Unit 2

Nursing Process
Reporting
Client Teaching
Key Words
„ Actual nursing diagnosis „ Critical pathways
„ Analysis „ Data clustering
„ Assessment „ Defining characteristics
„ Assessment model „ Delegation
„ Assumptions „ Dependent nursing
„ Bias interventions
„ Comprehensive „ Discharge planning
assessment „ Etiology
„ Evaluation
 Assessment

Diagnosis
Evaluation Nursing
Process

Planning & Outcome

Implementation Identification
North American Nursing
Diagnosis Association (NANDA)

„ NANDA-International is recognized as the

leader in development and classification of
nursing diagnoses

[http://www.nanda.org/html/about.html]
Nursing Process
Assessment
„ First step in the nursing process

„ Involves several steps

„ Data collection
„ Confirm the data is accurate
„ Organize the data
„ Interpret the data
Nursing Process - Assessment

Three types:

1. Comprehensive – provides baseline client data

2. Focused – limited in scope, targets a particular
need or health care concern
3. Ongoing – systematic monitoring & observation
related to specific problems
Nursing Process - Assessment
Two methods of Assessment
1. Subjective – client’s perspective
„ Examples: Report of fainting, complaint of
dizziness, nausea, headache

2. Objective – observable & measurable

„ Examples: Vomiting, unsteady gait, pale skin,
rapid breathing
 Nursing Process: Data Collection

Data collection occurs in 3 phases:

1. Before you see the client

2. When you see the client
3. After you see the client
Nursing Process
Organizing the Data
Assessment models

„ Maslow’s Hierarchy of Needs

„ Body Systems Model

„ Human response model

„ Neuman's System’s Model

Identification of Patterns
„ Distinguish between relevant and irrelevant
data

„ Determine whether and when there are gaps

in the data and

„ Identify patterns of cause & effect

Nursing Diagnosis
A clinical judgment about individual, family, or
community responses to actual or potential
health problems/life processes. A nursing
diagnosis provides the basis for selection of
nursing interventions to achieve outcomes for
which the nurse is accountable.
 Medical Diagnosis Nursing Diagnosis
Identifies conditions the Identifies situations the
MD is licensed & qualified nurse is licensed and
to treat qualified to treat
Focuses on the illness, Focuses on the client’s
injury, or disease process responses to actual or
potential health problems
Remains constant until a Changes as the client's
cure is effected response and/or health
changes
 Nursing Diagnosis Medical Diagnosis
Breathing Pattern, Chronic obstructive
Ineffective pulmonary disease
Activity Intolerance Cerebrovascular accident
(CVA)
Pain Appendectomy
Body Image Disturbance Amputation

Body Temperature, Risk Strep Throat

for Altered
 Development of the
Nursing Diagnosis
Two-part Statement
1. Problem statement – describes the client’s
response to an actual or potential health
problem (diagnostic label)
2. Etiology – cause of the problem
3. The diagnostic label & etiology are linked by
the terminology Related to (R/T)
Example:
Ineffective breathing pattern R/T neuromuscular
impairment.
 Development of the Nursing
Diagnosis
Example:
Two-part Statement
1. Problem statement Ineffective breathing pattern
2. Link R/T (related to)
3. Etiology neuromuscular impairment.
Nursing Process
Three-part-statement

1. Problem statement – describes the client’s

response to an actual or potential health
problem (diagnostic label)
2. Etiology – cause of the problem
3. The diagnostic label & etiology are linked by
the terminology Related to (R/T)
4. Defining characteristics
 Development of the Nursing
Diagnosis
Example:
Three-part Statement
1. Problem statement Ineffective breathing pattern
2. Link R/T (related to)
3. Etiology neuromuscular impairment.
4. Defining as evidenced by C-6
characteristics (signs spinal cord injury, poor
& symptoms) chest expansion
Nursing Diagnosis
Two-Part Statement
Decreased cardiac output,
related to alterations in rate,
rhythm, electrical conduction
Activity intolerance related to
prolonged bed rest/immobility
Three-Part Statement
Decreased cardiac output,
related to alterations in rate,
rhythm, electrical conduction, as
evidenced by diminished
peripheral pulses.
Activity intolerance related to
prolonged bed rest/immobility as
evidenced by fatigue and
weakness
Types of Nursing Diagnoses
„ Actual nursing diagnosis – a problem exists.
Composed of the problem statement, related factors
and signs & symptoms

„ Risk nursing diagnosis – indicates the problem

doesn’t exist but has special risk factors

„ Wellness nursing diagnosis – indicates the client’s

desire to attain a higher level of wellness in some
area of function.
Planning & Outcome Identification
„ Planning is formulation of the actual nursing actions

„ Three types of planning:

