, environmental, spiritual/transpersonal, and economic assessments. RNs may delegate some parts of an initial assessment to an LPN, but the RN is still responsible for ensuring that data collection is complete.

7. Types of assessment There are two types of assessments: A- Data base assessment. B- Focus assessment.

8. A- DATA BASE ASSESSMENT A data base assessment ( initial information about the client’s physical, emotional, social, and spiritual health) is lengthy and comprehensive . The nurse obtains data base information during the admission interview and physical examination. Information obtained during a data base assessment serves as a reference for comparing all future data and provides the evidence used to identify the client’s initial problems . Comparisons of ongoing assessments with baseline data help determine whether the client’s health is improving, deteriorating, or remaining unchanged .

9. B- Focus assessment A focus assessment is information that provides more details about specific problems and expands the original data base. Example if the client tells the nurse that he has constipation, the nurse will obtain data about the client’s dietary habits, level of activity, fluid intake, current medications, frequency of bowel elimination, stool characteristics and may ask the client to save a stool specimen for inspection. Focus assessments generally are repeated frequently or on a scheduled basis to determine client’s condition and responses to therapeutic interventions . Examples include monitoring the client’s level of pain before and after administering medications.

10. Steps of assessment

11. 1- Collect data Data collection is the process of gathering information about a client’s health status. Sources for Data: The primary source for information is the client. Secondary sources include the client’s family, reports, test results, information in current and past medical records, and discussions with other health care workers.

12. Cont. Collect data Client data should include past history as well as current problems. For example : - A history of an allergic reaction to penicillin is a vital piece of historical data. - Past surgica l procedures, and chronic diseases are also examples of historical data. - Current data relate to present circumstances, such as pain, nausea, sleep patterns, and religious practices.

13. Data Collection Methods The principal methods used to collect data are observing, interviewing, and examining. 1- Observing; occurs whenever the nurse is in contact with the client or support persons. 2- Interviewing ; is used mainly while taking the nursing health history . 3- Examining; is the major method used in the physical health assessment.

14. Types of Data: 1- Subjective data , also referred to as symptoms , can be described or verified only by the patient . Itching, pain, and feelings of worry are examples of subjective data. Subjective data include the client’s sensations, feelings, values, beliefs, attitudes, and perception of personal health status. 2- Objective data , also referred to as signs , can be detectable by an observer or can be measured or tested against an accepted standard. They can be seen, heard, felt, or smelled and include such data as blood pressure.

15. Stop • Think + Respond BOX 2-1 Which of the following represent objective data? 1. A client rates his pain as 8 on a scale of 0 to10, with 10 being the most pain he has ever experienced. 2. A client has an incisional scar in the right lower quadrant of the abdomen. 3. A client says she slept very well and feels rested. 4. A client’s blood pressure is 165/86 mm Hg. 5. A client’s heart rate is irregular.

16. 2- Organize data Interpreting data is easier if information is organized. Organization involves grouping related information. For example, consider the following list of words: apple, wheels, orchard, pedals, tree, and handlebars. At first glance, they appear to be a jumble of terms. If asked to cluster the related terms , however, most people would correctly group apple, tree, and orchard together, and wheels, pedals, and handlebars together. Nurses organize assessment data similarly . Using knowledge and past experiences, they cluster related data. Data organized into small groups is easier to analyze and takes on more significance than when the nurse considers each fact separately or examines the entire group at once.

17. Question

18. BOX 2-3 ! Organization of Data Assessment Findings Fatigue; distended abdomen; dry/hard stool passed with difficulty; fever; weak cough; thick sputum Organized data: Fatigue, fever Weak cough, thick sputum Distended abdomen; dry, hard stool passed with difficulty

19. 3- Validating data The information gathered during the assessment phase must be complete, factual, and accurate because the nursing diagnoses and interventions are based on this information. Validation is the act of “double-checking ” or verifying data to confirm that it is accurate and factual.

20. 4- Documenting data To complete the assessment phase, the nurse records client data. Accurate documentation is essential and should include all data collected about the client’s health status. Data are recorded in a factual manner and not interpreted by the nurse. For example, the nurse records the client’s breakfast intake (objective data) as “coffee 240 mL, juice 120 mL, 1 egg, and 1 slice of toast,” rather than as “appetite good” (a judgment). To increase accuracy, the nurse records subjective data in the client’s own words, using quotation marks.

