Nursing ProcessJane R Bordner, RN, BSN

Nursing InstructorHACCN100

Spring 2014

Nursing

The Changing Face of Nursing

What Do Nurses Do?

Nursing process gives us a direct and precise way to answer

Nursing process = a problem solving approach used to meet client needs

Nursing Process

Is an organized, systematic method of giving individualized nursing care that focuses on identifying and treating unique responses of individuals or groups to an actual or potential alteration in health.

Nursing Process continued…

Based on the fundamental belief that every person is endowed with personal worth and dignity, and has a right to high quality care regardless of socioeconomic status, cultural background, or religious belief.

Purpose of Nursing Process

ID nursing-related client health care needsEstablish a plan of care to meet needs Implement nursing interventions/actionsProvide basis for ongoing evaluation

Nursing Process and Critical Thinking

Critical thinking is very important in nursing decision making

Critical thinking is necessary to make complex decisions involved in patient care

Critical thinking answers the question: who benefits and whose outcomes are being met by my nursing actions?

Nursing Process and Critical Thinking

Critical thinking : analyze assumptions, challenge status quo, recognize limitations, and take actions to improve it.

Steps in the Nursing Process

Step 1 Assessment

Step 2 Nursing Diagnosis

Step 3 Planning Care

Step 4 Implementation

Step 5 Evaluation

Use of Nursing Process

Family member illnessAssessmentDiagnosisPlanningImplementationEvaluation

Role of the LPN

Assessment

Nursing Diagnosis

Planning

Implementation

Evaluation

Assist in data collection

Assist in choosing ND

Assist in formulating and choosing interventions

Carry out plan within scope of practice

Assist in evaluation and revision of plan of care

Step 1: Assessment Thorough and holistic Based on:

clinical and laboratory data medical history patient’s account of symptoms.

Requires: data collection data validation data sorting data documentation

Types of DataSubjective Data/Signs

Client’s perceptionsWhat the client tells

you.Example: “I am in pain.”

“I feel nauseous.”

Objective Data/SymptomsObservations or

measurementsThings the nurse

sees, hears, and feels.

Example: Vital signs, bowel sounds, temperature of skin

Subjective vs. Objective Data

1. ___ My leg pain is a throbbing pain2. ___ 2 seconds capillary refill3. ___ Lung sounds clear bilaterally4. ___ I have no allergies5. ___ I fell last night6. ___ Apical pulse 68 and regular7. ___ Patient moaning8. ___ Moderate yellow sputum9. ___ I am extremely tired10. ___ Skin warm and dry to touch

Shift Assessment

OrganizedSystematicBriefAccurateOrder depends upon presenting S&S

Types of Assessments

Shift Assessment

Focused Assessment

Comprehensive Health Assessment

Focused Assessment

Detailed assessment of particular systemBrief (2 to 5 minutes)“Quick check” ID changes in areas most likely to changeBased on problems ID’d in shift assessment

or new problems that ariseFind changes early and avoid complications

Example

Patient admitted with pneumonia. Though the nurse asks questions and assesses all systems, he/she will focus much more attention on the respiratory system - listening to breath sounds, asking about shortness of air, cough, etc…

Example

Next shift, same patient, New nurse enters his room and he reports

abdominal pain. The nurse will briefly assess all systems, but in addition to focusing on the respiratory system, he/she will also do a detailed assessment of the GI system.

WHATSUP guide to Symptom Assessment

W Where is it? H How does it feel? Describe it? A Aggravating and alleviating factors? T Timing: When did it start? How long

does it last? S Severity on scale of 1 to 10 U Useful other data. Other symptoms? P Patient’s perception of problem

Using WHATSUP

Mrs. Cooper, age 47, had a hysterectomy 2 weeks ago. She is admitted with a right calf deep vein thrombosis that she thinks resulted from having surgery. She rated her pain, which began 2 days ago and is constant, at 8. She has increased calf tenderness with leg movement. Leg elevation and Tylenol #3 increases her comfort. Her calf is hot to touch and red. Her legs measure: R calf 9 inches; L calf 8 inches; R thigh 14 inches; L thigh 14 inches.

