Foundations of Professional Nursing Lecture 4

Gather information about the client’s condition

Identify the clients problems

Set goals of care and desired outcomes and identify appropriate nursing actions.

Perform the nursing actions identified in planning

Determine if goals are met and outcomes achieved

What is the purpose of assessment?
to establish a DATABASE about the client’s perceived needs, health problems, and responses to these problems.

A series of steps or components needed to achieve patient driven goals
Nursing Process

What are the 5 steps to the nursing process?
1. Assessement
2. Diagnoses
3. Planning
4. Implementation
5. Evaluation

Medical Diagnosis
The identification of a disease condition based on the specific signs and symptoms.

Nursing Diagnosis
A clinical judgement about the client in response to an actual or potential health problem.

Collaborative Problem
an actual or potential complication that nurses monitor to detect a change in client status.

Dimensions of Diagnosis

Wellness Diagnosis
“something that the client is doing well.”

-Focus on something that is positive, rather than illness
-Assessment of client’s strengths
-How their behavior correlates with their knowledge.

What are some wellness behaviors?
-Gaining new info; learning new skills
-wound healing
-improving physical functional status
-Acquiring new roles
-Achieving maturation/developmental tasks
-Developing new strengths.

A Nursing Diagnosis is a 3 part statement
1. Choose the label
(nursing diagnosis)
2. Write a related to phrase
3. Write the defining characteristics
(signs & symptoms)

Actual Nursing Diagnosis
describes human responses to health conditions or life processes

Risk Nursing Diagnosis
Describes human responses to health conditions/life processes THAT MAY DEVELOP

it is the science that deals with the causes or origin of disease, the factors which produce or predispose toward a certain disease or disorder.

chronic obstructive pulmonary disease

Goals must be SMART, meaning?

Interventions must have 6 considerations…
-related to Nursing Diagnosis
-related to the Goals & Expected Outcomes
-Acceptable to the client
-Nurses competency

Nursing Care Plans contain
-Nursing Diagnosis
-Specific Interventions

A professional nurse’s approach to identify, diagnose and treat human responses to health and illness
Nursing Process

what are the sources for the Health Assessment?
client, family and significant others, health care team, medical records

Methods of Data Collection
1.Interview- an organized conversation with the client
2. Nursing health history- data about the client’s current level of wellness
3. Physical Exam
4. Review medical records and diagnostic tests
5. Collaborate with entire health care team and client’s significant other if appropriate

The first step in establishing the database is to collect…?
subjective data by interviewing the client.

The interview had 3 phases
1. Orientation Phase
2. Working Phase
3. Termination Phase

During this phase, you establish trust and confidence. You will also gather demographic data (age, race, DOB, etc).
Orientation Phase

During this phase, you will gather information about the client’s health status. Obtain a nursing health history in this phase as well.
Working Phase

The Nursing Health History Includes…
data about the patient’s
1.Current Level of Wellness
2. Review of body systems
3. Family & Health History
4. Sociocultural History
5. Spiritual Health
6. Mental and Emotional reactions to illness

During this phase of the interview, you give the client a polite clue that the interview is coming to an end.
Termination Phase

The client’s database originates with the client’s
perception of a symptom or health problem, and goes from there

The time and client priorities will determine how complete a history will be

things to addresses in Nursing Health History
Biographical Information, Reason for Seeking Care, Client Expectations, Present Illness or Health Concerns, Health Care History, Family History, Environmental History, Psychosocial History (support system, coping skills), Spiritual Health, and ROS.

Review of Systems (ROS)
a systematic method for collecting data on all body systems.
it is probable you will not cover all of the questions in each system every time you collect a history.

The systems you assess depend on the client’s condition and the urgency in starting care.

Assess the following…
-WHO has the problem: 1 day old newborn, 36 year old male, 14 year old G 1 P1
-WHAT is the problem: Pain, loss of fluid
-HOW did it happen: Accident, delivery, lifting an object, surgery
-WHERE is the problem: Chest, abdomen
-WHY is it a problem: Patient’s perspective, lab values

Subjective Data
client’s verbal description of their health problems

Objective Data
observations or measurements of a client’s health status.

Objective Data examples
What does the nurse see, hear, smell and feel?

What does the patient’s health history tell you about the patient’s problem?

What does your physical assessment tell you about the patient’s problem?

What are the lab values/diagnostic data/vital signs/monitoring assessment that contribute to this problem or concern?

After visiting with the client, the nurse documents the assessment data. Both objective and subjective information have been obtained during the assessment. Which of the following is classified as objective data?
a.Pain in the left leg
b.Elevated blood pressure
c.Fear of surgery
d.Discomfort on breathing

one way to graphically represent the connections between concepts and ideas that are related to a central subject (e.g., the client’s health problems).
Concept Mapping

A cluster is a set of signs or symptoms grouped together in a logical order.

After you have selected the Nursing Problem, an appropriately written nursing diagnosis identifies a problem using a…
a NANDA International diagnostic statement and connects it to its etiology

Defining Characteristics
the clinical criteria or assessment findings that support an actual nursing diagnosis

Clinical Criteria
Objective or Subjective signs and symptoms, clusters or signs and symptoms, or risk factors that lead to a diagnostic conclusion.

