Download Application of Nursing Process and Nursing Diagnosis: An

Application of Nursing Process
and Nursing Diagnosis:
An Interactive Text for Diagnostic
Reasoning
Sixth Edition
Copyright 2013 F.A. Davis Company
Chapter 1
The Nursing Process:
Delivering Quality Care
 "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."
The Nursing Profession
Definition of Nursing
The diagnosis and treatment of human
responses to health and illness (ANA,
1995)
The Nursing Profession:
 Has defined what makes nursing unique
 Has identified a body of professional
knowledge
The Nursing Profession
 The American Nurses Association, in its Nursing
Social Policy Statement, identified four
essential features of today’s contemporary
nursing practice...
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…
The Nursing Process
 Offers an orderly, logical, problem-solving
approach to patient care
 Incorporates an interactive/ interpersonal
approach for problem-solving and decisionmaking.
The Nursing Process
FIVE STEPS
 Assessment
 Diagnosis/Analysis
 Planning
 Implementation
 Evaluation
Diagram of the Nursing Process
The steps of the nursing process are interrelated, forming a
continuous circle of thought and action.
The Nursing Process
STEP 1
Assessment—
the systematic collection of data relating to
clients
The Nursing Process
STEP 2
Diagnosis—
the analysis of collected data to identify the
client’s needs or problems
The Nursing Process
STEP 3
Planning—
a two-part process of:
 identifying goals and desired outcomes
 selecting appropriate nursing interventions
The Nursing Process
STEP 4
Implementation—
putting the plan of care into action
The Nursing Process
STEP 5
Evaluation—
 determining the client’s
progress
 monitoring the client’s
response
How the Nursing Process Works
 A process you routinely use to solve problems
 Applies readily to client-care situations
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
Nursing Process Resources
 ANA Code of Ethics for
Nurses provides guidance
 Refer to Appendix A
Standards of Care
WHAT A REASONABLE PRUDENT
PROFESSIONAL WITH SIMILAR EXPERTISE
AND RESPONSIBILITIES WOULD HAVE DONE
UNDER SIMILAR CIRCUMSTANCES
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
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
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!
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)
CRITICAL THINKING
 ASSUMPTIONS
 INFERENCES
 BIASES
Chapter 2
The Assessment Step:
Developing the Client Database
The Assessment Step
Assessment involves three basic activities:
1. Systematically gathering data
2. Sorting and organizing data
3. Documenting data in a retrievable format
The Client Database
 The compilation of data collected about a client
 Consists of:
 nursing history (*interview)
 physical examination
 results of diagnostic studies
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
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
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
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
The Interview Process: 10 Key Elements
(cont.)





Addressing the business of the interview
Rapport
Sensitivity to client’s needs
Adequate time for recovery
Closure
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
Data Collection Techniques to Avoid
 Closed-end questions
 Leading questions
 Probing
 Agreeing/disagreeing
The Client History
Client history involves:
 Reviewing data
 Organizing and determining the relevance of each
item
 Documenting the facts
Guidelines for History Taking
 Listen carefully
 Sequence information
 Use active listening skills
 Document clearly
 Be objective
 Record data in a timely
manner
 Keep detail manageable
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.
good health.
2 sons, ages 17, 21, in
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.
______________________________________________________________________________________________________
Physical Examination
Four methods used:
 Inspection
 Palpation
 Percussion
 Auscultation
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.
COLLECTING DATA
 Physical exam
 GENERAL APPEARANCE
 MAY INCLUDE HEIGHT AND WEIGHT
 VITAL SIGNS
 TPR, BP
 INCLUDES PAIN
 MAY INCLUDE COUGH, SpO2
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)
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, nonproductive cough. SpO2 98 on room air.)
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.
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..)
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
Organizing Information Elements
 Cluster the collected data
 Review data
 Validate findings
Chapter 3
The Diagnosis Step:
Analyzing the Data
(Need/Problem Identification)
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
The Diagnosis Step
These terms may be used interchangeably:
 Analysis
 Need (or problem) identification
 Nursing diagnosis
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.
Defining Nursing Diagnosis
Nursing Diagnoses are:
 Derived from the assessment data
 Validated with the patient/others
 Documented within a nursing plan of care
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
TERMINOLOGY
 NANDA - North American Nursing Diagnosis
Association International
 Ex:
 Actual: Impaired Skin Integrity
 Potential: Risk for Injury
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.
The Use of Nursing Diagnoses
Benefits of the nursing diagnosis
1. Gives nurses a common language
2. Promotes identification of appropriate goals
3. Provides acuity information
4. Can create a standard for nursing practice
5. Provides a quality improvement base
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
Analyzing the Client Database
Six Steps in Problem Identification
1. Problem-Sensing
2.
3.
4.
5.
6.
Rule-Out Process
Synthesizing the Data
Evaluating or Confirming the Hypothesis
Listing the Client’s Needs
Reevaluating the Problem List
Analyzing the Client Database
Step 1: Problem-Sensing
 Data are reviewed and analyzed to identify
cues (signs and symptoms) suggesting
patient needs.
Analyzing the Client Database
Step 2: Rule-Out Process
 Alternative explanations considered
 Compare and contrast relationships among data
Analyzing the Client Database
Step 3: Synthesizing the Data
 Looking at all the data as a whole
 Creating a hypothesis
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
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
Analyzing the Client Database
Step 6: Reevaluating the Problem List
 List all nursing diagnoses according to
priority and classify according to status:
 an actual need
 a risk need
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.
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.
Writing a Client Diagnostic Statement
 The extent of independent function is
influenced by the nurse’s—
 experience
 expertise
 work setting
 established protocols
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)
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.
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.
Writing a Client Diagnostic Statement
 Collaborative problem: A need identified
by another discipline that contains a
nursing component requiring nursing
intervention
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
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
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
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