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Transcript of Application of Nursing Process and Nursing Diagnosis: An Interactive Text for Diagnostic Reasoning...
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Application of Nursing Process and Nursing Diagnosis:
An Interactive Text for Diagnostic Reasoning
Sixth Edition
Copyright 2013 F.A. Davis Company
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Chapter 1
The Nursing Process:
Delivering Quality Care
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"Do everything as quietly as possible. Step lightly and gently and avoid creaking shoes."
"Use no snuff, or any article of food, the smell of which may be offensive to weak nerves."
"Ask no unnecessary questions."
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The Nursing Profession
Definition of Nursing
The diagnosis and treatment of human responses to health and illness (ANA, 1995)
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The Nursing Profession:
Has defined what makes nursing unique
Has identified a body of professional knowledge
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The Nursing Profession
The American Nurses Association, in its Nursing Social Policy Statement, identified four essential features of today’s contemporary nursing practice...
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The Nursing Profession
1. Attention to the full range of human experiences….
2. Integration of objective data…3. Application of scientific knowledge…4. Provision of a caring relationship…
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The Nursing Process
Offers an orderly, logical, problem-solving approach to patient care
Incorporates an interactive/ interpersonal approach for problem-solving and decision-making.
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The Nursing Process
FIVE STEPS Assessment Diagnosis/Analysis Planning Implementation Evaluation
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Diagram of the Nursing Process
The steps of the nursing process are interrelated, forming a continuous circle of thought and action.
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The Nursing Process
STEP 1
Assessment—
the systematic collection of data relating to clients
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The Nursing Process
STEP 2Diagnosis—
the analysis of collected data to identify the client’s needs or problems
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The Nursing Process
STEP 3
Planning—
a two-part process of: identifying goals and desired outcomes
selecting appropriate nursing interventions
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The Nursing Process
STEP 4
Implementation—
putting the plan of care into action
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The Nursing Process
STEP 5
Evaluation—
determining the client’s progress
monitoring the client’s response
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How the Nursing Process Works
A process you routinely use to solve problems
Applies readily to client-care situations
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Basic skills the nurse must posses:
A thorough knowledge of science and theory Creativity Adaptability Intelligence
Well-developed interpersonal skills Competent technical skills Commitment to practice according to the standards of
care
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Nursing Process Resources
ANA Code of Ethics for Nurses provides guidance
Refer to Appendix A
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Standards of Care
WHAT A REASONABLE PRUDENT PROFESSIONAL WITH SIMILAR EXPERTISE AND RESPONSIBILITIES WOULD HAVE DONE UNDER SIMILAR CIRCUMSTANCES
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Standards of Care
Describes a competent level of nursing care Demonstrated by use of the nursing process Describes roles expected of all professional
nurses appropriate to their: education position practice setting
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Practice Advantages of the Nursing Process
Organizing framework Human response focus Structured decision making Patient involvement Control over practice Common language Means to assess economic contribution of
nursing to patient care
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CRITICAL THINKING
WHAT IS IT? PURPOSEFUL, FOCUSED THINKING GUIDED BY STANDARDS, POLICIES, ETHICS ,
AND THE LAW. BASED ON PRINCIPLES OF NURSING
PROCESS DRIVEN BY PATIENT NEEDS. IMPROVES WITH PRACTICE!
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CRITICAL THINKING“THE ART OF THINKING WHILE YOU ARE
THINKING IN ORDER TO MAKE YOUR THINKING BETTER: MORE CLEAR, MORE ACCURATE, OR MORE DEFENSIBLE.” (Paul, Binker, Adamson, and Martin)
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CRITICAL THINKING
ASSUMPTIONS
INFERENCES
BIASES
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Chapter 2
The Assessment Step: Developing the Client Database
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The Assessment Step
Assessment involves three basic activities:
1. Systematically gathering data
2. Sorting and organizing data
3. Documenting data in a retrievable format
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The Client Database
The compilation of data collected about a client Consists of:
nursing history (*interview) physical examination results of diagnostic studies
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The Client Database
Subjective data – what the client reports, believes, or feels
Objective data – what can be observed; for example, vital signs, behaviors, diagnostic studies
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Framework for Data Collection
Two commonly used nursing models: Doenges & Moorhouse’s Diagnostic Divisions Gordon’s Functional Health Patterns
Others: body systems, head-to-toe
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Framework for Data Collection
Nursing assessment model focuses data collection on the nurse’s concern—the human responses to health, illness, life processes
See Appendix B for a sample assessment tool
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The Interview Process: 10 Key Elements
Clear sense of the underlying purpose Preliminary research Request to conduct the interview Sound interviewing strategy Effective use of icebreakers
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The Interview Process: 10 Key Elements (cont.)
