Adult Health 2 Exam 1
Nursing Process Defined
A systemic, problem-solving process that is used to identify, diagnose, and treat human responses to health and
illness
- Nurse focus – Patients’ responses to symptoms and patients’ ability to care for self
- Physician focus – Disease process/pathology and treatment of disease
Steps of the Nursing Process
Five inter-related steps (ADPIE)
- Assessment
- Diagnosis
- Planning (Outcome and Interventions/Activities)
- Implementation
- Evaluation
Nursing Assessment
Accurate and comprehensive assessment leads to accurate nursing diagnosis
Assessment
1) Collect data – ongoing
2) Identify cues and make inferences
3) Validate
4) Organize (cluster data)
5) Identify patterns
6) Report and record
Leading to nursing diagnosis
Data Collection
Data Sources – patient/family, health care team, medical record, diagnostic, and lab data
Methods – Interviews/history, observations, physical assessment, medical record review
Subjective (symptoms) – what a person states or communicates in writing
Objective (signs) – observations or measurements of a patient’s health status
Identifying Data
Cues
- Information the nurse obtains through the use of the senses (S&O data)
- Relevant data – decide what information is meaningful/important
Inference
- Process of deriving logical conclusions from multiple observations (inductive reasoning)
- May be correct or incorrect, correct to within aa certain degree of accuracy; requires more data
,Organize Data
Identify patterns by organizing the cues into meaningful usable clusters
Data clusters – Set of signs and symptoms that are grouped together in a logical way
Identifying Nursing Diagnosis
Clusters and patterns of data contain defining characteristics (signs & symptoms) that support nursing diagnosis
NANDA also identifies potential related factors
- Functional, psychological, pharmacological, mechanical, physiological
Types of Nursing Diagnosis Labels
Actual – A problem that has been validated by the presence of major demining characteristics
Potential (risk for) – individual is vulnerable to development of problem(s)
Wellness – assist individual to pursue optimal health
Collaborative – potential complications of medical conditions nurse cannot treat independently
Risks of Nursing Diagnostic Errors
Problems will exist or progress without detection
Omitting interventions that are essential
Choose inappropriate interventions that may:
- Waste time, cause harm, aggravate the real problem, place yourself in legal jeopardy
Errors in Writing Nursing Diagnosis
Renaming a medical problem – Don’t rename a medical problem to make it sound like a nursing diagnosis
Legally incriminating
- Incorrect: risk for injury r/t lack of side rails on bed
- Correct: risk of injury r/t disorientation and attempts to get out of bed
Two problems in one diagnostic sentence – Don’t state two problems at the same time
Creating a nursing diagnosis from a physician’s order – Don’t make a nursing diagnosis out of a physician’s order
Value Judgements – Don’t write a nursing diagnosis based on value judgements (religion)
Developing Goals/Outcomes (SMART)
Specific (individualize to patient)
Measurable
Attainable
Realistic oriented
Timed (expected completion)
Prioritizing Interventions
1) Take care of immediate life-threatening issues (ABCs)
2) Safety issues
3) Patient-identified issues
4) Nurse-identified priorities
a. Based on overall picture, the patient as a whole person, and availability of time and resources
Implementation: Putting the Plan into Action
Perform the chosen prioritized, evidence-based interventions in a …
, - Safe, effective, organized way to get the results needed while preventing errors
- To meet the goals and outcomes of the plan
- Continually evaluate the effectiveness of each intervention and make revisions
Evaluation
Are the goals/outcomes criteria … completely, partially, or not met? How do you know? Can you revise the plan?
Reflect on why goal/outcome was not met… what must be changed in POC to move the patient toward outcome
Review all the steps if the nursing process
Update the care plan
GI Accessory: Acute Appendicitis
Pathophysiology
- Appendix becomes inflamed, increasing intraluminal pressure, causes edema and obstruction of orifice
Etiologies
- Result of becoming kinked or occluded with stool
- Lymphoid hyperplasia secondary to inflammation or infection ↓
- Rarely, foreign bodies (seeds) or tumors with or without
Clinical Manifestations
- Severe/steady pain
o Right lower quadrant – McBurney point; rebound tenderness
- Low grade fever/nausea
Complications
- Ischemia, gangrene, perforation
- Ruptured = peritonitis -
EMERGENCY
( can
Diagnostics causeseps as
- CBC – elevated WBC and Neutrophils
o WBC (5000-10000mm3)
o Neutrophils (55-70%)
- Urinalysis – r/o UTI/stones
- CT – right lower quadrant density
o Appendix enlargement (6mm or greater)
- Pregnancy test – r/o ectopic
Medical/Surgical
egsedIV fluids, antibiotics
open
- Appendectomy (laparotomy, laparoscopy),
Nursing Interventions artic
as
ofpatir corswakens
- Educate patient on surgery, administer pain medications, administer IV fluids/encourage PO fluids (after pass
is expected
what
gas), provide post op care and prevent post op complications, discharge instructions
*antibiotic therapy to decrease risk of rupture, ultrasound most common diagnostic tool, priority is to notify
physician of severe pain*
GI Accessory: Peritonitis
