The Nursing Process - Care Plan 4 (1)

7/31/2019 The Nursing Process - Care Plan 4 (1)

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The Nursing

Process


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Definition of theNursing Process

An organized sequence of problem-solving

steps used to identify and to manage the

health problems of clients.


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Overview of theNursing Process

The purpose of the nursing process is to

provide individualized, holistic, effective,

and efficient care to clients.


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Characteristics of theNursing Process

Cyclic and dynamic

Client-centerd


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Components of theNursing Process


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Assessment

Collection of data Direct Indirect

Comprehensive Before you see

client When you see clientAfter you see

clients

Methods Interview Observation

Physical exam

Check labs &

diagnostics


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Sources of Data

Primary source: Client

Secondary source: Clients family,reports, test results, information incurrent and past medical records, and

discussions with other health careworkers


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Types of Data To Collect:

Objective data-observable andmeasurable facts (Signs)

Subjective data-information that only theclient feels and can describe

(Symptoms)


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Assessment Exercise # 1

Identify the crucial assessment cuespresented by Richard in the caseprovided.

Specify the subjective andobjective data that are critical to

the nursing management of thisclient and indicate the methodsand sources that you would use tocollect these data.


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Verifying Data

Essential in critical thinking!!!!!

Double check personal observations

Double check equipment Check with experts and team members

Compare objective and subjective data

Clarify statements


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Data Organization

Determine the structure of assessmentthat is used by different health agencies

Utilize a theoretical framework toorganize data. E.g. Orem (nursing

model) arranges data according to theself care requisites of the client, whileMaslow (non-nursing) clusters dataaccording to a hierarchy of needs .


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Example of theory non-nursing

Maslows hierarchy of needs

Physiological

Safety and security

Love and belonging

Self-esteem Self actualization


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Assessment Exercise # 2

Use Maslows hierarchy of needs toidentify the needs of Richard that are

affected

Specify the ways in which his needs are

affected

Indicate your reasons for identifying

those needs as being affected


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NURSING DIAGNOSIS

Statement describing clients actual orpotential response to health problems

That the nurse is licensed & competent to treat

Clinical judgment about an individual, family

or community response to actual or potentialhealth problems & life processes


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NURSING DIAGNOSIS

Provides basis for selection of nursinginterventions to achieve outcomes for whichthe nurse is accountable


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Example

Assessment cuesloss of appetite; skin turgor poor; muscle tone flaccid;

mucous membranes dry; weight 120 pounds, height5 11; dry mouth; tearfulness; tiredness; loss of

interest in working out; death of father; verbalizesmissing his father; verbalizes knowledge of theright foods.

Cluster cues Weight loss; anorexia; dry mouth; poor skin turgor;

poor muscle tone; tiredness (nutritional) Death of father; tearfulness; missing father; loss of

interest in working out. (psychological)


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Steps in FormulatingNursing Diagnoses

Formulate nursing diagnosis

Actual Risk

Syndrome

Wellness


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Diagnosing: Formulating adiagnostic statement

Actual diagnoses are written when aproblem is manifested by subjective or

objective data.

Risk diagnoses are formulated when

the problem does not exist, but factorsare present that place the client at riskfor the problem developing


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Nursing Diagnoses

Syndrome

Comprises a cluster of actual or risk nursingdiagnoses that are predicted to present

because of a certain situation or event

Wellness

Is a clinical judgment about an individual,family, or community in transition from aspecific level of wellness to a higher level ofwellness


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DiagnosticStatements

Name of the health-related issue or problemas identified in the NANDA list

R/T - Etiology (its cause)AEB or AMB - Signs and Symptoms

The name of the nursing diagnosis is linked to theetiology with the phrase related to, and the signsand symptoms are identified with the phrase asmanifested (or evidenced) by


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Writing NursingDiagnoses

One Part

Wellness diagnosis will be written as one partstatements: Readiness for Enhanced ____. e.g.Readiness for Enhanced Parenting

Related factors are not present for wellness

nursing diagnosis because they would all bethe same: motivated to achieve a higher levelof wellness.


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Two Part

Risk for or possible nursing diagnosis

Problem + Etiology/Cause and RiskFactors

Related to links risk/possible problemwith the related factors present


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Sample

Risk for Impaired Skin Integrity related toimmobility & decreased circulation

Risk of infection related tocompromisednutritional state

Risk for Constipation related toimmobility &inadequate fluid intake


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Three Part

Actual nursing diagnosis; validated bydefining characteristics

Problem + Etiology + Sign/Symptoms

Related to links problem with etiology orrelated factors

As evidenced by states the evidence ordefining characteristics


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Sample

Diarrhea related torapid gastric emptying(dumping syndrome) as evidenced byliquidstools & abdominal cramping

Impaired Communication related to

language barrier as evidenced byinability tospeak or understand English & by use ofSpanish

Critique the following


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Critique the followingNursing Diagnostic

Statements

Risk for constipation related to low fluid

and fiber intake manifested by difficultpassage of hard stools

Risk for constipation related to reducedfluid and fiber intake


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Planning

Prioritizing client problems

Formulating client goals/desired outcomes

Selecting nursing interventions to meet

client goals

Constructing the nursing care plan


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Planning

Establishing priorities

Based on Maslows Hierarchy of Needs Physiologic

Safety

Affection Esteem

Self-actualization


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Stating patientgoals/objectives

Goals can be long term or short term

Goals are generally broad and non-specific.

Objectives are very specific and arewritten in terms of what the client isexpected to do


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Guidelines for writing objectives

Objectives should be

S-specific (identifies what will be done andby whom the client)

M-measurable (Provide criteria forevaluation)

A-achievable (provide condition under which

objective will be met) R-realistic

T-time-sensitive


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Planning exercise #2

Now write 1 additional goal and objective

for Richard from the problems/nursingdiagnoses you identified earlier


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NURSING


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NURSINGIMPLEMENTATIONS

Road maps directing the best ways toprovide nursing care.

Actions necessary for achieving goals &outcomes

Based on related factors


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Implementation

Types

Dependent

Independent

Collaborative


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Implementation

Independent Interventions

Nurse-initiated

Related to Nursing Diagnosis & client-centred goals

Requires no supervision or direction fromothers

Does notrequire physicians order


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Implementation contd

Remember to state a rationale for eachintervention

Rationale - scientific principles, theories orconcepts underlying nursing interventions

E.g. Perform tepid sponging prn

Rationale: to decrease bodytemperature through vaporization

http://www.bergen.edu/faculty/mmchale/assets/Nursing%20Care%20Plan%20Guide%20-%20revised%205-04.pdf


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Planning exercise #3

Now write two interventions for each ofthe problems you have identified.

State whether those interventionsA. are independent, interdependent, or

dependent

B. meet the patient's needs or measure the

outcome


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Evaluation

Relationship between goals & evaluation Comparison of data to outcomes & judgment of

clients progress

Reassess responses Identify variables affecting outcome achievement

Three possible outcomes of evaluation

Outcomes met terminate the plan Outcomes partially met continue plan as

written/modify the plan

Outcomes not met modify the plan


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Documents

The Nursing Process - Care Plan 4 (1)