Addressing the business of the interview Rapport Sensitivity to client’s needs Adequate time for recovery Closure
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Effective Data Collection Techniques
Open-ended questions Hypothetical questions Reflecting or mirroring responses Focusing
Giving broad openings Offering general leads Exploring Verbalizing the implied Encouraging evaluation
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Data Collection Techniques to Avoid
Closed-end questions Leading questions Probing Agreeing/disagreeing
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The Client History
Client history involves: Reviewing data
Organizing and determining the relevance of each item
Documenting the facts
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Guidelines for History Taking
Listen carefully
Use active listening skills
Be objective
Keep detail manageable
Sequence information
Document clearly
Record data in a timely manner
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PRACTICE HEALTH HISTORY
NAME_____J.F______________________AGE__42____DOB_______SEX___F________MARITAL STATUS____Divorced_______OCCUPATION_Radiology Technician__________
PHYSICIAN (OR USUAL SOURCE OF HEALTHCARE): Dr. Scot, Family physician
CHIEF COMPLAINT: Ear hurting for past 4 days.
HISTORY OF PRESENT ILLNESS (HPI): Worsening dull pain in right ear for past 3 days. Ear feels "blocked". Pain worse when lying down, relieved slightly with Tylenol. No pain in left ear. Denies sore throat or headache. Has not noticed any drainage from ear.
PAST MEDICAL HISTORY (PMH): HTN x 5 years, seasonal allergies, Migraine headaches.
PAST SURGICAL HISTORY (PSH): Appendectomy as child, carpal tunnel surgery left hand 2 years ago.
MEDICATIONS: Toprol XL 50 mg daily, hydrochlorothiazide 25 mg daily, Frova 2.5 mg as needed for migraine (uses approx 1/month). Baby ASA once daily. Motrin 1-2 times/week for muscle "aches and pains."
ALLERGIES/REACTIONS: Benedryl - rash.
SOCIAL HISTORY: Smoked 1 pack/day x 20 years, quit 2 months ago. 1-2 glasses wine q eve. Denies street drugs. Lives with boyfriend.
FAMILY HISTORY: Father has HTN, mother has osteoporosis, diabetes. 1 sister in good health. 2 sons, ages 17, 21, in good health.
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REVIEW OF SYSTEMS: (ALL-INCLUSIVE):
NEUROLOGICAL_____Denies tremors, difficulty walking. Has aura with migraines, otherwise
no vision problems.
CARDIOVASCULAR Occasional "skipped" heartbeats, denies chest pain, denies swelling in
legs.
RESPIRATORY No SOB, no cough. ______________________________________________________________________________________________________
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Physical Examination
Four methods used: Inspection Palpation Percussion Auscultation
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COLLECTING DATA
PHYSICAL ASSESSMENT ORGANIZATION – GUIDED EITHER BY PT
COMPLAINT OR DONE IN A ROUTINE FLOW PATTERN (HEAD-TO-TOE OR SYSTEMS)
DEVELOP AN APPROACH AND USE IT CONSISTENTLY.
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COLLECTING DATA
Physical exam
GENERAL APPEARANCE MAY INCLUDE HEIGHT AND WEIGHT
VITAL SIGNS TPR, BP INCLUDES PAIN MAY INCLUDE COUGH, SpO2
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COLLECTING DATA
PHYSICAL EXAM (CONT.) – SYSTEMS
NEURO - LOC, ORIENTATION, PUPIL REACTION (Example of documentation.: Alert, oriented x 3,
PERRL, speech clear ). ** May include ext. movement. (Glasgow coma scale)
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COLLECTING DATA
CARDIOVASC - HT RHYTHM/SOUNDS, PULSES, CAPILLARY REFILL (Doc. ex: HR 78 & regular, pedal pulses palpable
bilaterally, cap. refill <3 sec.)
RESP - RESP, LUNG SOUNDS, PULSE OX (Doc. ex: Resp. easy, lungs clear bilaterally, non-
productive cough. SpO2 98 on room air.)
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COLLECTING DATA
GI - ABD SHAPE, BS, TENDERNESS, BM (Doc. ex: Abd soft and non-distended, BS
auscultated x 4 quads. No tenderness on palpation. Soft brown, formed BM.
GU - URINE, FOLEY?, (Documentation: Voided clear yellow urine.
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COLLECTING DATA
SKIN - TEMP, MOISTURE, COLOR, LESIONS? (Doc. ex: Skin warm, dry, and fleshtone.)
MS - range of motion, active/passive? (Doc. ex: Active, full ROM in all 4 ext..)
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Laboratory Tests and Diagnostic Procedures Part of information-gathering stage
Used to: Diagnose disease Follow the course of a disease Adjust therapy
When analyzing laboratory tests, consider drugs being administered
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Organizing Information Elements
Cluster the collected data
Review data
Validate findings
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Chapter 3The Diagnosis Step: Analyzing the Data
(Need/Problem Identification)
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The Diagnosis Step
Purpose: To draw conclusions regarding a client’s specific needs or human responses so that effective care can be planned and delivered
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The Diagnosis Step
These terms may be used interchangeably:
Analysis
Need (or problem) identification
Nursing diagnosis
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The Diagnosis Step
What is Diagnosis?
Forming a clinical judgment identifying a disease/condition or human response through scientific evaluation of signs/symptoms, history, and diagnostic studies.
