3-1 Transition to Registered Nursing West Coast University Week 3 Nursing Process: Overview, Assessment and Nursing Diagnosis.

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Transition to Registered Nursing

West Coast University

Week 3

Nursing Process: Overview, Assessment and Nursing Diagnosis

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Objectives

• History of the Nursing Process and Nursing Diagnosis

• Discuss characteristics of Nursing Process and Nursing Diagnosis

• Describe Assessment • Formulate a Nursing Diagnosis

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This is Nursing

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This is Brian on Nursing

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History of Nursing Diagnosis

• 1950’s – Introduction only – mainly used in relationship to the care plan– only sporadically in the literature

• 1970’s– 1st National Conference for classification of Nursing Diagnosis and

formed the North American Nursing Diagnosis Association (NANDA)– ANA published standards of practice & a social policy statements

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History of Nursing Diagnosis

• 1970’s – continued– ANA published standards of practice & a social policy

statements• Defined nursing as diagnosis and treatment of human response

to actual or potential health problems

• 1990’s – 9th Conference of NANDA was held and Taxonomy II was

published

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Globalization of Nursing

• Nursing Diagnosis is recognized globally– Provides common language for nursing to talk to each other,

identifies problems, gives nursing greater accountability, and professional autonomy

– Captures nursing’s contributions to health, enables cross-country comparisons of nursing and promotes the development of nursing

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• Pre-1955: No clearly identifiable boundaries defined for nursing practice

• 1955: Term nursing process coined by Lydia Hall• 1973: ANA published Standards of Clinical

Nursing Practice

continues

Timeline

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Timeline

• 1973: Classification of nursing diagnoses began: North American Nursing Diagnosis Association (NANDA)

• 1980: ANA published A Social Policy Statement• 1982: NCLEX exams were revised

to include concepts• 1994: JCAHO initiated requirements for

accredited hospitals to use the nursing process • Current: Ongoing use of the five-step process• In 2006 NANDA had their 13 Conference

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Basic Characteristics of the Nursing Process

• Method of providing care• Purposeful, systematic, and orderly • Method of problem solving and decision making• Scientifically based—understanding of the

human body• Philosophically based—understanding of

philosophical views

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Nursing Process Characteristics

• Method for organization• Promotes wellness• Restores wellness• Maintains present state of health

continues

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Nursing Process Characteristics

• Promotes quality care• Promotes coordinated, ongoing care• Serves as a guide to avoid omissions or

inaccuracies• Provides a framework for nursing

continues

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Nursing Process Characteristics

• Client centered• Assists to plan according to client needs• Client participates• Promotes collaboration with other disciplines• Universally applicable

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Nursing Skills

• Interpersonal• Technical• Intellectual

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Critical Thinking

• Purposeful thought process• Strategy used in search for meaning• Deliberate questions are asked

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Problem Solving

• Gather data• Identify problem• Interpret data• Plan to resolve• Implement plan• Evaluate results

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Decision Making

• Based on scientific theories• Results from nurse’s ability to think critically• Perceptual and intellectual skills used

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Maslow’s Hierarchy of Needs

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Benefits of the Nursing Process

• Improved quality of care• Continuity of care• Promotes client participation in care• Delivery of care is organized, continuous,

and systematic• Efficient use of time and resources• Expectations of client and standards of

care are met• Holds nurses accountable and responsible

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Five Steps of the Nursing Process

• Assessment• Diagnosis• Planning and outcome identification• Implementation• Evaluation

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Scope and Standards of Practice

I. Assessment: Nurse collects dataII. Diagnosis: Nurse analyzes data in

determining diagnosesIII. Outcome identification: Nurse identifies

expected outcomesIV. Planning: Nurse develops a plan of care V. Implementation: Nurse implements

interventions identified in planVI. Evaluation: Nurse evaluates client’s progress

From American Nurses Association. (1991). Standards of clinical nursing practice. Washington DC: Author.

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continues

Questions Critical Thinkers Ask...

• What actual problems were identified during assessment?

• What are possible causes?• Is client at risk for developing other problems?• What are the factors involved?• Did the client indicate a desire to function at a

higher level of wellness?

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Questions Critical Thinkers Ask...

• What are the client’s strengths?• What additional data might be needed to answer

these questions?• What are possible sources of data collection?• Is collaboration needed at this time?• What data are pertinent to collect before

contacting the physician?

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Assessment

• Gathering data• Organizing• Verifying accuracy• Documenting data

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Characteristics of Assessment

• Systematic, ongoing, and continuous• Process of collecting data• Identification of problems• Data yield information regarding health status

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Types of Data

• Subjective• Objective• Complements, clarifies, supports

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Baseline Data

• Initial data becomes foundation• Accurate data collection is critical• Used for comparison of future data

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Data Collection

• Interview, physical exam, diagnostic exams• Communicated and documented• Begins when client enters health care system• Continues as long as there is a need

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Validating & Clarifying Data

• Subjective Data: “I feel like my heart is racing”• Objective Data: Pulse 150 beats per minute,

regular, strong

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Sources of Data

• Client• Family or significant other• Nursing records• Medical records• Consultations• Health care team members• Diagnostic results• Relevant literature

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Data Collection Tools

• Organization• Documentation• Nursing models• Holistic

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Methods of Data Collection

• Observation• Interview• Physical assessment

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Promoting Data Collection

• Use communication techniques– paraphrasing– clarifying– focusing– summarizing– open-ended questions