„ Initial planning – developing the preliminary plan

of care
„ Ongoing planning – updates of care based on

reassessment
„ Discharge planning – anticipation & planning of

client needs after discharge

Planning Phase
„ Prioritizing the nursing
diagnoses
„ Identifying long & short
term goals
„ Developing nursing
interventions
„ Recording the nursing
care plan in the client’s
medical record
Prioritizing Nursing Diagnoses
Self-
Actualization

„ Maslow’s Needs

hierarchy of
Self-Esteem
Needs

needs Love & Belonging Needs

Safety & Security Needs

Physiological
PhysiologicalNeeds
Needs
Prioritizing Nursing Diagnoses
Five system variables:
Betty Neuman's „

System Theory „ Physiological

„ Psychological
„ Sociocultural
Basic „ Developmental
structure & „ Spiritual
Energy
Protected by the lines of
Resources „
defense & resistance to keep
the system stable
Identification of Outcomes
„ Provides guidelines for individualized nursing
interventions

„ Establishes goals & evaluation criteria to measure

effectiveness of the nursing care plan
„ Short-term goals – 1 week

„ Long-term goals – weeks to months

 Goals
Short term Long term

Verbalizes the presence of Verbalizes comfort

pain

Identifies factors that

influence the pain
experience
Nursing Interventions
„ An action performed by the nurse
that helps the client achieve the
results specified by the goals and
expected outcomes.

„ Refer directly to the nursing

diagnoses.
Nursing Interventions
„ Independent nursing interventions – nursing
actions that are initiated by the nurse.

„ Interdependent nursing interventions –

actions that are implemented by the nurse in
conjunction with other health care
professionals

„ Dependant nursing interventions – requires a

physician order
Interventions
„Specific order – written in the medical record
or nursing care plan by a physician or nurse

„ Standing order – a standardized intervention

„ Protocol - a series of standing orders or

procedures that should be followed under
certain specific conditions.
Nursing Care Plan

A written guide,
organizing client data
into a formal
statements of strategies
to assist the client to
optimal health
Implementation
„ 4th step in the nursing process

„ Involves putting the nursing care plan into

action.

„ Nursing activities (interventions) to meet the

goals set with the client begin.
Documentation
„ Data to be recorded:
„ Client’s condition
prior to the
intervention
„ Intervention
performed
„ Client’s response to
the intervention
„ Client outcomes
Reporting
„ Activities completed & those yet to be completed

„ Current problems

„ Abnormal findings or changes in the client

assessment
„ Treatment results

„ Diagnostic tests completed with results (if available)

or tests scheduled
Evaluation
„ 5th step in the nursing process

„ Determines if client goals are met or not

„ Determination of continued or cessation of

plan
Critical Thinking
„ The rational examination of ideas, inferences,
assumptions, principles, arguments,
conclusions, issues, statements, beliefs and
actions.

„ Making a decision is the end point of using

critical thinking.
Decision Making
„ Recognizing and defining a problem

„ Gathering relevant information

„ Generating possible conclusions

„ Testing possible conclusions

„ Evaluating Conclusions
Decision Making & The Nursing Process

„ Recognizing and „ Assessment

defining a problem „ Assessment
„ Gathering relevant „ Diagnosis
information „ Planning & outcome
„ Generating possible identification
conclusions „ Implementation
„ Testing possible „ Evaluation
conclusions
„ Evaluating Conclusions
Class Activity
„ Use the steps in nursing process to
„ Describe how one would decide to purchase a
new car
„ Describe how one would select a restaurant
„ Describe how one would plan a wedding
„ Describe how one would select a pet
„ Describe how one would select a health
insurance
„ Describe how one would select a career
Documentation

Chapter 10
Documentation Defined
„ The interactions between and among health
professionals, clients, their families, and health
care organizations
„ The administration of tests, procedures,
treatments, and client education; and
„ The results of, or client’s response to,
diagnostic tests and interventions (Eggland &
Heinemann, 1994)
Effective Documentation
„ Follow the nursing „ Use of healthcare
process facility approved
„ Entries are made vocabulary and
chronologically abbreviations.
„ Date & time „ Signature
„ Observation „ Accurate
„ Intervention
„ Evaluation
Methods of Documentation

„ Narrative charting: describes the client’s

status, interventions and treatments in a
story form.

„ Source-oriented charting: narrative charting

by individual disciplines on separate records.
Methods of Documentation
„ Problem-oriented charting: problem-
oriented medical record (POMR)

„ SOAP charting: Subjective, Objective,

Assessment, Plan

„ SOAPIE/SOAPIER charting:Subjective,
Objective, Assessment, Plan,
Implementation, Evaluation/Revision
Methods of Documentation
„ PIE charting: problem, intervention and evaluation

„ FOCUS charting: uses a columnar format to chart

data, action and response (DAR)

„ Charting by Exception (CBE): documentation of

deviations for the baseline or established norms

„ Computerized documentation: electronic medical

record
Forms
„ Kardex – a summary worksheet reference of
basic client care information that traditionally
is not part of the medical record.

