SCHOOL OF NURSING
RN-BSN PROGRAM

COLLEGE 
OF 
HEALTH 
AND URBAN AFFAIRS

COURSE
DESCRIPTION

GENERAL INFO REQUIREMENTS

SCHEDULE
DUE DATES

 

RN-BSN MAIN PAGE

Transition to Professional Nursing
NURSING PROCESS

To e-mail the instructor  phillips@fiu.edu

ASSIGNMENT (FOR WEB-BASED ONLY STUDENTS):
Review the class handout below.

1.   Explore the North American Nursing Diagnosis Association (NANDA) web site: http://nanda.org

  • What is the purpose of NANDA?

  • What are the six goals explicated under NANDA’s strategic plan?

2.   Briefly describe one of your patients/clients who had a medical prognosis that was “negative,” but a nursing prognosis that was “positive.”  Why?  Describe one of your patients/clients who had a medical prognosis that was “positive” but a nursing prognosis that was “negative.”  Why?

3.   Does your practice setting use standardized plans of care?  Are they computerized or on paper? 
Are they user-friendly?  If your workplace does not use standardized plans of care, why not?

E-MAIL YOUR ANSWERS TO THE INSTRUCTOR (AT LEAST 200 WORDS).

CLASS HANDOUT

DEFINITION OF THE NURSING PROCESS
A systematic, rational method of planning and providing individualized nursing care.

CHARACTERISTICS OF THE NURSING PROCESS

EVOLUTION OF THE NURSING PROCESS
T
he nursing process has evolved as various nurse theorists and organizations wrote about the 
process:

 

 ASSESSMENT PHASE

DEFINITION OF ASSESSMENT
The collection, organization, validation, and recording of data.

ELEMENTS OF ASSESSMENT
Collecting data—the process of gathering information about a client’s condition.   Factors that may impede client assessment data: Language, anxiety, fear, acute illness/pain, limited mental capacity, previous negative experiences.

Organizing data
—the process of organizing data using an assessment framework that allows the establishment of patterns and priorities for care.   Types of organizing assessment frameworks in the literature:

Validating data—the process of verifying data for accuracy:

Recording data—the process of accurately documenting the data.

DIAGNOSTIC PHASE

DEFINITION OF NURSING DIAGNOSES
Nursing Diagnosis--A clinical judgement about individual, family, or community responses to actual and potential health problems/life processes.  Nursing diagnoses provide for the selection of nursing interventions to achieve outcomes for which the nurse is accountable.

Wellness Diagnosis--A clinical judgement about an individual, family, or community in transition from a specific level of wellness to a higher level of wellness (NANDA, 1990). 

HISTORY OF NURSING DIAGNOSES

DIAGNOSIS SUBMISSION GUIDELINES

COMPONENTS OF A NURSING DIAGNOSTIC LABEL

DIAGNOSIS

DEFINITION

ETIOLOGY
/RELATED FACTORS

DEFINING CHARACTERISTICS

Activity intolerance

A state in which an individual has insufficient psychological or psychological energy to endure or complete required or desired daily outcomes.

  • Sedentary lifestyle

  • Prolonged immobility

  • Sensory deficits

  • Impaired motor function

  • Alterations in oxygen transport

  • Lack of motivation

  • Obesity

  • Acute or chronic pain

Major (must be present)

  • Dysnea, SOB, tachypnea, rapid shallow respirations

  • Weak irregular pulse, tachycardia,
    EKG changes after activity.

  • Hypotension, failure of BP to increase with activity.

  • Weakness, fatigue.

Minor (may be present)

  • Pallor, cyanosis, vertigo, diaphoresis, confusion.

CHARACTERISTICS OF NURSING DIAGNOSES


TYPES OF NURSING DIAGNOSES
Actual diagnosis—a clinical judgment about a client’s response to a health problem that is present at the time of the nursing diagnosis.

Potential/risk diagnosis—a clinical judgment that a client is more vulnerable to develop than others in the same or similar situation.

Collaborative Problems

Possible diagnosis—a clinical judgment about a health problem that is unclear or the causative factors are unknown. 

Wellness diagnosis—a clinical judgment indicating a healthy response of a client who desires a higher level of wellness.

COMPONENTS OF A NURSING DIAGNOSIS
Problem Statement (P) (also known as the Diagnostic Label)

Etiology (E) /Related Factors

Defining Characteristics (also known as Signs/Symptoms (S)


THE DIAGNOSTIC PROCESS
Analyzing Data

Formulating Diagnostic Statements

One Part Statements (P)—used for wellness nursing diagnoses.

Two Part Statements (PE)—used for risk nursing diagnoses that are NOT “usual”.

Three Part Statements (PES)--used for actual nursing diagnoses

Collaborative Problem Statements—used for potential problems that are “usual”.

Setting Priorities

CORRECT VS. INCORRECT DIAGNOSTIC STATEMENTS

INCORRECT STATEMENT

CORRECT STATEMENT

Fluid replacement (need) related to fever.

