Hello and welcome to the unit to lecture on nursing process for nursing
fundamentals. So, our core competency is to use the nursing process and that's
what we should be able to do by the time we get done with this unit. The nursing
process is used to identify, diagnose, and treat human responses to health and
illness. The nursing process is a tool used consistently and methodically with
nurses with every patient encounter. So really, it's essential that you learn
and understand how to apply the nursing process because it really truly is the
underpinning of everything that we do as a nurse. The next three slides here are
your learning objectives for this lesson. There's a lot of them- you know this
topic is important. Use the attached sheet listing the learning objectives in a 360
as a study guide to prepare for the exam because remember, like we said week 1,
everything you need for the test is on these learning objectives. All the
questions come from these learning objectives. And additionally there's also
a study guide on you 360 if you want to fill that out to increase your
knowledge on that as well. So the nursing process is used, like we said, to identify,
diagnose, and treat responses to health and illness, and this differentiates the
nursing process from the medical process, which treats the illness itself.
Following the nursing process allows nurses to provide systematic and
patient-centered care, and the nursing process allows us as
professionals to use our nursing knowledge, judgment, and experiences to
cue in on patterns, signs, and symptoms that the patient show us. When we use
critical thinking and clinical reasoning, we're better able to care for our
patients. We remember our experiences with patients and these shape our future
planning and analyzing of patient data. The steps of the nursing process can be
remembered using the ADPIE acronym which is listed here, and we've got
assessment, diagnosis, planning, implementation and evaluation. So step
one in the nursing process is assessment or data collection.
Assessment includes the physical examination along with observation
skills. So that's like our brief- we walk in the door we look at the patient, what
do we think? You know, look for cues from the patient. Do they appear short of
breath? What's their color? How are they looking overall? And we also want to find
out you know what's the patient and the family's perception of the problem,
because sometimes the patient might not understand what's going on with them so
they may be you know way more upset than than what the situation would seem to
warrant, or they may not feel upset at all because they just simply don't
understand the the severity of what's going on with them. It's important to
always validate the data to make sure it's accurate, and that means that we're
gonna make sure that our observations, our assessments, what the patient or the
family is telling you, what all these things show makes sense with one another.
And if they don't then we need to you know clarify and try to see where the in
congruence is. Data clustering is a way of organizing data and grouping similar
data and this is something we always should do. For example, lung sounds,
respiratory effort and shortness of breath can all be clustered together and
they should be clustered together, because that helps give us an accurate
idea of what's going on. Analysis is looking at the data you've collected and
applying critical thinking. What does the data mean? You want to make sure you have
all the data you need to make a plan of care. So for example if your patient has
a fever, do you have the results of the complete blood count? The white blood
cell counts indicate infection, so if you're missing this part of the data,
well, you might miss an important part of the puzzle.
You also want to sort out normal from abnormal data. Like we said, look for
patterns in the data. This is another way to apply critical
thinking. So for example the patient's blood pressure is elevated today, but you
look back in his chart in the last three blood pressure checks where in normal range.
You've got to think about what that means. Maybe the patient is just having
an emotional day and that's why the blood pressure is elevated.
There are two types of data- this is subjective and objective. Subjective data
is what the patient or family reports and these are the symptoms. And this is
charted the same way it's reported exactly. So we say the patient states and
then in quotation we're going to write what they state end quotation. The
objective data is what you observe during your physical assessment and
these are the signs. So for example a sign of nausea might be retching while a
symptom of nausea is the patient stating
"I feel nauseated." So when we are going to start our assessment we're going to
start with the initial interview, and like I said you want to look for cues
through observation. We want to look at the patient's overall appearance and
we're gonna introduce ourself and we're gonna gain the clients trust. And this is
very very important, because the clients more likely to tell you details,
especially if they're private, personal, maybe embarrassing details, if you have
established a rapport with the patient first. Direct, closed-ended questions, such
as "are you having pain?" allow for a focused quick assessment and they're to
the point, whereas indirect, open-ended questions such as "tell me about how that
made you feel" gives the patient an opportunity to explore their feelings
and explain what they need to tell you. It's important not to brush over
questions, so if you have a patient that says you know you ask them "what's your
blood sugar been running?" and they say "well I haven't really been checking my
blood sugar" you want to look into that ask questions to try to get to the
bottom of why. You know you maybe ask them if their glucometer works, ask
them if they have lancets, ask them if they have medications. You know maybe see
if they even really understand how to check their blood sugar. So here's a
couple of questions you can ask yourself just as a stop and review. You can hit
pause and just make sure you can answer these questions. Alright, so step two,
after we've assessed and analyzed, we're going
to state our conclusions of our data in the form of a nursing diagnosis. It's
important, remember, to use nursing diagnosis and not medical diagnosis. So
for example, a headache is a medical diagnosis. But your patients here with a
headache, so what are we gonna do? You can still develop a plan of care using
that information- you just can't say you know they have a diagnosis of headache.
