Ha - Nursing Process (3)

7/31/2019 Ha - Nursing Process (3)

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http://cal.vet.upenn.edu/lgcardiac/normal_cases/equine_normals/physical_exam/ausculthart1.htmhttp://cal.vet.upenn.edu/lgcardiac/normal_cases/equine_normals/physical_exam/ausculthart1.htm


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After the discussion of the concept, thestudents will be able to:

1. Define assessment

2. Identify the role of assessment as part ofthe nursing process3. Differentiate nursing assessment from

medical assessment

4. Identify the role of assessment in all levelsof preventive healthcare5. Differentiate subjective and objective data


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6. Differentiate primary and secondary datasources

7. Identify the factors that affect communication8. Identify communication techniques

9.Identify the phases of interview

10.Describe data collection methods11. Define the four techniques of physicalassessment

12.Identify the methods used to validate

assessment data13. Describe the various documentation methods

for charting assessment data.


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the diagnosis and treatment of

human responses to the actual and

potential health problems

Diagnosis and treatment are achievedthrough a process, called..


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guides the nursing practice

a systematic, rational method of planningand providing individualized nursing care

used to identify, prevent and treat actualand potential health problems andpromote wellness

provides a framework in which to practicenursing

problem-solving method that has 5 steps


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Assessment

Nursing Diagnosis

Planning

Implementation

Evaluation


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Is the process of collecting, validating, andclustering the data.

It is the first and most important step in the

nursing process This phase sets the tone for the rest of the

process, the rest of the process flows fromit

This identifies your patients strengths and

limitations, and not performed once butcontinuously through the nursing process


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Has been identified by the American NursesAssociation (ANA) as the first Standard ofNursing Practice.

The Standard describes assessment as thesystematic, continuous collection of data aboutthe health status of patients.

Nurses are responsible not only for data

collection but also for making sure that the dataare accessible, communicated and recorded.

An ongoing process


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Collect data pertinent to the patientshealth status

Identify deviations from normal

Discover the patients strengths andcoping resources

Pinpoint actual problems Spot factors that place the patient at risk

for health problems


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Cognitive Skills

Problem-Solving Skills

Psychomotor Skills

Affective/Interpersonal Skills

Ethical Skills


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Assessment is a thinking process These are needed for critical thinking and clinical

decision making

Theoretical knowledge base enables you to assess

your patient holistically Knowledge base includes not only biophysical

knowledge but also developmental, cultural,psychosocial, and spiritual knowledge

Knowledge base enables you to differentiatenormal from abnormal findings, identify andprioritize


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Critical Thinking- a complex thinking

process that has been defined in manyways

- its reasonable thinking

- not just doing, it is asking why-involves inquiry, interpretation,analysis, and synthesis

- the alert art of thinking


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Clinical Decision Making- as to relevance

-look for the cues and makeinferences

-with experience, identifypatterns and recognize what

differs from norm and use data tomake decisions what will best

meet your patients needs

-use your knowledge, experienceand what the patient says to

validate the data.


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1. Reflexive Thinking-is automatic, withoutconscious deliberation, and comes with

experience2. Trial- and- error approach-hit- or miss

thinking

-fosters creativity and allows you toformulate new ideas

-look beyond the obvious, keep looking

until you find an answer


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3. Scientific Method- a systematic, critical

thinking approach to problem solving- involves identifying a problem andcollecting, supporting data and

formulating a hypothesis, planning asolution, implementing the plan and thenevaluating its effectiveness.

4. Intuition- a problem-solving method thatdevelops through experience


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These are needed to perform the fourtechniques of physical assessment:inspection, palpation, percussion and

auscultation. As a beginning practitioner,you may feel unsure of your techniqueand findings, but practice will hone yourskills. Input from others, throughexperience, you will become competentat performing the physical assessmentand confident in interpreting the findings


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Include both verbal and nonverbalcommunication skills

Establishing trust and mutual respect isessential before you begin theassessment

Seeing your patient as an individual andbeing sensitive to his or her feelingsconveys a message of caring andpromotes human dignity


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Interpersonal Skills are also needed tocommunicate with family members and

members of the health team tosuccessfully meet your patients goals


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Nonverbal messages and touch

Vocal cues and paralinguistics: quality of

voice, inflection, tone, intensity, andspeed

Action cues & kinetics: body movements,

posture, arm position, hand gestures,facial expression, eye contact


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Object cues: grooming, dress reflect his/her

identity and how he/she feels about himself orherself

Personal space: public, social, and personal,the territory surrounding a person that he/sheperceives as private or the physical distancethat needs to be maintained for the person tofeel comfortable