Comprehensive Health Assessment

Assessment of all body systems and detailed health history

Provides baseline of client’s health status and functional abilities at that time

Helps nurse determine plan of action to address client’s nursing needs

Abnormal assessment findings signal nurse to gather additional data in that area

Parts of Comprehensive Health Assessment

Interview

Physical ExamComplete shift assessment

Auxiliary Data

Components of Nursing Interview

Biographical DataChief ComplaintHistory of Present IllnessPast Medical HistoryEnvironmental HistoryPsychosocial and Cultural HistoryReview of Systems (ROS)

Important Interview Techniques Introduce yourselfUnhurried mannerGood eye contact (if culturally appropriate)Silence/Listening skills/Clarifying Observation skills (Get objective data

during interview)Age and developmental considerationsContinually work on developing therapeutic

relationship

What is Caring?

RespondingSensing emotionsAcceptanceMaking a connection“Caring for the Whole Person”

Critical Thinking: Data Collection

Your neighbor, Mr. Lewis, age 76, knocks on your door. He says “Look at my left foot. It is very swollen. I wore new shoes yesterday that felt tight. Now I can hardly get any shoes on this foot. There is a tender area on the top of my foot. I think something is wrong. Can you help me?”

Sources of Data

ClientFamily members or significant othersOther members of health care teamCurrent and previous hospital recordsDiagnostic studies/Laboratory reports

Documentation of Data

ALL objective and subjective data must be documented

Only what was observed by or stated to you

Subjective data using direct quotes NOT DOCUMENTED, NOT DONE

Common Diagnostic Tests

Blood CBC

Electrolytes

ABG’s

Blood Glucose

Urine Urinalysis (UA)

Urine Culture and sensitivity

Common Diagnostic Tests

Radiological Chest X-ray

Exams Upper GI

Lower GI

CT & MRI scans

Stool Ova and Parasites

Clostridium difficile (C. diff)

Occult blood

Common Diagnostic Tests

Sputum Culture and Sensitivity

Acid Fast BacilliCytology

Other EKG or ECGStress TestTB Test

Patient History

Medications

Laboratory Studies Assessment Data

Step 2: Nursing Diagnosis

Standardized label that identifies client’s problem

Makes it understandable to all nursesLanguage of nursesAddress actual or potential health

problems

Step 2: Nursing Diagnosis

ID’d by nurse after analyzing assessment data and comparing it with what is considered to be normal

Abnormal findings are organized into data clusters

Nursing diagnoses are developed from data cluster

Nursing, Medical, Collaborative Diagnoses

Nursing diagnoses: problems which can be treated independently by nurses

Medical diagnoses: those that require care that only a physician or nurse practitioner can render

Collaborative diagnoses: problems that can be helped by both medical and nursing interventions

Medical VS. Nursing Diagnoses

MedicalID’s pathological

basis for illnessFocuses on

physical condition only

Addresses actual problems

NursingID’s response to

illnessFocuses on

physical, psychosocial, and spiritual needs

Addresses actual and potential problems

Medical VS. Nursing Diagnoses

MedicalNot validated with

clientUses standardized

treatments and goals

May not be resolvable

NursingValidated with

clientUses individualized

goals and interventions

Usually resolvable

Medical VS. Nursing Diagnosis

Client admitted with medical diagnosis of congestive heart failure (CHF)

Look up medical diagnosis in front of your Nursing Diagnosis Handbook.

Many potential nursing diagnosis based on one medical problem

Assessment data will reveal which may best FIT YOUR client

Writing Nursing DiagnosesPart 1 Nursing Diagnosis

Label related to (R/T)

Part 2 Etiology (cause)as evidenced by (AEB)

Part 3 Signs and Symptoms

Example

Client has abdominal surgery this am. Assessment data reveals that the client is experiencing pain. It is rated by the patient as 4 on a scale of 0 to 5. The patient is also exhibiting facial grimacing and is moaning.

The nursing diagnosis related to this assessment data is ACUTE PAIN.

Writing Nursing DiagnosisPart 1 Acute pain

related to…

Part 2 actual tissue damage from abdominal

surgeryas evidences by…

Part 3 Patient stating “My pain is 4 of 5.”

Moaning/ facial grimacing

Part 1 of StatementNANDA list of approved nursing diagnosis

labelsProblems that nurses routinely address in

practiceList in back of your Nursing Diagnosis

Handbook“I am so nauseated from my chemo

treatments that I cannot eat anything.”

Part 2 of StatementEtiology or causeStatement follows nursing problem and

words “related to” = R/TComes from your nursing knowledge and

assessment dataEtiology is individualized for each clientNO MEDICAL DIAGNOSIS“I am so nauseated from my chemo

treatments that I cannot eat anything.”