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Defining Nursing DiagnosisNursing Diagnoses are: Derived from the assessment data
Validated with the patient/others
Documented within a nursing plan of care
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Medical vs. Nursing Diagnoses
Medical diagnoses illnesses/conditions; reflect alteration of the structure or function of organs/systems; verified by medical diagnostic studies
Nursing diagnoses address human responses to actual and potential health problems/life processes
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TERMINOLOGY
NANDA - North American Nursing Diagnosis Association International
Ex: Actual: Impaired Skin Integrity
Potential: Risk for Injury
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Defining Nursing Diagnosis
NANDA’s Definition
Nursing diagnosis is a clinical judgment about responses to actual and potential health problems.
Nursing diagnoses provide the basis for selecting nursing interventions to achieve results for which the nurse is accountable.
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The Use of Nursing Diagnoses
Benefits of the nursing diagnosis 1. Gives nurses a common language2. Promotes identification of appropriate goals3. Provides acuity information4. Can create a standard for nursing practice5. Provides a quality improvement base
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Identifying Client Needs
During the Assessment step, the collection, clustering, and validation of client data flow directly into the Diagnosis step of the nursing process
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Analyzing the Client Database
Six Steps in Problem Identification
1. Problem-Sensing
2. Rule-Out Process
3. Synthesizing the Data
4. Evaluating or Confirming the Hypothesis
5. Listing the Client’s Needs
6. Reevaluating the Problem List
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Analyzing the Client Database
Step 1: Problem-Sensing Data are reviewed and analyzed to identify
cues (signs and symptoms) suggesting patient needs.
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Analyzing the Client Database
Step 2: Rule-Out Process
Alternative explanations considered
Compare and contrast relationships among data
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Analyzing the Client Database
Step 3: Synthesizing the Data
Looking at all the data as a whole
Creating a hypothesis
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Analyzing the Client Database
Step 4: Evaluating or Confirming the Hypothesis
Test hypothesis for fit by: reviewing the nursing diagnosis definition comparing the assessed data with NANDA’s
related or risk factors comparing the signs/symptoms with NANDA’s
defining characteristics
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Analyzing the Client Database
Step 5: Listing the Client’s Needs Combine the accurate nursing diagnosis
label with the assessed etiology and signs/symptoms
“PES” STATEMENT
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Analyzing the Client Database
Step 6: Reevaluating the Problem List List all nursing diagnoses according to
priority and classify according to status: an actual needa risk need
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Identifying Client Problems:Other Considerations The medical/psychiatric diagnosis can provide a
starting point for identifying associated client needs.
Even if the need seems to exist only in the mind of the patient, it needs to be addressed and resolved.
Reduce the problem to its basic component to identify more clearly the appropriate interventions to be taken.
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Writing a Client Diagnostic Statement
Nursing diagnoses identify client needs that can be positively affected, or possibly prevented, by nursing actions.
Some diagnoses permit greater independent function; others are more collaborative.
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Writing a Client Diagnostic Statement
The extent of independent function is influenced by the nurse’s— experience expertise work setting established protocols
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Writing a Nursing Diagnosis
P-E-S Statement – 3 part statement Problem - Diagnosis according to NANDA Etiology - the cause or risk factors, stated as “related to”- Signs and symptoms – called defining characteristics, the
evidence that showed your diagnosis or problem. Stated as “as evidenced by”
PROBLEM R/T ETIOLOGY AEB SIGNS AND
SYMPTOMS. (No “S” if potential problem)
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Writing a Nursing Diagnosis
(P) Constipation R/T (E)use of opioid analgesics AEB (S) abdominal discomfort and hard, small stools.
Impaired verbal communication R/T aphasia AEB inability to communicate basic needs.
Imbalanced nutrition: Less than body requirements R/T vomiting AEB weight loss of 3 lbs over 2 days.
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Writing a Nursing Diagnosis
Knowledge deficit of med administration R/T lack of recall AEB patient statement “I can never remember to take those pills”
Risk for fluid volume deficit R/T fluid loss secondary to NGT to continuous suction.
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Writing a Client Diagnostic Statement
Collaborative problem: A need identified by another discipline that contains a nursing component requiring nursing intervention
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Writing a Client Diagnostic Statement
Common Errors:
Using the medical diagnosis: Self Care deficit r/t stroke
Confusing the etiology or signs/symptoms for the need:
Postoperative lung congestion r/t bedrest
Use of a procedure instead of the “human response”:
Catheterization r/t urinary retention
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Writing a Client Diagnostic Statement
Common Errors:
Lack of specificity:
Constipation r/t nutritional intake
Combining two nursing diagnoses: Anxiety and Fear r/t separation from parents
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Writing a Client Diagnostic Statement
Common Errors:
Relating one nursing diagnosis to another: Ineffective coping r/t anxiety
Use of judgmental or value-laden language: Chronic pain r/t secondary/monetary gain
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Writing a Client Diagnostic Statement
Common Errors:
Making assumptions: Risk for impaired Parenting, risk factors of inexperience (new mother)
Writing a legally inadvisable statement: Impaired Skin Integrity r/t not being turned every 2 hours