CLINICAL DECISION MAKING AND NURSING PROCESS SV

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Nursing Diagnosis

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CLINICAL DECISION MAKING AND NURSING PROCESS:

CLINICAL DECISION MAKING AND NURSING PROCESS 1 T. Valenta MSN, FNP-BC

WHAT IS HEALTH ASSESSMENT?:

WHAT IS HEALTH ASSESSMENT? The systematic collection, organization, and evaluation of data about a patient's state of health and wellness . First step in the Nursing Process 2

RN RESPONSIBILITIES :

RN RESPONSIBILITIES Conduct and document nursing assessments of the health status of patients. Gather both objective and subjective data. Adjust assessments as the patients' status changes. Relays assessment findings as needed to other members of the healthcare team. 3

JCAHO MANDATE:

JCAHO MANDATE The Joint Commission for Accreditation of Healthcare Organizations (JCAHO) mandates that each patient's nursing care needs, related to his/her admission, be assessed by a registered nurse . 4

RN Responsibility:

RN Responsibility Manage Nursing Care Monitor Medical Condition 5

ASSESSMENT Point of Entry in an Ongoing Process:

ASSESSMENT Point of Entry in an Ongoing Process Subjective data What patient says about himself or herself during history taking Objective data P.E.-Inspect, percuss, palpate and auscultate. Lab data, diagnostic tests 6

DATA BASE:

DATA BASE Your patient complains of "feeling very tired" - patient history – subjective data. Your observe conjunctiva pallor - physical examination – objective data. You check the patient's Hgb & Hct and see that both values are below normal – (laboratory data) – the most objective data. 7

Clinical Decision Making Models:

Clinical Decision Making Models Diagnostic reasoning Nursing process Critical thinking 8

Diagnostic Reasoning:

Diagnostic Reasoning Attend to initially available cues Cue : piece of information, sign, symptom, or piece of laboratory data Formulate diagnostic hypotheses Hypothesis : tentative explanation for cues used as a basis for further investigation Gather data relative to tentative hypotheses Evaluate each hypothesis with new data collected to arrive at final diagnosis 9

Nursing Process:

Nursing Process Assessment Diagnosis Outcome identification Planning Implementation Evaluation 10

Nursing Process: Assessment:

Nursing Process: Assessment Collect data Review of clinical record Interview/Health history Physical examination Functional assessment Cultural and spiritual assessment Consultation Review of the literature 11

Nursing Process: Diagnosis:

Nursing Process: Diagnosis Interpret data Identify clusters of cues Make inferences Validate inferences Compare clusters of cues with definitions and defining characteristics Identify related factors Document the diagnosis 12

Nursing Dx:

Nursing Dx The process of sorting and analyzing the subjective and objective data for the identification of an: Actual problem Potential problem 13

WHAT IS A NURSING DX?:

WHAT IS A NURSING DX? Deals with the human response to actual or potential health problems and life processes.   Must be an issue that can be modified by nursing interventions NANDA approved nursing DX (North American Nursing Diagnosis Association) 14

Nursing Dx Guidelines::

Nursing Dx Guidelines: Never write anything in a nursing diagnosis that: suggests that other members of the healthcare team have made mistakes or failed to do their jobs properly. suggests that the patient is "bad" or "foolish" or is to blame for his/her problems. 15

HOW DO I WRITE A NSG DX? :

HOW DO I WRITE A NSG DX? 1. Problem: The Diagnostic Label: the human response to alterations in health and wellness 2. Etiology : Related issues or causative/ contributing/risk factors. 3. Signs & Symptoms: Evidence/data (defining characteristics) that support the nursing diagnosis. 16

PART 1 : PROBLEM “DIAGNOSTIC LABEL”:

PART 1 : PROBLEM “DIAGNOSTIC LABEL” Make sure that the first part of a nursing diagnosis is stated in terms of a human response not a patient need. (NANDA) Example : Constipation 17

PART 2: ETIOLOGY “CONTRIBUTING FACTORS”:

PART 2: ETIOLOGY “CONTRIBUTING FACTORS” Identifies the related to (r/t) issues: causative/contributing/risk factors Provides direction for managing the problem: should be something that nursing can treat Part 1 Constipation Part 2 r/t inadequate fluid intake, low fiber diet, and decreased activity 18

Etiology:

Etiology The etiology may be identified as secondary to a medical problem, but a medical diagnosis should not be the primary etiology . Example: Constipation r/t decreased activity secondary to paraplegia… 19

PART 3 : STATE THE EVIDENCE “SIGNS & SYMPTOMS”:

PART 3 : STATE THE EVIDENCE “SIGNS & SYMPTOMS” State the evidence/data (signs and symptoms) collected by the nurse to support the nursing diagnosis. 20

Example::

Example: Constipation related to inadequate fluid intake, low fiber diet, and decreased activity as evidenced by patient's complaints of abdominal discomfort and no BM for 5 days. 21

Nursing Process: Outcome Identification:

Nursing Process: Outcome Identification Identify expected outcomes Individualize to patient Ensure outcomes are realistic and measurable Include a time frame 22

Nursing Process: Planning:

Nursing Process: Planning Establish priorities Develop outcomes Set time frames for outcomes Identify interventions Document plan of care 23

Nursing Process: Implementation:

Nursing Process: Implementation Determine patient readiness Review planned interventions Collaborate with other team members Supervise by delegating appropriate responsibilities Counsel person and significant others Involve person in health care Refer for continuing care Document care provided 24

Nursing Process: Evaluation:

Nursing Process: Evaluation Refer to established outcomes Evaluate individual’s condition and compare actual outcomes with expected outcomes Summarize results of evaluation Identify reasons for failure to achieve expected outcomes Take corrective action to modify plan of care Document evaluation in plan of care 25

Clinical decision making:

Clinical decision making Identifying Assumptions Recognize information taken for granted or not based in fact Organized approach Use an organized, systematic approach Validation Check for verify accuracy and reliability of data Normal and abnormal Signs and symptoms: are they normal or abnormal? 26

Clinical decision making:

Clinical decision making Inferences or drawing valid conclusions Interpreting data and deriving correct conclusions Clustering related cues Assists seeing relationships among data Relevance Look at clusters of data and consider which are important for health problem Inconsistencies Recognize subjective data at odds with objective data 27

Clinical decision making:

Clinical decision making Identify patterns Helps to see whole picture and discover missing pieces of information Missing information Identify gaps in data or need for more specific interviewing or laboratory data to make diagnosis Health promotion Identify and manage known risk factors for individual’s age group and cultural status 28

Clinical decision making:

Clinical decision making Risk diagnosis Identify actual and potential risks from full list of both medical and nursing assessment data Nursing diagnoses are clinical judgments about a person’s response to an actual or potential health state 29

NURSING PROCESS PUTTING IT ALL TOGETHER :

NURSING PROCESS PUTTING IT ALL TOGETHER 30

EBP:

EBP Evidence-based practice (EBP) is a systematic approach to practice that emphasizes the use of best evidence in combination with the clinician’s experience, as well as patient preferences and values, to make decisions about care and treatment. 31

Quote of the Week:

Quote of the Week A decision is made with the brain. A commitment is made with the heart. Therefore, a commitment is much deeper and more binding than a decision. ~ Nido Qubein 32

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