Observe the rate, depth, and character of the client's respirations.
Rationale:
The nurse should apply the nursing process priority-setting framework when caring for this client. The nurse can use the nursing process to plan client care and prioritize nursing actions. Each step of the nursing process builds on the previous step, beginning with assessment or data collection. Before the nurse can formulate a plan of action, implement a nursing intervention, or notify a
provider of a change in the client's status, the nurse must first collect adequate data from the client. Assessing or collecting additional data will provide the nurse with knowledge to make an appropriate decision; therefore, the first action the nurse should take is to assess the client's respiratory status.
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Data gathered about patient-both objective and subjective, vitals & labs
Process of learning.
Type of information needed: specific knowledge, pts type of learning (Cognitive, psychomotor, affective), pts motivation (pt may need help to see need for learning, nurse should remove barriers), pts needs (health behavior desired, current level of understanding, skill level, pts attitudes and beliefs, social cultural and environmental
factors)
assessment
Assessing is the systematic and continuous collection, organization, validation, and documentation of date. 4 types of assessments.
* Initial nursing assessment
* Problem-focused assessment
* Emergency assessment
* Time-lapsed assessment
assessment data
Information about a client's health status
database
contains all the information about a client; it includes the nursing health history, physical assessment, primary care provider's history and physical examination, results of laboratory and diagnostic tests, and material contributed by other health personnel.
evaluation
to measure if goals in the planning step were met; a step in the nursing process
implementation
consists of doing and documenting the activities that are the specific nursing actions needed to carry out the interventions.
intervention
A nursing intervention is "any treatment, based upon clinical judgement and knowledge, that a nurse performs to enhance patient/client outcomes".
nursing care plan
Written guidelines of nursing care that document specific nursing diagnoses for the client and goals, interventions, and projected outcomes.
nursing diagnosis
A nursing diagnosis is a statement of client health status that nurses can identify, prevent, or treat independently.
Responces
nursing process
a systematic, rational method of planning and providing individualized nursing care
planning
a deliberate, systematic phase of the nursing process that involves decision making and problem solving.
priority setting
the process of establishing a preferential sequence for addressing nursing diagnoses and interventions.
problem
(Diagnostic Label) The problem statement, or diagnostic label, describes the client's health problem or response for which nursing therapy is given. It describes the client's health status clearly and concisely in a few words.
problem-solving
Depending on the type of client problem, the nurse writes interventions for observation, prevention, treatment, and health promotion.
nursing health history
data about the client's current level of wellness - included a review of body systems, family and health history, sociocultural history, spiritual health, and mental and emotional reactions to illness
Objective data
also referred to as signs or overt data, are detectable by an observer or can be measured or tested against an accepted standard. They can be seen, heard, felt, or smelled and are obtained by observation or physical examination.
~Example~ labs or temperature
Subjective data
also referred to as symptoms or covert data, are apparent only to the person affected and can be described or verified only by that person. For example: itching, pain, feelings of worry.
Medical Diagnosis
A medical diagnosis is made by a physician and refers to a condition that only a physician can treat.
Describes a disease, illness or injury.
actual health care problems
An actual nursing diagnosis is based on the presence of associated signs and symptoms.
potential health care problems (high risk for....)
Risk factors indicate that a problem is likely to develop unless nurses intervene.
quality assurance
refers to evaluation of the level of care provided in a health care agency, but it may be limited to the evaluation of the performance of one nurse or more broadly involve the evaluation of the quality of the care in an agency, or even in a country.
rationale
the evidence-based principle given as the reason for selecting a particular nursing intervention.
priority
status established in order of importance or urgency
patient-centered goals
in terms of observable client responses, what the nurse hopes to achieve by implementing the nursing interventions.
outcome criteria
Descriptions of specific patient behaviors or responses that demonstrate meeting of or achievement of goals related to each nursing diagnosis. These statements, like goals, should be verifiable, framed in behavioral terms, measurable, and time specific. Outcome criteria are considered to be specific, whereas goals are broad.
projected outcomes
Begin with "Patient will..."
Desired outcome ("...attain ____..." or "...maintain ____...") and explicit evaluation criteria ("...as evidenced by...")
Time Frame ("...by...")
activities of daily living
Behaviors related to personal care that typically include bathing, dressing, eating, toileting, getting in or out of a bed or a chair, and walking.
dependent interventions
activities carried out under the orders or supervision of a licensed physician or other health care provider authorized to write orders to nurses.
Example~ Medical Doctor perscribes a patient a medication.
independent interventions
those activities that nurses are licensed to initiate on the basis of their knowledge and skills.