Instead you're gonna say as a nursing diagnosis, maybe, your patients having
"acute pain". So how do we separate a medical diagnosis from a nursing
diagnosis anyway? Medical diagnosis are related to disease processes in their
pathology. It's outside of a nurse's scope of practice to form a medical
diagnosis. Examples of this would be diabetes or pneumonia. A nursing
diagnosis on the other hand describes how the person responds to their health
problem or life process. This does fall within the nursing scope of practice so
we can do these diagnoses. So if you have your patient that's here with diabetes,
we can't diagnose diabetes, but we can diagnose alteration in metabolism, which
goes along with diabetes. There's three types of nursing diagnosis. We've got an
actual diagnosis, which means the patient has the problem right now. So for example,
the patient has a headache right now. So the diagnosis would be "acute pain
related to complaints of globalized headache as evidenced by rates pain as
an 8 out of 10. An actual diagnosis has to be in PES format- the problem- etiology-
signs and symptoms. So it includes the problem, what contributes to the problem,
and the signs and symptoms of the problem. An at-risk diagnosis means the
problem isn't here quite yet, but it has a really good chance of developing. So
for example, a patient who's immobile is at risk for skin breakdown. So the
diagnosis would be "risk for impaired skin integrity related to immobility" and
note here that the signs and thumbs are not needed for an at-risk
diagnosis, because they don't have the problem yet, so they're not going to have
the signs and symptoms of the problem. Then a wellness diagnosis focuses on a
patient strengths. So for example, a newborn with a feeding disorder might
have a diagnosis of "readiness for enhanced family coping" because the
family may show signs that they're ready to figure out how to care and deal
with this newborn with this problem. An example of an inaccurate nursing
diagnosis would be "lack of adequate nutrition" -the diagnosis should be
"imbalance nutrition: less than body requirements". So it takes a little bit of
practice and finesse to get the hang of what's approved and what's not approved
for a diagnosis, but you can use your resources to just practice with that. The
Lippincott website and your nursing diagnosis handbook and also in your
textbook Cravin there's some good examples on page 222 of accurate and
inaccurate nursing diagnosis and then 224 to 226 has some good examples of
nursing diagnosis organized by functional health patterns. So just
remember that key takeaway that nursing diagnosis is not medical terminology,
symptoms, patient needs, or treatments and it's certainly not a medical diagnosis.
This slide breaks down the actual components of a nursing diagnosis, and
we're gonna discuss this more in class also, but this is just to give you a
general idea of the components. The problem is the patient's NANDA
diagnosis, the etiology is what contributes to the problem and must be
treatable by nursing, and then the signs and symptoms are the defining
characteristics of the problem and not the etiology. So it's related back to the
problem. And recall from scope of practice last week that the LPN can
collect the data, but they can't analyze the data and they can't evaluate either,
so LPN can't make the nursing diagnosis but they can carry out the interventions
as long as they fall within the LPN scope of practice.
So take a break here pause the slide and just look either in Lippincott
or in your nursing diagnosis handbook and try to figure out one nursing
diagnosis complete in PES format for a patient admitted with stroke and then
will be prepared to share a diagnosis in class. So the next phase or step in the
nursing process is planning. During the planning phase of the nursing process we
write the care plan. Think of it as the "playbook" for the nursing care for the
patient. The nursing care plan is the culmination of data collected during
your assessment, the nursing diagnosis, outcomes, nursing interventions, and
evaluation of the interventions. It tells staff how to manage the patient
based on the patient's individual needs or problems. So it is very patient
specific. And when we're planning we're going to set priorities for
interventions, and this is where we're gonna think back to our discussion last
week of Maslow's hierarchy of needs, because this directly applies to nursing
interventions and care planning. We always always always want to attend to
high-priority, life-or-death needs first! These are anything that would result in
harm to the patient or others, such as respiratory distress or hemorrhage, which
is a significant bleeding. We want to consider what the patient feels as a
high-priority too, and if we can work with that, we're gonna fit that in with
our high priority interventions. Sometimes though, like with a patient and
family what they think is you know super important to them, and they'll fixate on
one thing like you know the patient needs turned, the patient needs turned, the
patient needs turned, and what we're thinking in our head is the patient is
so very very sick that if we turn them they won't have a blood pressure anymore
and they could have a cardiac arrest. So we need to kind of weigh those and
really be a patient advocate and look out for what's best for that patient. But
always take into consideration the patient and family. Intermediate
priorities are then addressed next. These are things that aren't
life or death, but they really should be attended to such as imbalance nutrition.
