Practical nursing clinical (online help)
Jack Fowler
PNC121Week8-NursingProcessandCarePlanPPT2221.pptxThe Nursing Process & Care Plan Development
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What is the nursing process?
Intellectual process of reasoning
Aims to identify, diagnose, and treat actual and potential health issues and challenges of clients from a holistic perspective
Guides clinical judgement, decision making, and reflective practice
Encourages critical thinking
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5 Phases of the Nursing Process
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Phase one : Assessment
Systematic collection of data to determine the client’s current and past health and functional status.
Nurse collects a variety of different types of data in order to fully understand the client priority needs(can you think of types of data that may be collected by the nurse?)
Holistic and comprehensive assessment
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Phase Two: Diagnosis
Nurse analyzes the assessment data in order to determine the key issues and make clinical judgements in the form of a nursing diagnosis
This step directs the plan of care for the client
Identify outcomes for the client that are individualized to the client and the client’s situation
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Phase Three: Planning
Creation of a formal plan
Prescribes strategies and alternatives to attain the expected outcome
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Phase Four: Implementation
Carrying out the plan
May occur by coordinating care delivery, providing health teaching and health promotion activities, , consulting with other health care professionals, or providing medications or other therapies (can you think of any other examples?)
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Phase Five: Evaluation
Evaluating the client’s response to the selected interventions
Determine whether the interventions were effective
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Let’s look at each phase in more detail
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Phase One - Assessment
Critical thinking is foundational to a comprehensive and accurate nursing assessment
Enables the nurse to have a broader perspective from which to form conclusions and make decision concerning client’s health condition
Includes collection and verification of data from a variety of sources.
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Assessment – Primary Sources of Data
Primary Sources of data – the client.
This is the best source of data if the patient is able to provide it
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Assessment – Secondary Sources of Data
Secondary sources of data: this includes the family and significant others.
Health Care Team - Every member of the health care team is a source of information for identifying and verifying information about the client
Medical Records
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Assessment – Tertiary Sources of Data
Literature
Nurse’s Experience
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Assessment (Cont’d)
While gathering data during the assessment phase of the nursing process the nurse:
Synthesizes relevant knowledge
Recalls prior clinical experiences
Applies critical thinking standards and available evidence
Uses standards of practice directing assessment in a meaningful and purposeful way
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Types of Data: Subjective Data
Subjective data are obtained through the health history and the nurse’s questions
It is the client’s verbal descriptions of their health concerns
ONLY client’s provide subjective data
Data can reflect physiological changes which nurses further explore through objective data collection. For example the client may state she has chest pain the nurse will then collect further data to support this symptom.
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Types of Data: Objective Data
Objective data are observations or measurements of a client’s health status, based on an accepted standard(Celsius, kilograms, milliliters, known characteristics of behavior such as anxiety or paranoia)
Objective may be considered a normal or abnormal finding
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Methods of Data Collection: Nursing Health History
Family History
Physical Exam including observation of client behavior
Diagnostic and laboratory data
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Interpreting Assessment Data
When nurses critically think about interpreting assessment information, they determine the presence of abnormal findings
Nurses who critically think about interpreting assessment findings know what further observations are needed to clarify information and the client’s health problems
Validation of assessment data is necessary to avoid making incorrect inferences
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Phase Two - Diagnosis
Diagnostic language is shared by nurses
A clinical judgement about individual, family, or community responses to actual and potential health problems or life processes that is within the domain of nursing
A judgement that is based on a comprehensive nursing assessment
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Components of a Nursing Diagnosis/Problem
Diagnostic Label: describes the essence of the client’s response to health conditions in as few words as possible
Related Factors: A condition or etiology identified from the client’s assessment data. Associated with the clients actual or potential response to the health problem and can be altered through the use of nursing interventions
Also an “as evidenced by” portion that connects the diagnosis to the signs and symptoms
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Components of a Nursing Diagnosis/Problem (cont’d)
Definition: Nanda approved definitions for diagnoses, not necessarily used now. Can use nursing problems instead.
Risk Factors: Environments, physiological, phycological, genetic, or chemical elements that increased the vulnerability of an individual, family, or community to an unhealthful event
Support of the nursing diagnostic statement: Nursing assessment data must support the nursing diagnostic label and the related factors must be included in these data
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Phase Three – Planning: Establishing Priorities
Set client centered goals, expected outcomes, plan and prioritize nursing interventions
Multiple nursing diagnoses are possible
Rank the nursing diagnoses or client problems using principles such as urgency to establish an order for nursing actions attending to client’s most important needs first
High priority nursing diagnoses examples: Decreased cardiac output, risk for violence, impaired gas exchange
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Planning - Establishing Goals and Expected Outcomes
Goals and outcomes are specific, measurable client behavior or physiological responses that nurses set to achieve through a nursing diagnosis.
They provide a focus for the type of intervention required to care for the client
A Client-centered goal is a specific and measurable behavioral response that reflects a client’s highest possible level of wellness and independence in function
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Planning - Establishing Goals and Expected Outcomes (cont’d)
Short-term goal: objective behavior or response that the client is expected to achieve in a short time, usually less than 1 week or in acute care may be in just a few hours
Long-term goal: objective behavior or response that a client is expected to achieve over a longer period, several days, weeks, or months
Mutual goal setting includes client’s and client’s families
Ensure SMART goals
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Phase Four - Implementation
Selection of nursing interventions involves complex decision making and is based on critical thinking to ensure that an intervention is correct and appropriate for the clinical situation
Refer to the standards and practice guidelines of each agency
Standards of practice are guidelines are standards of practice and sanction principles to provide safe and competent care
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Types of Nursing Interventions
Independent nursing interventions: do not require direction or orders from other health providers e.g. elevating an edematous leg
Dependent nursing interventions: require an order or direction from a physician or NP and are directed towards managing a medical diagnosis, e.g., administering a medication
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Phase Five: Evaluation
This is the final step
It involves two components:
An examination of a condition or situation
A judgement as to whether change has occurred
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Evaluation Process
Identifying evaluative criteria and standards
Collecting evaluative data
Interpreting and summarizing findings
Documenting findings
Revising, discontinuing, modifying a care plan
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Schematic of Care Plan Development
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Concept Map of Care Plan Development
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