21. 2- Diagnosis Diagnosis , the second step in the nursing process, is the identification of health-related problems. Diagnosis results from analyzing the collected data and determining whether they suggest normal or abnormal findings.

22. A nursing diagnosis A nursing diagnosis is a health issue that can be prevented, reduced, resolved, or enhanced through independent nursing measures. It is an exclusive nursing responsibility.

23. Steps of diagnosis

24. 1- Analyzing Data In the diagnostic process, analyzing involves the following steps: 1. Compare data against standards (identify significant cues). 2. Cluster the cues (generate tentative hypotheses). 3. Identify gaps and inconsistencies.

25. 2- Identifying Health Problems, Risks, and Strengths After data are analyzed, the nurse and client can together identify strengths and problems. This is primarily a decision-making process

26. 3- Formulate nursing diagnosis The name of the nursing diagnosis is linked to the etiology with the phrase “related to,” and the signs and symptoms are identified with the phrase “as manifested (or evidenced) by”. (Box 2-4). P: 21 chapter #1

27. Categories of nursing diagnosis 1- Actual nursing diagnosis: An actual nursing diagnostic statement contains three parts: 1. Name of the health-related issue or problem as identified in the NANDA list. 2. Etiology (its cause). 3. Signs and symptoms.

28. 2- Risk diagnoses: Risk diagnoses are prefaced with the term “ risk for, ” as in Risk for Impaired Skin Integrity related to inactivity. The word “ possible ” is used in a diagnostic statement to indicate uncertainty—for example, Possible Sexual Dysfunction related to anxiety. Risk and possible nursing diagnoses do not include the third part of the statement.

29. Collaborative Problems Collaborative problems are physiologic complications that require both nurse- and physician-prescribed interventions. They represent an interdependent domain of nursing practice

30. 3- Planning Planning, is the third step in the nursing process. Planning, is the process of prioritizing nursing diagnoses and collaborative problems, identifying measurable goals or outcomes , selecting appropriate interventions , and documenting the plan of care .

31. Steps of planning

32. 1- setting priorities Setting priorities, is important to determine which problems require the most immediate attention. Prioritization involves ranking from those that are most serious or immediate to those of lesser importance. The ranking can change as problems are resolved or new problems develop.

33. 2- Establishing Goals /formulate outcome A goal (expected or desired outcome) helps the nursing team know whether the nursing care has been appropriate for managing the client’s problems. There are two types of goal: Short-term goal: outcomes achievable in a few days to 1 week, most often in acute care settings because most hospital stays are no longer than 1 week. Long-term goal: desirable outcomes that take weeks or months to accomplish) for clients with chronic health problems that require extended care in a nursing home or who receive community health or home health services. An example of a long-term goal for the client with a cerebrovascular accident (stroke) is the return of full or partial function to a paralyzed limb.

34. characteristics of Short-term goals (SMART) Developed from the problem portion of the diagnostic statement. Client-centered , reflecting what the client will accomplish, not the nurse 3. Measurable , identifying specific criteria that provide evidence of goal achievement 4. Realistic , to avoid setting unattainable goals, which can be self-defeating and frustrating 5. Accompanied by a target date for accomplishment , the predicted time when the goal will be met.

35. BOX 2-6 !Components of Short-Term Goals Nursing Diagnostic Statement Constipation related to decreased fluid intake, lack of dietary fiber, and lack of exercise as manifested by no normal bowel movement for the past 3 days, abdominal cramping, and straining to pass stool Short-Term Goal The client will_________________ client–centered have a bowel movement _________ identifies measurable criteria that reflect the problem portion of the diagnostic statement in 2 days (specify date) __________ identifies a target date for achievement within a realistic time frame (The client will have a bowel movement in 2 days)

36. 3- Selecting Nursing Interventions Both of the patient and the nurse are responsible for selecting nursing interventions which will be used for accomplishing goals. Nursing interventions are directed at eliminating the etiologies. Nursing interventions must be safe, within the legal scope of nursing practice, and compatible with medical orders.