Personal conversation is about 18 inches to 4feet

Touch- is also a means of communication


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1. Affirmation/Facilitation-acknowledge your patientsresponse through both verbal and nonverbal

communication to reassure him/her that you are payingmuch attention to what he/she is saying, verbal cuessuch as ah ha, or nonverbal gestures such asnodding, leaning forward

2. Silence- it can be very effective at facilitatingcommunication. Periods of silence allow your patient tocollect her/his thoughts before responding

3. Restating-would show that you are listening

4. Clarifying- rephrase what she said by saying I

want to make sure5. Reflectionwhen a patient expresses feelings, you echo

it back in a form of question

6. Informing- giving information

7. Broad & general openings-use open-ended questions


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8. Active listening9. Humor- to reduce anxiety

10. Redirecting- redirecting your patient helps

keep the communication goal-directed. It isuseful if the patient goes off on a tangent.

11. Sharing perceptions- you give yourinterpretation on what has been said in order to

clarify things and prevent misunderstandings


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13. Identifying themes-this may help yourpatient make a connection and focus onthe major theme for example, you might

say From what youve told me, it soundslike every time you were discharged fromthe hospital to home, you has a problem

14. Sequencing events15. Presenting reality be more realistic


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Focusing

Suggesting

Summarizing-allows patient to clarifyany misconception you may have


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Genuineness- be open, honest and sincere

Respect-everyone should be respected as a

person of worth and value. Dont be judgmentalin your approach

Empathy-knowing what your patient meansand understanding how he/she feels.

Acknowledge patients feelings, showacceptance, care and concern


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Nursings Goal

To diagnose and treat human responses

to actual or potential health problemsMedicines Goal

To diagnose and treat disease


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Primary

To focus on health promotion and illnessprevention, minimize the risk of healthproblems ( immunization, nutritional

instruction)Secondary

To focus on early detection, prompt

intervention, and health maintenanceTertiary

To focus on rehabilitation and extended

care to continually monitor health status


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Subjective

Covert, not measurable symptoms

example is health historyObjective

Overt, measurable signs examples are

physical examination and diagnosticstudies


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1. Initial Comprehensive Assessmentinvolves collection of subjective dataabout the clients perception of her healthof all body parts or systems, past healthhistory, family history, lifestyle, andhealth practices as well as objective datagathered during the step-by-step physical

examination-examines the patients overall health

status


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2. Ongoing or Partial Assessment

- Consist of data collection that occursafter the comprehensive data base isestablished

- Consist of mini-overview of the clientsbody systems and holistic health patternsas a follow up on his health status

- Brief reassessment of the clients normalbody system or holistic health patterns isperformed to detect any new problems


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3. Focused or Problem-Oriented

Assessment- Does not take the place of the

comprehensive assessment

- Consists of thorough assessment of aparticular client problem and does notcover areas not related to the problem


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4. Emergency Assessment

-rapid assessment performed in life-

threatening situations(choking, cardiacarrest, drowning)

-assess the ABC of patient


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1. The Interview

Types of interviews: directive (are structuredwith specific questions) or non-directive

(controlled by patient, although the nurse oftenneeds to summarize and clarify the data)

Types of questions: open (elicit patientsperception like What brought you to thehospital?) or closed (Often that elicit a yes orno response)

Interviewing tips or techniques/pitfalls


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1. Introductory Phase

-time to introduce yourself

-put patient at ease and explain purpose of theinterview and time frame needed to complete it

- client may display some resistive behaviors

- these behaviors inhibit involvement,cooperation or change

- can be overcome by conveying a caringattitude, genuine interest, and competence

- trust can be developed- involves risk, as onebecomes vulnerable but enables the client to

express thoughts and feelings openly


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2. Working (Maintaining) Phase

-data collection occurs-listen to what the patient is sayingboth verbally and nonverbally

- begin to view each other as uniqueindividuals

- starts to care about each other


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3. Termination Phase

- expect some feelings of loss

- needs to develop a way of sayinggoodbye

- methods to terminate the relationship:

Summarizing or reviewing

Express feelings about termination honestlyand openly

Needs to be discussed in advance to allowtime to adjust


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2. Observation

3. Physical Examination


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Data reviewAre data accurate and

complete?

Data interpretation- What are the patients actual

and/or potential problems?

- Develop a problem list basedon the data; prioritize the

patients problems


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THE NURSE USE A WRITTEN FORMAT

THAT ORGANIZES THE ASSESSMENT

DATA SYSTEMATICALLY. THIS IS

OFTEN REFERRED TO AS NURSING

HEALTH HISTORY, NSG ASSESSMENT

OR NURSING DATABASE


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VALIDATION is the act of

double checking or verifying

data to confirm that it isaccurate and factual

Ensure that objective andrelated subjective data

agreed


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The nurse records client data. Accuratedocumentation is essential and should

include all collected data about clientshealth status data are recorded in afactual manner.