Example~ home meal plan
interdependent interventions
also called collaborative interventions. Actions the nurse carries out in collaboration with other health team members, such as physical therapists, social workers, dietitians, pharmacists and primary care providers.
preventive nursing action
promote health and prevent illness to avoid the need for acute or rehabilitative health care
protocol
predeveloped to indicate the actions commonly required for a particular group of clients.
standing order
a written document about policies, rules, regulations, or orders regarding client care.
audit
refers to the examination or review of records.
inspection
The skill of observing the client in a deliberate, systematic manner
palpation
to examine by touch
percussion
tapping a part of the body for diagnostic purposes
auscultation
listening to sounds within the body (usually with a stethoscope)
physical exam
head to toe, skin color, hygiene, mental status, movement, posture
What Is the Nursing Process?
A systematic problem-solving process that guides all nursing actions
What is the Purpose of the Nursing Process?
To help the nurse provide goal-directed, client-centered care
What are the Phases of the Nursing Process?
Assessment
Diagnosis
Planning
outcomes
Planning interventions
Implementation
Evaluation
Core Value 2: Holistic Caring Process
Provide care that recognizes the totality of the human being using an integrated and comprehensive approach.
A 'circular' process way of thinking.
Holistic nurses focus on care interventions that promote healing, peace, comfort, and a subjective sense of well-being for the person.
What is the " General Survey"?
The overall impression of the client.
* It begins at first contact and continues throughout the exam.
First Impressions
Facial Characteristics
Body Type and Posture
Dress, Grooming, and Hygiene
Cultural Considerations
Signs of Distress
Nursing Process: Assessment
Assessment is the systematic gathering of information related to the physical, Mental, Spiritual, Socioeconomic, and cultural status of an individual group, or community.
Nursing Process: Assessment (cont'd)
Assessment includes:
Collecting data
Using a systematic and ongoing process
Categorizing data
Recording data
What is the difference between Medical assessments and Nursing Assessments?
Medical Assessments focus on disease and pathology.
Nursing Assessments focus on the client's responses to illness.
Type of Nursing Assessments
Initial
Ongoing
Comprehensive
Focused
Special Needs
Collecting Data
Primary data: directly from the client
Secondary data: from a family member or another person
The Nursing interview
Purposeful communication
Structured communication
Involves questioning the client
The purpose is to gather subjective data for the nursing database
Relation to Other Steps
Diagnosis
* Data are used to identify the
client's actual or potential health problems and strengths.
Planning outcomes and interventions
* Data helps you formulate realistic goals and choose the interventions most likely to be acceptable to and effective for the client.
Relation to Other Steps (cont'd)
Implementation
* You gather data by observing the client's responses as you perform interventions.
Evaluation
* You assess client
responses to interventions; client responses are data.
Basic Physical Assessment Techniques
Inspection
Palpation
Percussion
Auscultation
Organizing Data
How do we organize data?
Nursing Models
Non-Nursing Models
Organizing our Thinking
Gordon's Functional Health Patterns
*Describe common patterns of behavior that can be functional or dysfunctional
*Model intended for nursing assessment.
*Functional Health Pattern are major model concepts.
Organizing Our Thinking: Gordon's Functional Health Patterns
Sexuality-Reproductive
Cognitive-Perceptual
Psychosocial (Role-relationship, Self-perception, Value-
belief)
Activity Exercise/ Sleep Rest
Health Perception-Health Managment
Nutritional-Metabolic/Elimination
Supports (Coping-Stress Tolerance)
Remember+ things can fall into more than one place of data
Clinical Data Tool Example
Knowledge Check
Which action by the nurse may be a barrier to obtaining complete and reliable information from an interview with a client?
a. Nothing that the client's body language indicates that he or she is fatigued.
b. Maintaining eye contact with the client if it is not culturally inappropriate to do so.
c. Carefully guiding the conversation so that important topics are discussed
d. Asking the client directly, "Why are you not taking your insulin?"
Validating Data- When to Validate
Subjective/objective
data do not agree or make sense
Client's statements differ at different times in the interview
Data are far outside normal range
Factors are present that interfere with accurate measurement
Knowledge Check
When gathering admission assessment data, the nurse obtains a weight of 200 pounds. The client States, "I've never weighed that much!" The nurse should?
a. Explain to the client how weight gain occurs.
b. Check the calibration and re-weigh the client.
c. Document the weight as 200 pounds.
d. Instruct the nursing assistant to re-weigh the client in 2hrs.
Documenting Data
Document as soon as possible
Write legibly without using acronyms
Avoid using inferences ("just the facts")
Use the client's own words
Record only pertinent, important, and relevant data
Reflecting on the Assessment
-Are my data complete, accurate, validated?
-Did I record data, not conclusions?
-Did I follow up with special needs assessment if indicated?