37. 4- Documenting the Plan of Care Plans of care can be written by hand, standardized forms, computer generated, or based on an agency’s written standards or clinical pathways. Documenting the Plan of Care; describe the routine care needed to meet basic needs (e.g., bathing, nutrition), or documents that specify the nurse’s responsibilities in carrying out the medical plan of care (e.g., keeping the client from eating or drinking before surgery).

38. 4- Implementation Implementation , the fourth step in the nursing process, means carrying out the plan of care. The nurse implements medical orders as well as nursing orders , which should complement each other. Implementing the plan involves the client and one or more members of the health care team.

39. Steps of Implementation

40. 1-Reassessing the client Just before implementing an intervention, the nurse must reassess the client to make sure the intervention is still needed. Even though an order is written on the care plan, the client’s condition may have changed. For New data may indicate a need to change the priorities of care or the nursing activities.

41. 2- DETERMINING THE NURSE’S NEED FOR ASSISTANCE When implementing some nursing interventions, the nurse may require assistance for one or more of the following reasons : 1- The nurse is unable to implement the nursing activity safely or efficiently alone. 2- Assistance would reduce stress on the client (e.g., turning). 3- The nurse has lacks of knowledge or skills to implement a new particular nursing activity.

42. 3- IMPLEMENTING THE NURSING INTERVENTIONS It is important to explain to the client what interventions will be done, what sensations to expect, what the client is expected to do, and what the expected outcome is. When implementing interventions, nurses should follow these guidelines: 1- Base nursing interventions on scientific knowledge, nursing research, and professional standards of care. 2- Clearly understand the interventions to be implemented 3- Adapt activities to the individual client. 4- Implement safe care . For example, when changing a sterile dressing, the nurse practices sterile technique to prevent infection. 5- Provide teaching, support, and comfort. 6- Be holistic . The nurse must always view the client as a whole and consider the client’s responses in that context.

43. 4- SUPERVISING DELEGATED CARE If care has been delegated to other health care personnel, the nurse responsible for the client’s overall care must ensure that the activities have been implemented according to the care plan.

44. 5- DOCUMENTING NURSING ACTIVITIES After carrying out the nursing activities , the nurse completes the implementing phase by recording the interventions and client responses in the nursing progress notes. These are a part of the agency’s permanent record for the client. Nursing care must not be recorded in advance because the nurse may determine on reassessment of the client that the intervention should not or cannot be implemented. The nurse may record routine or recurring activities (e.g., mouth care) in the client record at the end of a shift. In the meantime, the nurse maintains a personal record of these interventions on a worksheet.

45. The medical record is legal evidence that the plan of care has been more than just a paper trail. The information in the chart shows a correlation between the plan and the care that has been provided. The record also describes the quantity and quality of the client’s response. Appropriate documentation maintains open lines of communication among members of the health care team, ensures the client’s continuing progress, complies with accreditation standards, and helps ensure reimbursement from government or private insurance companies.

46. 5- Evaluation Evaluation , the fifth and final step in the nursing process, is the way by which nurses determine whether a client has reached a goal. By analyzing the client’s response, evaluation helps to determine the effectiveness of nursing care. Patient, health team members, or families may invite the to participate for discontinuing, adding, or changing.

47. Steps of evaluation

48. 1- COLLECTING DATA Using the clearly stated, precise, and measurable desired outcomes as a guide , the nurse collects data so that conclusions can be drawn about whether goals have been met. Some data may require interpretation. - Examples of objective data requiring interpretation are the degree of tissue turgor of a dehydrated client - Examples of subjective data needing interpretation include complaints of nausea or pain by the client.

49. 2- COMPARING DATA WITH DESIRED OUTCOMES Both the nurse and client play an active role in comparing the client’s actual responses with the desired outcomes . Did the client drink 3,000 mL of fluid in 24 hours? Did the client walk unassisted the specified distance per day? -- When determining whether a goal has been achieved, the nurse can draw one of three possible conclusions: 1. The goal was met ; that is, the client response is the same as the desired outcome. 2. The goal was partially met ; that is, either a short-term outcome was achieved but the long-term goal was not, or the desired goal was incompletely attained. 3. The goal was not met .