Pathophysiology
Nursing Process Defined
A systemic, problem-solving process that is used to identify, diagnose, and treat human responses to health and
illness
- Nurse focus – Patients’ responses to symptoms and patients’ ability to care for self
- Physician focus – Disease process/pathology and treatment of disease
Steps of the Nursing Process
Five inter-related steps (ADPIE)
- Assessment
- Diagnosis
- Planning (Outcome and Interventions/Activities)
- Implementation
- Evaluation
Nursing Assessment
Accurate and comprehensive assessment leads to accurate nursing diagnosis
Assessment
1) Collect data – ongoing
2) Identify cues and make inferences
3) Validate
4) Organize (cluster data)
5) Identify patterns
6) Report and record
Leading to nursing diagnosis
Data Collection
Data Sources – patient/family, health care team, medical record, diagnostic, and lab data
Methods – Interviews/history, observations, physical assessment, medical record review
Subjective (symptoms) – what a person states or communicates in writing
Objective (signs) – observations or measurements of a patient’s health status
Identifying Data
Cues
- Information the nurse obtains through the use of the senses (S&O data)
- Relevant data – decide what information is meaningful/important
Inference
- Process of deriving logical conclusions from multiple observations (inductive reasoning)
- May be correct or incorrect, correct to within aa certain degree of accuracy; requires more data
,Organize Data
Identify patterns by organizing the cues into meaningful usable clusters
Data clusters – Set of signs and symptoms that are grouped together in a logical way
Identifying Nursing Diagnosis
Clusters and patterns of data contain defining characteristics (signs & symptoms) that support nursing diagnosis
NANDA also identifies potential related factors
- Functional, psychological, pharmacological, mechanical, physiological
Types of Nursing Diagnosis Labels
Actual – A problem that has been validated by the presence of major demining characteristics
Potential (risk for) – individual is vulnerable to development of problem(s)
Wellness – assist individual to pursue optimal health
Collaborative – potential complications of medical conditions nurse cannot treat independently
Risks of Nursing Diagnostic Errors
Problems will exist or progress without detection
Omitting interventions that are essential
Choose inappropriate interventions that may:
- Waste time, cause harm, aggravate the real problem, place yourself in legal jeopardy
Errors in Writing Nursing Diagnosis
Renaming a medical problem – Don’t rename a medical problem to make it sound like a nursing diagnosis
Legally incriminating
- Incorrect: risk for injury r/t lack of side rails on bed
- Correct: risk of injury r/t disorientation and attempts to get out of bed
Two problems in one diagnostic sentence – Don’t state two problems at the same time
Creating a nursing diagnosis from a physician’s order – Don’t make a nursing diagnosis out of a physician’s order
Value Judgements – Don’t write a nursing diagnosis based on value judgements (religion)
Developing Goals/Outcomes (SMART)
Specific (individualize to patient)
Measurable
Attainable
Realistic oriented
Timed (expected completion)
Prioritizing Interventions
1) Take care of immediate life-threatening issues (ABCs)
2) Safety issues
3) Patient-identified issues
4) Nurse-identified priorities
a. Based on overall picture, the patient as a whole person, and availability of time and resources
Implementation: Putting the Plan into Action
Perform the chosen prioritized, evidence-based interventions in a …
, - Safe, effective, organized way to get the results needed while preventing errors
- To meet the goals and outcomes of the plan
- Continually evaluate the effectiveness of each intervention and make revisions
Evaluation
Are the goals/outcomes criteria … completely, partially, or not met? How do you know? Can you revise the plan?
Reflect on why goal/outcome was not met… what must be changed in POC to move the patient toward outcome
Review all the steps if the nursing process
Update the care plan
GI Accessory: Acute Appendicitis
Pathophysiology
- Appendix becomes inflamed, increasing intraluminal pressure, causes edema and obstruction of orifice
Etiologies
- Result of becoming kinked or occluded with stool
- Lymphoid hyperplasia secondary to inflammation or infection ↓
- Rarely, foreign bodies (seeds) or tumors with or without
Clinical Manifestations
- Severe/steady pain
o Right lower quadrant – McBurney point; rebound tenderness
- Low grade fever/nausea
Complications
- Ischemia, gangrene, perforation
- Ruptured = peritonitis -
EMERGENCY
( can
Diagnostics causeseps as
- CBC – elevated WBC and Neutrophils
o WBC (5000-10000mm3)
o Neutrophils (55-70%)
- Urinalysis – r/o UTI/stones
- CT – right lower quadrant density
o Appendix enlargement (6mm or greater)
- Pregnancy test – r/o ectopic
Medical/Surgical
egsedIV fluids, antibiotics
open
- Appendectomy (laparotomy, laparoscopy),
Nursing Interventions artic
as
ofpatir corswakens
- Educate patient on surgery, administer pain medications, administer IV fluids/encourage PO fluids (after pass
is expected
what
gas), provide post op care and prevent post op complications, discharge instructions
*antibiotic therapy to decrease risk of rupture, ultrasound most common diagnostic tool, priority is to notify
physician of severe pain*
GI Accessory: Peritonitis
Pathophysiology
