Chapter 4

1. Chapter 4 Nursing Process and Decision Making

2. Nursing Process Terminology • Nursing process • Decision-making framework • Nursing diagnosis • Labels a problem resulting from medical diagnosis • Nursing goals • Overall direction to improve a problem • Expected outcomes • Statements of measurable patient actions

3. Care Plan • Documented plan of care • Nursing diagnosis • Goal • Physician ordered interventions • Nursing interventions • Evaluation

4. Types of Nursing Interventions • Dependent • Requires a health-care provider’s order • Independent • Can be performed without consulting anyone else • Collaborative • Involves working with other health-care professionals in the hospital setting

5. Critical Thinking Skills • Using skillful reasoning and logical thought to determine the merits of a belief or action • Thinking purposely • Avoiding jumping to conclusions • Do not just follow orders • Validating information obtained

6. Five Steps of the Nursing Process • Assessment • Diagnosis • Planning • Implementation • Evaluation

7. Assessment • Gathering of information • Interviewing the patient • Ask questions • Listen • Verbal and nonverbal communication skills • Head-to-Toe body assessment or focused body system assessment • Review results of laboratory and diagnostic tests • To determine problems and/or needs of the patient

8. Objective Data vs. Subjective Data • Objective data • Can be OBSERVED through senses of hearing, sight, smell, and touch • Describe what you see, hear, smell or feel • Subjective data • Information known only to the patient or family members

9. Techniques Used to Gather Data • Inspection • Visual examination of the patient’s body for skin conditions and normal appearance of body parts • Palpation • Touching or feeling the torso and limbs for pulses, abnormal lumps, temperature, moisture, and vibrations

10. Techniques Used to Gather Data (cont.) • Auscultation • Listening to body organs for abnormal sounds in the lungs, heart, or bowel • Percussion • Using tapping movements to detect abnormalities of the internal organs

11. Primary Data vs. Secondary Data • Primary data • Information provided by the patient • Secondary data • Information obtained from family members, friends, and the patient’s chart

12. Diagnosis • Formulated through analysis of the assessment information • Nursing diagnosis related to the needs or problems the patient is experiencing • Completely different than a medical diagnosis

14. Medical Diagnoses vs. Nursing Diagnoses • Medical diagnoses • Based on signs, symptoms, lab findings, and test results • Nursing diagnoses • Focused on the needs of the patients

15. Planning • Process of determining priorities and what nursing actions should be performed to help resolve or manage each patient problem • Expected outcomes • Realistic time frame

16. Implementation • Process of taking actions to resolve the patient’s problems—the nursing diagnoses • The actions are referred to as interventions • Performance of the interventions—implementation

17. Evaluation • When the nurse reflects on the interventions he or she has performed • Did they bring the patient to achieving the goals or outcomes set in the planning step • If not—then revise and change the interventions to better fit the needs of the patient

18. Question • What is the difference between the role of the RN and the role of the LPN in the nursing process? • What does ADPIE stand for?

19. Initial Steps of Nursing Interventions • Nursing students—before you begin any intervention—you must be sure that you know how to perform it! • NEVER PERFORM ANY SKILL OR INTERVENTION THAT YOU HAVE NOT BEEN TAUGHT HOW TO DO • Your instructor must be present

20. Initial Steps of Nursing Interventions (cont.) • Standard Protocol • Initial steps for most nursing interventions • Read: Initial Intervention Steps--Page 63 • Refer to handout