Application of the Nursing Process

1
Application of the Nursing Process
2
Steps of the Nursing Process (Review)

• Assessment
• Nursing Diagnosis
• Planning
• Implementation
• Evaluation

3
Data Sources

• Subjective
• Client
• Family/Significant other(s)
• Health Care team members
• Health care or other records
• Objective
• Physical examination
• Diagnostic and laboratory test findings
• Pertinent nursing and medical literature

4
Components of Nursing Care Plan

• Nursing Diagnosis or Problem Statement
• Goals /or Expected Outcomes
• Interventions specific to client
• Evaluation

5
Purpose of Nursing Care Plan

• Guide for clinical care
• Document that communicates clients nursing care
  to all members of the health care team
• Ready reference for nursing care interventions

6
How do you make a Nursing Diagnosis?

• Gather data
• Validate data
• Analyze and interpret data
• Cluster data
• Group signs and symptoms
• Classify and organize
• Identify defining characteristics
• Identify client needs
• Formulate diagnosis statement

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What is the difference between Nursing and
Medical Diagnoses?

• Nursing Diagnosis
• clinical judgment about individual, family, or
  community responses to actual or potential health
  problems or life processes (NANDA, 2003)
• Medical Diagnosis
• Identification of disease condition based on
  evaluation of physical signs and symptoms,
  medical history and test results

8
How do educational and institutional care plans
differ?

• Institutional
• Blueprint for nursing action
• Directions for implementation of plan
• Framework for evaluation
• Educational
• More detailed and elaborate
• Focuses on application of problem solving
  techniques, nursing process, and written
  communication and organizational skills
• Fosters application of knowledge from literature
  and classroom to practice

9
What are Nursing Interventions?

• Any treatment, based upon clinical judgment and
  knowledge, that a nurse performs to enhance
  client outcomes (Dochterman Bulechek, 2004)

10
What is Collaborative Care?

• Care that is provided to a client which includes
  therapies that require knowledge, skill, and
  expertise of multiple health care professionals
  (Potter Perry, p. 324)

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Rationales

• What are they?
• Why are they important?

12
How does outcome criteria relate to evaluation?

• With clearly defined goals and expected outcomes
  the nurse has objective criteria from which to
  judge the clients response to care (Potter
  Perry, p. 357)

13
Client Teaching and the Nursing Process

• Can apply steps of Nursing Process to determine
  client readiness to learn and what client needs
  to learn as well as how learning will best be
  accomplished and evaluated.
• Each Nursing Diagnosis should include
  teaching/learning interventions

14
Nursing Role

• What is the nurses role in maintaining
  continuity of care from admission, transfer, and
  discharge from the acute care setting?