„ Flowsheets – columnar format makes

documenting dates and times of particular
assessments easier to track.
Review of Medical Record Forms

After reviewing the different healthcare

organization’s document, discuss the
method of documentation for each (flow
chart, computerized, FOCUS charting,
etc.)
Reporting

„ Based on the nursing process a verbal report

of the client’s health status, needs,
treatments, outcomes and responses is
communicated to other members of the
health care team.
Client Teaching
„ Teaching-learning process is a planned
interaction that supports behavioral change
that is not a result of maturation or
coincidence.
„ Formal teaching – planned and goal

directed

„ Informal teaching – initiated at any time a

learning need is identified
Client Teaching

Learning – a process
whereby an
individual integrates
information that
results in a
behavioral change.
Learning Domains
„ Cognitive – intellectual understanding
(learning the technique for giving a clean
catch urine specimen)

„ Affective – related to attitudes, beliefs and

emotions (recognizing the value of diet)

„ Psychomotor – motor skills (learning to

perform blood sugar testing)
Adult Leaner: Basic Assumptions
„ Personality develops from dependence to
independence

„ Learning readiness is affected by

developmental stage and sociocultural factors

„ Previous learning experiences can be used as

a foundation

„ Opportunities to use the new knowledge

reinforces the new knowledge
Learning Principles

„ Relevance „ Reinforcement
„ Motivation „ Participation
„ Readiness „ Organization
„ Maturation „ Repetition
 Learning Styles
„ Visual learner –
processing information
sight

„ Auditory learner –
processing listening

„ Kinesthetic learner-
experiencing the
information through
touching, feeling &
doing
Barriers to the Teaching-Learning Process

„ Physiological

„ Psychological

„ Environmental

„ Sociocultural
Teaching Methods
„ Discussions

„ Formal lecture

„ Question and answer sessions

„ Role play

„ Games/computer activities
Class Activity
„ Assignment: Break into
3 groups (Children,
adolescents, older
adults). Present to the
class the:
„ MOST significant
factors that influence
learning for your
assigned developmental
stage
„ Types of learning needs
„ Strategies to enhance
learning at each stage
VITAL SIGNS
The “Signs of Life”
„ Temperature

„ Pulse

„ Respirations

„ Blood Pressure
Temperature [T]
„ Routes:
„ Oral
„ Rectal
„ Axillary
„ Skin
„ Tympanic membrane
Temperature [T] –Readings
Route Normal Reading Variations

Axillary 36.5ºC or 97.6º <36ºC or 96.8ºF

F Hypothermia

Tympanic 37ºC or 98.6ºF >38ºC or 100.4ºF

Pyrexia

Oral 37ºC or 98.6ºF

Rectal 37.5ºC or 99.6ºF

Pulse [P]
„ Terms to know
„ Pulse rate
„ Bradycardia
„ Tachycardia
„ Pulse rhythm
„ Pulse amplitude
„ Pulse deficit
 Pulse [P]
Pulse Points
„ Brachial „ Temporal
„ Ulnar „ Carotid
„ Radial „ Apical
„ Popliteal „ Femoral
„ Posterior „ Dorsalis pedis
Tibial
Pulse - Readings
Vital Sign Normal Variations
Reading
[P] 60-100 <60
beats/minute Bradycardia
>100
Tachycardia
Respirations [R]
„ Terms to Know:
„ Eupnea
„ Bradypnea
„ Hypoventilation
„ Tachypnea
„ Hyperventilation
„ Dyspnea
Respirations - Readings
Vital Sign Normal Variations
Reading
[R] 16-20 <60
respirations/ Bradycardia
minute
>100
Tachycardia
Blood Pressure (B/P)
„ Measures the force exerted
by the blood against the walls
of the blood vessels.
„ Dependent upon the Cardiac
output –volume of blood per
minute pumped by the left
ventricle; Peripheral
Resistance – pressure within
a vessel that resists the flow
of blood.
Blood Pressure - Terms
„ Arterial pressure
„ Diastolic blood pressure
„ Systolic blood pressure
„ Pulse pressure
„ Orthostatic hypotension
Blood Pressure - Readings
Vital Sign Normal Variations
Reading
[B/P or BP] 90/60 – <90/60
140/90 Hypotension
>140/90
Hypertension
Unit 3: Health Promotions

Chapter 15: Wellness Concepts

Key Terms
„ Health
„ Wellness
Health Promotion
„ Class discussion:
„ What is a eudaemonistic approach to
health?
„ What is the Healthy People 2000? 2010?
„ What are the leading cases of death
associated with lifestyle factors that can be
controlled?
The End
„ Next class topics for review:
„ Prevention as Intervention
„ Basic Nutrition
„ Diet Therapy
„ Nutritional Support
„ Excretion/Elimination
„ Nursing Process & Client Nutrition
„ Rest & Sleep & the Nursing Process
„ Assignment: Keypoints to teaching body
mechanics due Sept. 16, 2003