And then low priorities can affect the patient's future but aren't necessarily
pressing so they should be addressed last. So without a measurable outcome,
which is also part of this planning phase, it's really difficult to evaluate
if the interventions were successful or not. There's two types of outcomes. We've
got outcome goals, which are broad, such as the patient will have a normal bowel
function, but then we have outcome criteria which are SMART, which are
specific, measurable, achievable, realistic, and timely and these are related back to
the problem they're here with, or the P of the PES format. So if the problem's
constipation, the outcome goal is gonna be broad, like "the patient will have no
signs or symptoms of constipation" but the outcome criteria should be more
narrow focused and measurable, like "the patient will pass one moderate soft BM
by discharge" rather than simply saying "the patient will have a BM" because
that's not very specific at all. Notice how much more detailed outcome criteria
is. The outcome criteria is how we know the outcome goal is met, and the outcome
criteria is more related to the E or the as evidenced by and the outcome
goal is more related to the P or problem in the PES nursing diagnosis. Nursing
interventions are anything the staff does for the patient in the plan of care.
Interventions should be safe and appropriate, achievable, in-line with the
client's belief systems, and aligned with other therapies, and conform to current
standards of care. Each nursing intervention should be evidence-based
and should include a rationale. Please please please cite your resources to
show your interventions follow evidence-based practice. In this class
and in your clinicals and everything else anytime you're using a care plan
you really really really need to make a source. Evidence-based means that there's
research or evidence to support it, so we know
that it just didn't come out of thin air, and it also must be something that falls
within the nurse's scope of practice. So these are the types of interventions
you're going to develop in your care plan. Independent nursing interventions
are interventions that nurses are licensed to implement based on their
education and experience. Provider interventions or provider initiated
interventions- these are interventions that require a provider's order or
protocol, but they also require nursing knowledge to perform. And then
collaborative interventions require a multidisciplinary approach to complete.
So next, we've done our planning and we move on to implementation. Implementation
is the action phase of the care plan! This is where all this planning comes
together and you actually perform the interventions you established. It's
collaborative so it's not just nursing doing these tasks. Performing the
intervention allows you to reassess the goals you can make sure that the
intervention is relevant and your patient understands what's to be
expected. This is very important! Be sure to document what's done. And the nurse is
responsible for teaching the patient and family about the interventions. This is
something that you're not gonna delegate to the CNA or to anybody else. This is
something the nurse really needs to handle. The care plan is designed to
engage the patient in a partnership with staff to achieve the goals. And engaging
and involving the patient is what makes it patient-centered care and makes the
patient more likely to be compliant with the plan. You need to tell your patient
that goals and you need to tell them why. You need to give them rationales! A
patient with severe surgical pain is more likely to coughing deep breathe if
they understand that they're doing it to prevent pneumonia rather than if you
just say "hey you need to do your coughing and deep breathing" because all
they're gonna think in that case is "that hurts and I don't want to do that". So
take a few minutes here again, pause, and answer these questions just so make sure
you're on track with where we're going so far. So, we've
implemented our care plan and now we come to the final phase which is
evaluation. Evaluation takes place after the interventions are carried out and it
can only be done by the nurse. So this is another area where the LPN cannot do the
evaluation, the RN can do the evaluation. And this step looks at whether or not
the interventions were effective at meeting the outcomes as they're stated
and on the date that was specified. Have there been any changes that require the
plan of care to be changed? Have goals been met and can be dropped off the care
plan? Outcomes that have not been met may have had the wrong interventions, wrong
outcomes, or the interventions may not have been implemented correctly, and in
any event they need to have the interventions revised. So at this point,
we re-evaluate the plan of care. We go back to the planning phase, we rewrite
our implementation or rewrite our interventions, excuse me, and then we re-
implement. And this cycle just continues until discharge or until the things on
the plan of care have been met. So to recap, today we talked about the nursing
process, and care planning, and writing nursing diagnosis, and we will practice
this more in class but just try to remember for now this acronym ADPIE
that outlines the steps of the nursing process. So thank you, and that's it for
this lecture and we will see you guys all next week!
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