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Definitions

A. Medical Diagnosis identification of adisease condition based on a specificevaluation of physical signs, symptoms,

history, laboratory test and procedures.

B. Nursing Diagnosis a statement thatdescribes the clients actual or potentialresponse to a health problem that the nurse islicensed and competent to treat.


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A. To analyze assessment

data.

B. Identify health problems involving theclient and family.

C. Provide direction for

the nursing care plan (NCP).


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PROBLEM

Impaired skin

integrity

Impaired verbalcommunication

CAUSE

Physical

immobilization, lowoxygen saturation

Inability to speakdominant language


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1. Impaired Skin integrity related to physicalimmobilization, low saturation, andincontinence as manifested by disruption ofthe skin surface over the elbows

2. Impaired verbal communication related to

cultural differences as manifested by inabilityto speak English


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Steps in Nursing Diagnosis

A. Analyze and interpret data recognizepatterns and trends, comparing these with normalhealth patterns and drawing conclusions about theclients response.

1. Examine the clusters in the data

base.

2. When a relationship is identified, a

list of client-centered

problems/needs will emerge.3. Group together the cluster and

patterns consisting of defining

characteristics


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B. Identify client problems consider allassessment data and focus on pertinent

and abnormal data. In describing healthproblem, the nurse moves from generalto specific.


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Planning- is a category of

nursing behaviors in

which a client-centered goals and

strategies are

designed

to achieve goals.


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A. Establish priorities.-Nursingdiagnosis are ranked mutually by thenurse and the client in order ofimportance (based on clients desires,needs and safety) so as to identify,also in order, the nursing

interventions to be providedespecially when the client has multipleproblems


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1. Maslows hierarchy of needs isuseful in determining priorities.Physiological needs are givenpriority over safety needs.

.


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2. Classification2.1 High- nursing diagnosis that if

untreated, could result in harm toclient or others

2.2 Intermediate- involve the nonemergency, non life threatening

needs of the client2.3 Low- clients needs that may not

be directly related to a specificillness or prognosis

3. In situations when the client andnurse assign different priorityranking, it should be resolvedthrough open communication


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1.Definitions1.1 Goals-guideposts to the selection of

nursing interventions and criteria in the

evaluation of nursing interventions1.2 Client centered goal- a specific and

measurable objective designed to reflect

the clients highest level of wellness andindependence in function


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1.3Expected outcome-specific step by

step objective that leads the attainment ofthe goal and the resolution of the cause ofnursing problem

-Involves the physiological, social,

emotional, developmental or spiritualdimensions

-Determines when the specific, clientcentered goal has been met and assists in

evaluating the response to nursing careand resolution of the nursing diagnosis


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2.Purposes2.1They provide direction for the

individualized nursing intervention2.2 Used to determine the

effectiveness of the interventions .They

identify a specific means to evaluate theclients response to nursing care


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3.Types of Goals

3.1 Short Term Goal- an objective that isexpected to be achieved in a short period of time,usually less than a week. It is usually the aim of theimmediate care plan. E.g , a a short term goal for

Ineffective thermoregulationis Body temperature37C within an hour after tepid sponge bath

3.2 Long-term goal- an objective that is expectedto be achieved over a longer period of time, usually

over weeks or months. Are appropriate for problemresolution after discharge.

4 Functions of expected outcomes


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4. Functions of expected outcomes4.1 Provide a direction for nursing activities.4.2 Provide a projected time span for goal

attainment and an opportunityto state any additional resources that may berequired to achieve the goal, including additionalequipment, personnel or knowledge.

4.3 Serve as criteria to evaluate the effectiveness

of nursing activities.5. Guidelines for writing goals andexpected outcomes.

5.1 Should be client-centered. e.g The newly

delivered mother will breastfeed her newborn babyon demand. i.e Whenever the baby is hungry .5.2 Should address only one behavioral response

at a time so as to provide a more precise method toevaluate client response to the nursing action.


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E.g Clients temperature willdecrease to 37C and respiratory rate

will be 16-20 minute 1 hour afteradministration of ordered antipyreticshould be split into two:

Temperature will decrease and Respiratory rate will be

5.3 Expected outcome should be


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5.3 Expected outcome should beobservable e.g Bowel movement willdecrease in frequency after 24 hours.

5.4 should contain outcome criteria and arewritten to give the nurse a standard againstwhich to measure the clients response tonursing care. Terns specifically describing

quality, quantity, frequency and weightallow the nurse to evaluate the expectedoutcome. Value qualifiers like normal,acceptable or sufficient are not allowed.