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Data Clustering

• Determines relation• Finds patterns

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Diagnosis

• Analysis• Problem identification• Nursing diagnosis

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Nursing vs. Medical Diagnoses

Nursing Diagnosis • Determined by the nurse• Clinical judgment about the client• Human responses to disease or treatment• May change

Medical Diagnosis • Determined by physician• Indicates disease, illness• Doesn’t change

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Definition: Nursing Diagnosis

• A clinical judgment about individual, family, or community responses to actual or potential health problems/life processes. Nursing diagnosis provides the basis for selecting interventions to achieve outcomes for which the nursing is accountable

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Types Nursing Diagnosis

• Actual• Risk• Possible• Syndrome• Wellness• Collaborative

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Making a Nursing Diagnosis• Know diagnoses

– Collect valid & pertinent data, cluster data, differentiate nursing diagnosis from collaborative problems, prioritize

• Defining the characteristics– Major & Minor

• Related factors– Pathophysiological– Treatment– Situational– Maturational

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Actual ND

• Represents a problem that has been validated by the presence of major defining characteristics.

• Has four parts– Label

– Definition

– Defining characteristics

– Related factors

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Risk ND

• Clinical judgment that an individual, family or community is vulnerable to develop the problem than others in the same or similar situation

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Possible ND

• Describes a suspected problem requiring additional data. This is where data is not complete or an evaluation has not been completed

• Not a NANDA ND because it is not classified, yet viable for the clinical nurse for further clarification of a problem

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Syndrome ND

• Clustering of predictable actual or high-risk NDs related to events or situations

• Complex clinical situation, use with care and stated as a one-part statement

• There should be a clustering of other NDs

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Wellness ND

• Clinical judgment about an individual, family or community transition from a specific level of wellness to a higher level

• Stated as a one-part

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Collaborative Problems

• Physiologic complications that nurses monitor to detect onset or changes in status. Nurses manage collaborative problems with PCP-prescribed (dependent nursing functions) and Nursing-prescribed (independent nursing functions) to minimize complications

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Cultural, Ethical & Spiritual ND

• Cultural Needs– Where is the cultural component?– Belief system, knowledge, food, environment, powerlessness

• Ethical Issues– What do you do with issues that are illegal, or different from your

belief system?

• Spiritual Concerns– Does, or how does the patient utilize spirituality in there health care?

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Components of a Nursing Diagnosis

• Stated as one, two or three parts

Type of Diagnosis Parts needed

Actual 3 – Label, Factors, S/S

Risk 2 – Label, Factors

Possible 2 – Label, Factors

Syndrome 1 – Label

Wellness 1 – Label

Collaborative Need the stem: Potential Complications (PC)

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Formulating Nursing Diagnosis

Diagnostic Label(Stem)

Contributing Factors(Etiology – RT)

Signs & Symptoms(AEB)

Related to

As evidenced by/secondary to

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Example of Actual Nursing Diagnoses

• Hyperthermia– Client’s temperature is 104.6°F.

• Impaired Gas Exchange– Client’s oxygen saturation in arterial blood is 92%.

continues

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Example of Actual Nursing Diagnoses

• Pain– Client states pain level “8” on scale of one to ten.

• Anxiety– Client states he is experiencing anxiety.

• Self-care deficit– Client is unable to perform ADLs.

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Components of Actual Nursing Diagnoses

• Problem• Etiology• Defining characteristics

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Problem

• Label• Nursing diagnosis

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Etiology

• Related to (R/T) or related factor• Involved in development of problem• Becomes focus for interventions• Cause component• Gives direction to problem statement

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Defining Characteristics

• As evidenced by (AEB)• Clinical evidence• How response is manifested

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Examples

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Scenario One:

The nurse is caring for a client who was involved in a motor vehicle accident and sustained superficial skin trauma. The client’s epidermal layer of skin on the right knee, forearm, and hand is excoriated, reddened, and bleeding as the result of sliding across a cement pavement.

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Answer:

• Impaired Skin Integrity• R/T: mechanical factors, shearing forces • AEB: disruption of skin surface, destruction of

skin, layers, traumatized skin excoriated, reddened, bleeding

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Scenario Two

The client you are caring for has been medically diagnosed with a right cerebral vascular accident (stroke). He experiences partial paralysis on the left side of his body. He is unable to turn over while in bed without assistance and has demonstrated decreased muscle strength and control in the left extremities.

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Answer:

• Impaired Physical Mobility • R/T: neuromuscular impairment• AEB: inability to purposefully move within the

environment, decreased muscle strength, control, left-sided partial paralysis

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Components of Risk Nursing Diagnoses

• Potential problem• Risk factor• No evidence• Problem does not exist

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Risk Nursing Diagnoses Examples

• Cancer patient, Risk for Infection– Risk Factors (R/T): inadequate secondary defenses,

immunosuppression

• Client with surgical incision, Risk for Infection– Risk Factors (R/T): inadequate primary defenses,

invasive procedure

continues

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Risk Nursing Diagnoses Examples

• Client who is semi-conscious, vomiting, Risk for Aspiration – Risk Factors (R/T): reduced level of

consciousness, vomiting

• Neonate unable to maintain his body temperature, parent does not keep the child covered, Risk for Hypothermia – Risk Factors (R/T): extremes of age,

inadequate clothing