-Think about the client interview
-Review the physical assessment, observation, and examination
What is Diagnosing?
Using critical thinking skills to identify
patterns in the data and draw conclusions about the client's health status
Includes strengths, problems, and factors contributing to the problems
Evolution of Nursing Diagnosis
"The diagnosis and treatment of human response to actual or potential health problems." (ANA, 1980)
1980s: Most state nurse practice acts began to designate nursing diagnosis as an exclusive responsibility of registered
professional nurses.
Human responses to Health Problems
-A health problem is any condition that requires intervention in order to promote wellness or to prevent or resolve disease/illness
-Decide how to treat it: independently or collaboratively
Types of Nursing Diagnosis
Actual: An actual nursing diagnosis describes a clinical judgment that the nurse has validated because of the presence of a major defining characteristic.
Risk: A risk nursing diagnosis describes a clinical judgment that an individual/ group is more vulnerable to develop the problem than others in the same or a similar situation because of risk factors.
Possible
Syndrome
Wellness: A wellness diagnosis is a clinical judgment about an individual, family, or community in transition from a specific level of wellness to a higher level of wellness
Analyzing Data
-Identify significant data
-Cluster cues
-Identify data gaps and inconsistencies
-Draw conclusions about health status
-Make inferences
-Identify problem etiologies
-Verify problems with the patient
Prioritizing Problems
Places problems in order of importance
Does not
mean that you must resolve one problem before attending to another
Determined by the theoretical framework you use
Maslow- Prioritization
Organize and prioritize care to the framework of Maslow
NANDA-I Nursing Diagnosis: Components
Diagnostic label
Definition
Defining characteristics
Related factors
Risk
factors
How to Choose a NANDA-I Label
Identify the broad topic (or domain) that seems to fit the cue cluster
Narrow your search (to the class or most likely labels)
Use a nursing diagnosis handbook; compare definitions and defining characteristics of the diagnostic labels with your cue cluster
How Nursing Diagnosis Relates to Outcomes and Interventions
The problem suggests the goal.
The etiology suggests interventions.
What is Planning?
Planning can be formal or informal
" Formal Planning is a conscious, deliberate activity involving decision making, critical thinking, and creativity" (Wilkinson et al..., 2016)
Informal planning: Making mental notes or plans
Why is a written nursing care plan important?
Ensures care is complete
Provides continuity of care
Promotes efficient use of nursing efforts
Provides a guide for assessing and charting
Meets requirements of accrediting agencies
Planning Client Goals/Outcomes
Goals: Describe the changes in client health status you hope to achieve
Nursing-sensitive outcomes: Those that can be influenced by nursing interventions
Reflecting Critically About Expected Outcomes/Goals
Is each expected outcome:
Appropriate for the nursing diagnosis?
Derived from only one nursing diagnosis?
Descriptive of only one client response/behavior?
Stated as a client behavior, not a nurse activity?
Reflecting Critically About Expected Outcomes/Goals (cont'd)
Is Each expected outcome:
Stated in positive terms?
Measurable or observable?
Given specific and concrete performance criteria?
What are Nursing Interventions?
Purpose: to achieve client outcomes
Also called nursing actions, measures, strategies, activities
Based on clinical judgment and nursing knowledge
Reflect
direct and indirect care
Process Used for Generating and Selecting Interventions
1. Review the nursing diagnosis
2. Review the desired client outcomes
3. Identify several interventions/ actions.
4. Choose the best interventions for this client.
5. Individualize the standardized interventions.
Implementation Phase
Doing, delegating, and documenting
Documentation
The final step of implementation
Records the nursing activities and client's response
Evaluation
The final step of the nursing process
* Evaluate
*Client's progress towards goals
*Effectiveness of nursing care plan
*Quality of care in the healthcare setting
Evaluating and Revising the Care Plan
Relate outcome to interventions
Draw conclusions about problem status
Revise the care plan
Checklist for Evaluating the Care Plan
Review assessment
Review diagnosis
Review planning outcomes
Review planning interventions
Review implementation
Common Errors of Evaluation
Failing to evaluate systematically
Failing to record results
Failing to use reassessment data to reexamine and modify the care plan
Activity and Exercise Functional Health Pattern
Activity and Exercise
Assessment is focused on the activities of daily living requiring energy expenditure, including self- care activities,
exercise, and leisure activities. The status of major body systems involved with activity and exercise is evaluated, including the respiratory, cardiovascular, and musculoskeletal systems.
Wellness Diagnosis
One Part Statement
Diagnostic label/ category
"Readiness for Enhanced ________________" (e.g. Readiness for enhanced self-care management)
A client has a desire to increase wellness in a particular area and the client is currently functioning effectively in a particular area.