Fluid volume deficit (problem) related to fever.

Impaired skin integrity related to improper positioning (implies liability).

Impaired skin integrity related to immobility (legally acceptable).

Spiritual distress related to strict rules necessitating church attendance (judgmental).

Spiritual distress related to inability to attend church services (nonjudgmental).

Potential ineffective airway clearance related to emphysema (medical terminology).

Potential ineffective airway clearance related to accumulation of secretions in lungs (nursing terminology).

Social isolation related to laryngectomy (nurse can do nothing about the laryngectomy).

Social isolation related to loss of speech (loss of speech provides the nurse with direction for planning alternative communication methods).

 
[PROGNOSIS PHASE]

Some authors add an additional step (prognostic phase) between the diagnostic and planning phase.

DEFINITION OF NURSING PROGNOSIS
Prognosis—A prediction of the possible or probable course of events and outcomes associated with a particular health status or situation under various treatment options or lack of treatment. 

CHARACTERISTICS OF A NURSING PROGNOSIS
A nursing prognosis is similar to a medical prognosis in that it precedes treatment decisions, but it differs from a medical prognosis in that prognostic data relate to the client’s functioning capacities.

Nursing prognoses deal with the likelihood that the client and his/her support system will be able to respond in such a way that:

COMPONENTS OF A NURSING PROGNOSIS

Prognostic Variables (Indicators)
Examples of variables are the client age, general health, effects of health problem and treatment, functional capacity for ADL, demands placed on support system, health care resources, etc.

Prognostic Outcome—can predict success, failure, or some improvement.

Trajectory—deals with the course of events as well as the outcomes.

PLANNING PHASE

DEFINITION OF PLANNING
The phase of the nursing process that involves decision-making and problem solving.

ELEMENTS OF PLANNING
Setting Priorities
the process of establishing a preferential order for nursing strategies.

·    Establishing Client Goals/Expected Outcomes
Also known as outcome criterion, objective, predicted outcome or outcome identification.
  Well-stated goals/expected outcomes are:

Goals—a broad statement.  EX: “The client’s nutritional status will improve.”

Expected Outcomes—measurable criteria.  EX:  as evidenced by moist mucous membranes by 11/05/01.”

Components of Goal/Expected Outcome Statements

Selecting Nursing Strategies

Developing Nursing Care Plans
May be pre-planned and pre-printed (standardized), computerized, or completely handwritten.  Standardized plans of care:

  • Ensure that minimally accepted standards of care are provided.

  • Promote efficient use of nurses time by eliminating repetition in writing. 

  • Must be individualized to the patient. 

 

RELATIONSHIP BETWEEN NURSING DIAGNOSIS,
CLIENT GOALS AND OUTCOME CRITERIA

DIAGNOSTIC STATEMENT

CLIENT GOALS

OUTCOME CRITERIA

Altered peripheral tissue perfusion (left leg) related to impaired arterial circulation manifested by cool skin temperature, decreased left popliteal and pedal pulses, capillary refill < 3 sec.

The client will have improved peripheral tissue perfusion in left leg and foot as evidenced by

  • Skin intact, pink and warm.

  • Lt pedal and popliteal pulses palpable and equal to right.

  • Capillary refill 1-3 sec.

  • Verbalizes factors that increase circulation.

Fear related to outcome of cardiac catheterization manifested by sleeplessness, repeating same questions about procedure.

The client will have decreased fear as evidenced by

  • Ability to describe what is expected of him before and after the procedure.

  • Ability to communicate concerns clearly and logically.

  • Ability to sleep


IMPLEMENTATION (INTERVENTION) PHASE

DEFINITION OF IMPLEMENTATION
Consists of doing, delegating, and recording. 

ELEMENTS OF IMPLEMENTATION
Reassessing the Client
Determining the Need for Nursing Assistance
(to carry out the plan)
Implementing Nursing Strategies

Communicating Nursing Actions

NURSING INTERVENTION CLASSIFICATION (NIC)


EXAMPLE OF A STANDARDIZED NURSING INTERVENTION LABEL

LABEL

DEFINITION

ACTIVITIES

Respiratory Monitoring

Collection and analysis of client data to ensure airway patency and adequate gas exchange.

  • Monitor rate, rhythm, depth and effort of respirations.

  • Monitor for noisy respirations such as crowing or snoring.

  • Percuss anterior and posterior thorax from apices to bases bilaterally.

  • Monitor for increased restlessness, anxiety, and air hunger.

  • Monitor patients ability to cough effectively.

 

Benefits of Nursing Intervention Classification (NIC)


EVALUATION PHASE

DEFINITION OF EVALUATION
Process of making judgments on goals/expected outcomes.

TYPES OF CLIENT EVALUATION

COMPONENTS OF CLIENT EVALUATION

EVALUATING QUALITY OF NURSING CARE
Quality assessmentexamination of services only.
Quality assuranceimplies evaluation of and assurance of quality health care.

Types of Evaluation for Nursing Care

Approaches to Evaluating Nursing Care