Part 3 of StatementDefining characteristicsFollows words “as evidenced by” = AEBList signs and symptoms obtained from

assessment S&S that supports your statementUse all relevant information

ObjectiveSubjective

“I am so nauseated from my chemo treatments that I cannot eat anything.”

Nursing Diagnosis

Nausea R/T

treatment/medications AEB

pt stating “I am so nauseated from my chemo treatment that I cannot eat anything”.

Nursing Diagnosis: Actual vs. High Risk Problems

ActualExisting problemClient has S&S of

problemRequires 3 part

nursing diagnosis statement

High RiskHigh probability of

occurring in futureThere are no S&SRequires 2 part

nursing diagnosis statement

High Risk Diagnosis

Assessment DataPatient has been on bedrest for 1 weekPatient is incontinent of urinePatient unable to move or turn self in bedSkin is clean and intact

High Risk Diagnosis

Risk of impaired skin integrity: Risk factors: incontinence and physical immobility.

*Note: This is a risk problem because no skin breakdown has occurred yet. You are going to use your nursing skill to prevent skin breakdown.

Nursing Diagnosis

Nursing Diagnosis Practice

Assessment DataPatient states she is feeling “nervous and

anxious”.Her hand are shaking.Staff observes her crying.Progress notes state that her physician told

her earlier that her lung biopsy was positive for cancer.

Nursing Diagnosis

Anxiety R/T

change in health status AEB

pt stating that she feels “anxious and fearful” and episodes of crying and shakiness.

Nursing Diagnosis Practice

Assessment Data92 year old female.Patient has weakness in all extremities.Fatigues rapidly with activity.Unable to perform ADL’s without becoming

fatigued. Frequently makes statements such as “I feel

so tired and weak”.

Nursing Diagnosis

Activity intolerance R/T

generalized weakness AEB

inability to perform ADL’s without fatigue and stating “I feel so tired and weak”.

Nursing Diagnosis Practice

Assessment Data82 year old malePast medical history of a stroke with left-sided

weakness and bilateral cataracts Walks with a walkerShuffling gait

Nursing Diagnosis

Risk for falls R/T

impaired vision/impaired mobility

Impaired physical mobility R/T

neuromuscular impairment AEB

left-sided weakness and using walker to ambulate

Nursing Process Worksheet

READ and HIGHLITE abnormal data IDENTIFY objective vs. subjective dataWhat does abnormal data tell us?What are some nursing diagnoses?

Nursing Diagnoses

What problems do you see here?Are they actual problems or high risk

problems?How would you write them?Look at NANDA list. What works for this

patient?

Nursing Diagnosis Worksheet

ACTIVITY PROBLEMS

1. Activity intolerance related to ____________ AEB ______________________________.

2. Sleep deprivation related to ____________ AEB ______________________________.

Nursing Diagnosis Worksheet

3. Fatigue related to ____________________ AEB ______________________________.

Nursing Diagnosis Worksheet

• PAIN1. Chronic pain related to

_________________ AEB ______________________________.

• NUTRITION1. Imbalanced nutrition: less than body

requirements related to ________________ AEB _______________________________.

Nursing Diagnosis Worksheet• SAFETY

1. Impaired skin integrity related to _________________ ABE ___________________________________.

• RISK PROBLEMS1. Risk for injury related to

______________________________.

Nursing Diagnosis Worksheet

• OTHERS?1. Impaired physical mobility related to

_________________________ AEB ______________________________.

Nursing Process Summary

The nursing process is a problem solving approach. Experienced nurses engage in this type of thinking as a matter of routine.

You need to learn how to think this way in order to be a successful nurse.

Nursing Process Summary

Types of Assessments

Shift Assessment

Focused Assessment

Comprehensive Health Assessment

Shift Assessment

Involves a brief systemic review of client’s condition at beginning of a shift

Nurse compares assessment findings with those from previous shift

Takes 10 to 15 minutes

Preparation ID clientPrivacyKeep client comfortableBody mechanicsLighting Quiet Equipment

Shift Assessment

Equipment NeededStethoscopeBP cuffThermometerWatch with a second handPen lightMeasuring Tape (maybe)

Cultural Sensitivity

Cultural differences influence a patient’s behavior

Recognition of cultural diversity helps to respect the patient

Consider a patient’sHealth beliefsUse of alternative therapiesNutritional habitsFamily relationshipsUse of personal space