50. After determining whether or not a goal has been met, the nurse writes an evaluation statement (either on the care plan or in the nurse’s notes). An evaluation statement consists of two parts: A conclusion. Supporting data. Goal met: Oral intake 300 mL more than output; skin turgor resilient; mucous membranes moist.

51. 3- RELATING NURSING ACTIVITIES TO OUTCOMES The third phase of the evaluating process is determining whether the nursing activities had any relation to the outcomes. It should never be assumed that a nursing activity was the cause of or the only factor in meeting, partially meeting, or not meeting a goal . For example, a client was obese and needed to lose 14 kg. When the nurse and client drew up a care plan, one goal was “Lose 1.4 kg in 4 weeks.” A nursing strategy in the care plan was “Explain how to plan and prepare a 1,200-calorie diet.” Four weeks later, the client weighed herself and had lost 1.8 kg. The goal had been met—in fact, exceeded.

52. 4- DRAWING CONCLUSIONS ABOUT PROBLEM STATUS The nurse uses the judgments about goal achievement to determine whether the care plan was effective in resolving, reducing, or preventing client problems. When goals have been met, the nurse can draw one of the following conclusions about the status of the client’s problem: 1- Discontinues the care for the problem>>>> The actual problem stated in the nursing diagnosis has been resolved, or the potential problem is being prevented and the risk factors no longer exist. 2- The nurse keeps the problem on the care plan>>>>The potential problem stated in the nursing diagnosis is being prevented, but the risk factors are still present. 3- The nursing interventions must be continued even though this one goal was met>>>The actual problem still exists even though some goals are being met. For example, a desired outcome on a client’s care plan is “Will drink 3,000 mL of fluid daily.” Even though the data may show this outcome has been achieved, other data (dry oral mucous membranes) may indicate that the nursing diagnosis Deficient Fluid Volume is applicable. Therefore,

53. When goals have been partially met or when goals have not been met, two conclusions may be drawn: • The care plan may need to be revised , since the problem is only partially resolved. The revisions may need to occur during the assessing, diagnosing, or planning phases, as well as implementing. OR • The care plan does not need revision, because the client merely needs more time to achieve the previously established goal(s). To make this decision, the nurse must assess why the goals are being only partially achieved, including whether the evaluation was conducted too soon

54. 5- CONTINUING, MODIFYING, OR TERMINATING THE NURSING CARE PLAN After drawing conclusions about the status of the client’s problems, the nurse modifies the care plan as indicated. Depending on the agency, modifications may be made by drawing a line through portions of the care plan, marking portions using a highlighting pen, or indicating revisions as appropriate for electronic charting systems. The nurse may also write “Discontinued” (“ dc’d ”), “goal met,” or “problem resolved” and the date. Whether or not goals were met, a number of decisions need to be made about continuing, modifying, or terminating nursing care.

55. QUESTIONS#1 Three nursing diagnoses are on a client’s plan of care: (Ineffective Breathing Pattern, Social Isolation, and Anxiety) Which has the highest priority, and why?

56. QUESTIONS#2 When managing the care of a client, which of the following nursing actions is most appropriate to perform first? 1. Develop a plan of care. 2. Determine the client’s needs. 3. Assess the client physically. 4. Collaborate on goals for care.

57. QUESTIONS#3 According to most nurse practice acts, if a charge nurse assigns a licensed practical nurse to admit a new client, the licensed practical nurse’s primary role is to 1. Create an initial nursing care plan. 2. Gather basic information from the client. 3. Develop a list of the client’s nursing diagnoses. 4. Report assessment data to the client’s physician.

58. QUESTIONS#4 At a team conference, staff members discuss a client’s nursing diagnoses. A nursing assistant questions which nursing diagnosis is of highest priority. From the list that follows, the licensed practical nurse is most accurate in identifying 1. Ineffective Airway Clearance 2. Ineffective Coping 3. Deficient Diversional Activity 4. Interrupted Family Processes

59. References: 1- Timby , B K. Fundamental Nursing Skills and Concepts, 12th Edition (International Edition), 2020. ISBN/ISSN 9781975141769 Publisher: Wolters Kluwer. 2- Berman, A. Snyder, C and Frandsen , G. Kozier & Erb's Fundamentals of Nursing, 10th Edition, 2016. ISBN13: 9781292106106 Publisher: Pearson