Always examine the defining characteristics in your database carefully to support or eliminate a nursing diagnosis
To be more accurate, review all characteristics, eliminate irrelevant ones, and confirm the relevant ones.

Diagnostic Label
the name of the nursing diagnosis as approved by NANDA International.

describes the essence of a client’s response to health conditions in as few words as possible.

Examples of descriptor words
compromised, decreased, deficient, delayed, effective, imbalanced, impaired, and increased.

Related Factor
it is associated with the client’s actual or potential response to the health problem and can change by using nursing interventions

a condition or etiology identified from the client’s assessment data.

Related Factors include 4 categories
1.Pathophysiological (biological or psychological)
2. Treatment-related
3. Situational (Environmental or Personal)
4. Maturational

the “related to” phrase is NOT a cause-and-effect statement; rather, it indicates the etiology that contributes to or is associated with the client’s diagnosis.

The etiology of the nursing diagnosis is always …?
within the domain of nursing practice and a condition that responds to nursing interventions.

Defining Characteristics Phrase
These are the signs and symptoms that were identified in the client assessment.

“as evidenced by”

“as evidenced by”
may be used to connect the etiology (related to) with the defining characteristics

related to

In instances where the client is healthy but has not completely achieved a developmental task, the nurse can identify client strengths and focus on wellness.
This is called..?
a Wellness Diagnosis

there is no AEB statement in a….?
Wellness Diagnosis

as evidenced by

Diagnostic Errors
These errors occur in the nursing diagnostic process during data collection, clustering, interpretation, and statement of the diagnosis.

State some areas of Diagnostic Errors
–Data collection: omission & commission
–Interpretation of data
–Clustering of Data: making the diagnosis fit the signs & symptoms
–The diagnostic statement: nursing diagnosis stated as a medical diagnosis or medical terminology is used to describe the cause

-A broad statement that describes the desired change in a client’s condition or behavior
-An aim, intent, or end

Expected outcome
Measurable criteria to evaluate goal achievement

Goals establish a framework for the patient to achieve something

In writing goals for your patient, make sure you can evaluate them.

Client-centered goal
A specific and measurable behavior or response

-reflect a client’s highest possible level of wellness and independence in function.
A goal must be realistic and can be realistically achieved and based on the client’s needs and resources

Short-term goal
An objective behavior or response expected within hours to a week

Long-term goal
An objective behavior or response expected within days, weeks, or months

Nursing Diagnosis:
Deficient Knowledge related to function of external fixation & performance of pin care manifested by temperature of 100.6 & erythema surrounding pin site
Goal/Desired Outcomes:
Patient will verbalize knowledge of rationale for the external fixator and indicators of pin site infection.
Patient demonstrates performance of pin care at least 24 hr before hospital discharge.

Dependent Nursing Orders/Interventions
Physician-initiated. Require an order from a doctor or another health care professional
They may depend on an order from the physician

Independent Nursing Orders/Interventions
nurse initiated interventions are autonomous actions based on scientific rationale

Collaborative or Interdependent Interventions
therapies that require the combined knowledge, skill, and expertise of multiple health care professionals.

Your patient is experiencing nausea and abdominal distention postoperatively. You initiate the interventions listed below. Which of the interventions are examples of independent interventions? (Choose all that apply.)
a. Provide frequent mouth care
b. Maintain IV infusion at 100 mL/hr
c. Administer anti-emetic as ordered
d. Consult with dietitian on initial foods to offer client
e. Control aversive odors or unpleasant visual stimulation that trigger nausea

Interventions should alter the etiological (related to) factor or signs and symptoms associated with the diagnostic label

Nursing Care Plan
enhances the continuity of nursing care by listing specific nursing interventions needed to achieve the goals of care.

Specific nursing interventions so that any nurse is able to quickly identify a client’s clinical needs and situation.

Assessment phase of the nursing process in which data are gathered to identify actual or potential health problems Subjective Data data of s/s that include the client’s feelings and statements about his or her health problems WE WILL WRITE A …

American Nursing Association (ANA) – Nursing The protection, promotion, and optimization of health and abilities, prevention of illness and injury, alleviation, of suffering through the diagnosis and treatment of human response, and advocacy in the care of individuals, families, communities, …

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Actual nursing diagnosis Judgement that is clinically validated by the presences of major defining characteristics. Clinical criterion Objective or subjective signs and symptoms, clusters of signs and symptoms or risk factors. WE WILL WRITE A CUSTOM ESSAY SAMPLE ON ANY …

Diagnosis A clinical judgment based on information. Medical Diagnosis Identification of a disease condition based on specific evaluation of signs and symptoms. WE WILL WRITE A CUSTOM ESSAY SAMPLE ON ANY TOPIC SPECIFICALLY FOR YOU FOR ONLY $13.90/PAGE Write my …

critical thinking “…the process of questioning, analysis, synthesis, interpretation, inference, inductive and deductive reasoning, intuition, application, and creativity [and]…underlies independent and interdependent decision making” (AACN, 2008, p. 36; as cited in EKU BSN Student Handbook). nursing process “…a problem solving …

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