Physical Assessment Includes

InspectionPalpationPercussionAuscultation

Inspection

The use of vision and hearing to distinguish normal from abnormal findingsUse adequate lightingPosition and expose body partsInspect for size, shape, color, symmetry,

position, and abnormalitiesSide to side comparisonPay attention to detail

Palpation

Involves using the handsExamine accessible body partsPalpate skin

Temperature, moisture, texture, turgor, tenderness, and thickness

Palpate abdomenTenderness, distention, or masses

Percussion

Tapping the body with fingertips to produce a vibration

Character of soundDetermines location, size, and density of

structuresDepends on the density of tissuesAbnormal sounds can be mass, air, or fluid

Auscultation

Listening to sounds produced by the bodyAssess sounds heard in the heart, lungs,

and gastrointestinal systemsRequires the use of a stethoscopeCharacteristics include

FrequencyLoudnessQualityDuration

General Survey

Begins when you first meet a patientBegins with review of primary health

patternThe survey provides information regarding

Characteristic of illnessHygieneSkin conditionBody imageEmotional stateDevelopmental status

General Appearance and Behavior

Gender and Race Age

Signs of Distress Body Type

Posture Gait

Body Movements Hygiene and Grooming

Dress Body Odor

Affect and Mood Speech

Patient Abuse Subculture Abuse

Shift Assessment Includes

Vital signs IntegumentaryNeurologicalMusculoskeletalCirculatoryRespiratoryGastrointestinalGenitourinaryPsychosocial

Skin

AssessmentNursing history

ColorMoistureTemperatureTextureTurgorVascularityEdemaLesions

Nails

Inspection and palpationCondition of nails reflects

General healthNutritional statusOccupationsLevel of self-care

Hair and Scalp

Use inspectionAssess

DistributionThicknessTextureLubrication

Neurological

Mental StatusOrientationSpeech

Neurological System

Conduct a nursing historyAssess

LanguageIntellectual functionCranial nerve functionSensory nerve functionMotor function

Head and Neck

Inspection and palpationAssess

Headache, dizziness, seizures, poor vision, loss

of consciousnessHead size, shape contour of head and skullFacial symmetry

Nose and Sinuses

Inspection and palpationAssess for exposure to

DustPollutantsAllergiesNasal obstructionTraumaDischarge, postnasal dripHeadaches

Mouth and Pharynx

Assesses overall healthDetermine oral hygiene needsDevelop therapies for dehydrationAssess oral traumaAssess for airway trauma

Oral Cavity

Neck

Neck musclesLymph nodesCarotid arteriesJugular veinsThyroid glandTrachea

Eyes

Vision

Ears

Hearing

Circulatory

Core Body TemperatureSkin

ColorTemperature

Turgor

Capillary Refill

Edema

Skin Integrity/Alterations

BP

APICAL PULSE

Peripheral Pulses

Radial Pulses80A/80R

IV’s

Peripheral

PICC

Mediport

Breasts

Examine both female and male breastsTake a health history Use inspection and palpation

Respiratory

RespirationsCough

O2

nasal cannula

face mask

Lung Sounds

RUL LULRML LLLRLL

LUNG SOUNDS

Gastrointestinal

NutritionDiet% eatenN&VHt. & Wt.

LOOK, LISTEN, & FEEL

Abdomen

Right Upper Quadrant Left Upper Quadrant

Right Lower Quadrant Left Lower Quadrant

RUQ LUQ

RLQ LLQ

BowelsWhat is “normal”?Ask about

FrequencyColorConsistencyAmount

Genitourinary

UrineIntake and OutputPerineal Area

Foley CatheterDraining urine

Female Genitalia

Examination of the genitalia includes external and internal sex organs

Must provide privacyNeed to understand cultural sensitivityConduct a nursing historyUse inspection and palpation

Male Genitalia

Assess the integrity of external genitalia, inguinal ring, and canal

Conduct a nursing historyUse inspection and palpation

MusculoskeletalGaitPostureExtremities

Contractures/AmputationsEnlargementAlignment/SymmetryHeat, tenderness, edema

ROM

Muscle Strength

Abnormal Sensations

Musculoskeletal

BUE RUE LUE

BLELLERLE

Psychosocial

EmotionalSupport SystemCulturalSpiritual/ReligionSocial Interaction

Additional Data

PainSelf-care Deficits

Wounds/Incisions 1. Kocher/Subcostal

2. Midline

3. McBurney

4. Battle

5. Lanz

6. Paramedian

7. Transverse

8. Rutherford Morrison

9. Pfannenstiel

Tubes/Drains