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Standards of Practice
The collection of data is systematic
Derive nursing diagnosis from data
Plan nursing care including goals
Plan includes priorities and nursing approaches
Nursing actions provide for client participation in
health promotion, maintenance, and restoration
Evaluation of progress or lack of progress
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Otten/403
The
Nursing
Process
Assessment
Phase
Assessment Data
Subjective Data
- The client states . . .
Objective Data
- Vital signs
- Physical assessments
- Previous documentation
Examples of Data
Temp of 102 degree
I feel tired
WBC 24,000/mm3
I need help to walk
B/P 180/96
My leg hurts
Redness and swelling in R ankle
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ASSESSING
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Type of Assessment
Time Performed
Purpose
example
Initial assessment
Performed within
specified time after
admission to a health
care agency
To establish a complete
data base for problem
identification, reference
and future comparison
Nursing admission
assessment
Problem focused
Ongoing process
integrated with
nursing care
- Hourly assessment
of fluid intake and
urinary output
- Rapid assessment
of airway, breathing
status and circulation
(emergency)
- Suicidal tendencies
Emergency
assessment
During any
physiologic or
psychologic crisis of
the client
-The ability to
perform self-care
while assisting to
bathe
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Type
Time
performed
Purpose
Time-lapsed
assessment
Example
Reassessment
of a clients
functional
health patterns
in a home care
or outpatient
setting or in a
hospital, at shift
change
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Types of Data
Subjective data
Symptoms or covert data
Apparent only to the person affected and can be described or
verified by him alone
Sensation, feelings, values, beliefs, attitudes, perception of
personal health status and life situation
Objective data
Sign or overt data
Detectable by the observer or can be measured or tested
against an accepted standard.
Seen, hear, felt, or smelled
Obtained by observation or PE
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Sources of Data
Primary source
Secondary source
Support people (significant others SO)
Client records
Health care professionals
Literature
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INTERVIEWING
Interview is a planned communication or a
conversation with a purpose (to get/ give
information), to identify problems of mutual concern,
evaluate change, teach, provide support, or provide
counseling or therapy.
Nursing health history
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Nondirective interview
Or rapport- building interview (rapport is understanding between two
people)
Client control the purpose, matter and pacing
A combination of the two is important during information-gathering
interview.
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INTERVIEW QUESTIONS
Closed questions
in directive interview
Restrictive require only yes, no, short factual
answers
Begin with when, where, who, what, do (did, does),
is (are, was)
are you in pain, how old are you
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Open-ended questions
Nondirective interview
Invite clients to discover and explore, elaborate,
clarify or illustrate their thoughts or feelings
Specifies only broad topic to be discussed.
Begin with how or what
what brought you to he clinic?, how are you feeling
today?
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Neutral question
Client can answer without direction or pressure from
the nurse
Open-ended, used in nondirective interview
How do you feel about that?
Leading question
Usually closed, used in directive interview.
youre stressed about surgery tomorrow, arent you?
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Time
Place
Seating arrangement
Distance
Language
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TIME
Physically comfortable
Free of pain
Interruptions are minimal
Make the client feel comfortable and unhurried
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PLACE
Well-lighted, well-ventilated, moderate-sized room
Free of noise, movement and interruptions
Encourage communications
Others cannot hear or see (privacy)
SEATING ARRANGEMENT
Equal terms parties sit in two chairs at right angle to
a desk or table, few feet apart, with no table between
Creates less formal atmosphere
If standing or looking down if client on bed, makes
intimidating, nurse can sit 45 degree angle to bed
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DISTANCE
Between the interviewer & interviewee should neither
be too small nor too great, because people feel
uncomfortable when talking to someone who is too
close or too far.
Maintaining a distance of 2-3 feet
Some clients require a more or less personal space
depending on their cultural and personal needs.
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LANGUAGE
Failure to communicate in language the client can
understand is a form of discrimination.
Convert complicated medical terminology into
common English or language for the client.
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STAGES OF INTERVIEW
THE OPENING
Most important part, what is said and done sets the tone for the
remainder of the interview.
Establish rapport
Orientation
THE BODY
The client communicates what she thinks, feels, knows and
perceives in response to nurses questions
THE CLOSING
Nurse terminates or ends the interview
Clients may also terminate it (page 268)
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EXAMINING
Physical assessment or physical examination
A systematic collection of data that uses observation
to detect health problems
I-P-P-A approach can be used.
Head-to-toe, body systems approach
the nurse may also focus on a specific problem
identified
Screening examination or Review of Systems is a
brief review of essential functioning of various body
parts, compared against standard
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Diagnosis
Phase
Medical Diagnosis
Describes a specific disease
process
Oriented to pathology & remains
constant
Well defined classification
system
Teaches clients about treatments
Disadvantages:
Inconsistently used
Not always formally recognized (by MDs.)
Some problems dont fit diagnostic statements as
outlined by NANDA
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Clustering cues:
Determine the relatedness of facts and determining
whether any patterns is present.
The nurse may cluster data inductively, or use a
framework, or deductively.
Data clustering involves making inferences about the
data, interpret the meaning by making tentative
diagnostic hypotheses (Table 17-5)
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FUNCTIONAL HEALTH
PATTERN
CLIENT CUE
CLUSTERS
INFERENCES
DIAGNOSTIC
STATEMENTS
ACTIVITY / EXERCISE
Difficulty sleeping
because of cough
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2. Nutritional-Metabolic Pattern.