Two Part Statements
"Risk" nursing diagnoses has two parts. The validation for a risk nursing diagnosis is the presence of risk factors. The risk factors are the second part (etiologies)
~Example~ Risk for impaired skin integrity related to immobility.
Three Part Statements
An actual nursing diagnosis consists of three parts:
Diagnostic label/ category
Contributing Factors/ etiologies
Signs and symptoms/ clinical manifestations
~Example~ Impaired skin integrity related to immobility as evidenced by a 2cm wound on the left foot.
Holistic Nurse Caring Process
The nursing process and the standard of Practice for Holistic Nursing define what holistic nurses do:
Assessment
Diagnosis (pattern, problem, need, health, issue)
Planning/ Outcomes Identification
Implementation
Evaluation
Holistic Assessment - The holistic nurse collects comprehensive data pertinent to the person's health and/ or the situation
Nurse and client identify health patterns and prioritize health concerns.
*A continuous
process
Includes physical, functional, psychological, mental emotional, cultural, spiritual, transpersonal, and energy field assessment of the whole person.
Involves scientific and intuitive approaches (analytical and "gut feelings")
Intuitive Thinking
Collection and evaluation of information and patient data from an intuitive, nonverbal (right brain) mode.
Emerges when the nurse is open and present to the patient's subtle clues.
Allows a nurse to know something immediately without consciously using reason
Intuitive Perception & Intuition
Intuitive Perception: allows one to know something without consciously using reason.
Intuition: the perceived knowing of things and events without the conscious use of rational processes; using all of the senses to receive information
Clinical Intuition: "process by which we know something about a client that cannot be verbalized, or is verbalized poorly, or for which the source of the knowledge cannot be determined."
Holistic Diagnosis - the holistic nurse analyzes assessment data to determine the diagnosis or issues expressed as actual or potential patterns, problems, needs, and/ or health issues.
Identification of the patterns, needs &
challenges obtained from the assessment data to provide an understanding of the client's experience.
* it is easier to see patterns in others rather than ourselves
Identification of client risk factors that influence health.
The focus is on the client's goals to increase well-being and health
Holistic Care Planning - Develops a plan with strategies and alternatives to attain expected outcomes.
The holistic nurse creates a care plan that...
Respects the client's experience and the uniqueness of each healing journey.
uses both biomedical treatments and conventional care in conjunction with complementary/ integrative care and therapies.
Holistic Outcomes Identification - Identifies expected outcomes for an individualized plan to the person and/or situation.
The holistic nurse identifies outcomes...
Based on the client's values and beliefs, preferences, age, spiritual practices, environment, ethical considerations, and or situations.
Partners with the person to identify realistic goals based on the persons present and potential capabilities and quality of life.
Holistic Implementation/ Intervention - The holistic nurse implements the identified plan in partnership with the person.
The therapeutic use of self is one of the best ways a nurse can help/ intervene and promote healing for clients.
Also includes:
* Coordination of care
* Health Teaching/ Promotion
* Consultation
* Treatment (referrals, therapies)
Holistic Evaluation
In partnership with the client and others, the holistic nurse.....
Evaluates if care is effective
Notes changes in the health experience of the individual
Realizes that outcomes are continuous and that frequent changes occur with illness and health.
Monitors if the outcomes were successfully achieved.
Reflective Practice
Reflective practice is a mindful process of self-observation in the midst of an experience, as well as after an experience.....
for the purpose of resolving values and practice contradictions, to gain new self-insight and empowerment, and to respond more congruently in future situations.
Core Value 1: Holistic Philosophy, Theories, Ethics
Theory of Integral Nursing
A comprehensive way to organize multiple phenomena of human experience related to four perspectives of reality.
Theory of Integral Nursing
An integral worldview and approach that can help each nurse and student nurse increase her or his self-awareness, as well as awareness of how one's self-affects others-- the patient, family, colleagues, the workplace, and the community."
Guiding Principles in Dossey's Theory of Integral Nursing
Holistic- addressing all aspects of our lives incorporating experiences and relationships
Evolutionary- to evolve our lives to higher levels of being
Intentional- the capacity to attend, to choose, and act accordingly
Person-centered- focus on unique characteristics of self and others
Dynamic- Respect and concern for the vital movement and flow of our lives
Two Views on the Nursing Process:
Linear Process:
*Step by step depiction of nursing work
*Mirrors the scientific process
*Helps nurses think
through the connections between each step in the nursing process
*Provides a framework that helps nurses identify their contribution to care.
Circular Process:
*The understanding that every step of the nursing process may be happening all at once and that the nurse may be addressing multiple clients needs simultaneously.
~Example~ A nurse might be assessing a patient while also interviewing the patient