E.g Blood pressure will return to 120/80mm Hg a day after administration ofantihypertensive drug.

5.5 A time frame is necessary for each goaland expected outcome.


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Write the Nursing Care Plan

Definition: A written guideline for clientcare.

Contents2.1 Nursing diagnoses

2.2 Goals

2.3 Specific nursing activities andstrategies

2.4 Expected outcomes

P


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Purposes

3.1Documents the clients health care needs,which are determined by assessment and thenursing diagnoses, priorities and goals andexpected outcomes formulated duringplanning.

3.2 Coordinates nursing care, promotescontinuity of care and list outcome criteria tobe used in the evaluation of nursing care.

3.3 Communicates to other nurses and healthcare professionals pertinent assessmentdata, a list of problems and therapies.

3 4 k ibl h di i f


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3.4 makes possible the coordination of

nursing care, subsequently consultations

and scheduling of diagnostic tests.

3.5 Identifies and coordinates resources

used to deliver nursing care.

3.6 Enhance the continuity of nursing care

by listing specific nursing actions necessary to achieve the goals of care.


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3.7 Organizes information exchanged by

nurses in change-of-shift reports.

3.8 Can be adapted to the discharge needs

of the client.

3.9 provides direction for implementation of

the plan and a framework for evaluation

of the clients response to nursing

actions.


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Institutional care plans concisedocuments that become part of theclients medical record. Manyhospitals use the Kardex, a tradename for a card-filing system thatallows quick reference to theparticular needs of the client for

certain aspects of nursing care: diet,medications, activity level, level ofself-care, treatments and procedures.


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Standardized care plans formscreated for a specific clinical area,(e.g ICU, OPDs, DRs) in order tostreamline and augment careplanning. They are not intended toreplace the NCP but to avoid a

situation in which are not nurse mustwrite the same generalized planagain


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Students NCPs essential for learning theproblem-solving technique, the nursing

process, skills of written and verbalcommunication and organizational skillsneeded for nursing care. Students are able toapply the theoretical knowledge to a practice

situation. In fact is more elaborate than thefirst two, consisting of 5 columns:assessment, goals, implementation, rationale(the reason that, based on supportingliterature, a specific nursing action waschosen) and expected outcomes.


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Definition- a category of nursingbehavior in which the actions

necessary for achieving theexpected outcomes of nursingcare are initiated andcompleted. It includes:


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Performing, assisting or directingthe performance of activities of

daily living. (ADL) Counseling and teaching the

client and family Giving direct

care to achieve client centeredgoals


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any act by the nurse that implementsthe nursing care plan (NCP) or any

specific objective of the plan. It maybe in form of support, medication,treatment for the current condition or

to prevent future health problems orclient family education


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Types of Nursing Intervention

A. Independent nursingactions-


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B. Interdependent Nursing Actions

- carried out by the Nurse incollaboration with another health careprofessional. Collaboration is a

partnership wherein the power onboth sides is valued by both


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Dependent nursing actions- are based on the instruction or

written orders of another professional,the implementation of which requiresspecific nursing responsibilities andtechnical nursing knowledge.


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An ongoing, dynamic and everchanging component of the nursing

process which measures the clientsresponse to nursing actionsperformed and the level of successin achieving clients goals. In other

words, It ensures qualityprofessional nursing practice.


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Degrees of Goal Attainment

a. Met Goal-if the clients responsematches or exceed the outcome criteria

b. Partially met goal-if the clientsbehavior begins to show changes butdoes not yet meet specified criteria

c. Unmet goal-there is no progress at all


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Consider the following assessment of MaryRutherford: after a cholecystectomy. Herassessment data include the following:

>it hurts to take a deep breath

>pain rated 8/10

>guarding abdomen

>v/s BP 144/90mmhg,PR-108bpm,RR-24cpm,T-

38 degree Celcius>decreased breath sounds

>dressing dry and intact


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Subjective data Objective data

Assessment/Clinical judgment-Ineffectivebreathing pattern related to incisional pain

Plan-pt will establish effective breathingpattern; pt will experience no signs ofrespiratory complications

Interventions-encourage coughing and deep

breathing, encourage ambulation, maintainadequate hydration

Evaluation-patient coughing and deepbreathing, ambulating, v/s


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Data

Action

Response


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Problem-Ineffective breathing patternrelated to incisional pain

Interventions

Evaluation


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4/14/09 8AM. Patient stated It hurts to

take a deep breath, rates pain 8/10, v/s

BP 144/90 mmHg, T- 38 degreeCelcius,pr 108, RR 24,

9AM. Patient coughing and deep breathing,ambulating with assistance