Describe your Familys typical daily food intake? Do you consider
your family healthy eaters?.
Describe your familys typical daily fluid intake? Do you
drink alcohol? .
Does anyone consider themselves over or under weight? Is there
any unexplained weight gain or loss?
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Verify
Build a good knowledge base and acquire clinical
experience
Have a working knowledge of what is normal
Consult resources
Base diagnoses on patterns on behavior over time
rather than on an isolated incident
Improve critical thinking skills.
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NCP format
CUES
NURSING
DIAGNOSIS
RATIONALE TO
NURSING
DIAGNOSIS
Subjective
Objective
NANDA
[P-E-S / P-E]
Planning
Phase
PLANNING
Is a deliberative, systematic phase of the nursing
process that involves decision making and problem
solving
Refer to the clients assessment data and diagnostic
statement
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NURSING INTERVENTION
any treatment, based upon clinical judgment and
knowledge, that a nurse performs to enhance
patient/ client outcomes. (McCloskey & Bulecheck)
Product is a client care plan
Nurses plan WITH the client. Encourage the clients
to participate.
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TYPES OF PLANNING
Initial planning
From the first client contact until nurse-client relationship ends
(discharge).
Ongoing planning
Done by nurses who work with the client, as nurses obtain new
information (individualize)
To determine if status has changes, set priorities for care during the shift, decide
which problem to focus during the shift, coordinate nurses activities, so more than
one can be addressed at each client contact
Discharge planning
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STANDING ORDER
A written document about policies, rules, regulations,
or orders regarding client care .
Gives nurses the authority to carry out specific
actions under certain circumstances , often when a
physician is not immediately available
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Concept Map
Page 312 (Ineffective airway clearance)
It is a visual tool in which ideas or data are
enclosed in circles or boxes of some shape and
relationships between these are indicated by
connecting lines or arrows
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Planning Process
Setting priorities
Establishing client goals/ desired outcomes
Selecting nursing interventions
Writing nursing orders
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1. SETTING OF PRIORITIES
Priority setting is the process of establishing a
preferential sequence for addressing nursing
diagnosis and interventions (together with the client)
High, Medium, Low priority
Life-threatening problem high priority
Health threatening medium priority ( acute illness,
decreased coping)
Arises from normal developmental needs/ or requires
minimal nursing support low priority
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Planning Phase:
Goals & Outcomes
Goals are broad statements about the
effects of nursing interventions on the client
(overall, non-measurable statements)
Outcomes are specific, measurable criteria
used to evaluate whether goals have been
met based on specific nursing interventions
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Nursing Functions
Dependent: activities performed
based on the physicians orders
Administration of medication
Carrying out specific treatments
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being crushed
Observations show facial grimace, SOB
(shortness of breath), and diaphoresis
(perspiring)
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Goal of Nursing:
works with the
whole person
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Nursing
interpretation: Pain
in the chest
Probable Nursing
Diagnosis: chest
pain related to
cardiac disease
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Nursing Plan:
independent functions
Monitor EKG and
dysrhythmia
Assess chest pain
Employ comfort
measures, allow rest
Alleviate anxiety
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NURSING ORDERS
Implementation
Phase
Implementing
Consists of doing and documenting the activities
that are the specific nursing actions needed to
carry out the interventions or nursing orders.
Nurses performs or delegates, then finally
records the activities & resulting client responses
The nurse may act on the clients behalf, but
professional standards support client & family
participation in all phases of the nursing process
The aim: to make the client independent
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COGNITIVE SKILLS
Include:
Problem solving
Decision making
Critical thinking
Creativity
INTERPERSONAL SKILLS
TECHNICAL SKILLS
Hands-on skills such as:
Manipulating equipment, giving injections and
bandaging, moving, lifting, and repositioning clients.
also called:
Tasks, procedures, psychomotor skills
Psychomotor skills includes interpersonal component
(like when you communicate with the client)
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Be holistic
Always view the client as a whole
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Evaluation
Phase
Otten/403
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Evaluating
To judge or to appraise
A planned, ongoing, purposeful activity in which clients
and health care professionals determine:
clients progress toward achievements of goals/outcomes
The effectiveness of the NCP
Important part because conclusions drawn from the
evaluation determine whether nursing interventions should
be terminated, continued or changed
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Evaluation is continuous
Done immediately after implementation
At a specified interval
It is continued until the client achieves the health
goals or discharged from nursing care
At discharge includes the status of goal
achievement
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Evaluation Process
Compare the actual to expected outcomes
- Did my client achieve their outcomes?
- If not, determine why outcomes were unmet - Were the
outcomes realistic? Correct problem? Enough time to
achieve outcomes?
If you determine the outcomes to be appropriate, assess
the interventions
-Were the interventions appropriate? Were they completed?
Does the client require other nursing interventions?
If everything looks good, continue with plan of care,
observing for improvement
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Collect data
Use the clearly stated, precise, measurable desired outcomes
both objective & subjective data
example: Goal met: Oral intake 300 ml more than output, skin
turgor is good, mucous membrane moist
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Assessment
Objective
Diagnosis
Assessment
Plan
Implementation
Plan
Evaluation