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The Nursing Process
What is the nursing process?
- How we think as nurses
- How we determine what is going on
- How we plan care for patients
- How we evaluate if our care worked
- Problem solving and Clinical decision making!
- Thinking critically about what is going on! Assessment: What do you want to KNOW?
- What do I see, hear, and know?
- Gather data
- Health history
- Questioning
- Observations
- Physical assessment Nursing Diagnosis :
- Take your assessment data – analyze
- Determine the nursing problem (not medical)
- Helps plan nursing care for your patient
- Three types of nursing diagnosis: o Actual : going on right now ▪ Example: Impaired skin integrity o Risk : may develop because patient is vulnerable ▪ Example: Risk for impaired skin integrity o Health Promotion : enhance health behaviors ▪ Example: Readiness for enhanced self-care Parts of a Nursing Diagnosis :
- Nursing Diagnostic label a. Patient’s response to a health problem
- Related to: a. Associated with patient’s actual problem or health b. Cause of the patient’s problem/reason for the diagnosis As evidenced by…
- Three-part format to Nursing Diagnosis (PES) o Problem (NANDA list) o Etiology (related to) o Symptoms – as evidenced by… (from previous example)- pain when moving, report of pain
Planning Care :
- Once you have your diagnosis…. plan your care for your patient.
- Set patient centered goals for NURSING care
- Collaborate with the patient and family – what do they want?
- What do you want to TEACH? Patient Goals :
- Be precise – single outcome
- Observable – see change in patient status
- Measurable – According to standards
- Time Limited – when you expect this to happen
- Mutual factors – agree with patient/family
- Realistic – able to reach based on assessment Implementation of Care: What do you want to DO?
- Independent nursing actions – nurse can initiate and act on patient’s behalf; require no supervision or direction from others
- Dependent nursing interventions – require an order from physician or health care professional; need specific nursing knowledge
- Collaborative interventions – work with health care team. Is the order appropriate? Patient care conference with team Implementing the Interventions :
- Perform nursing care
- Help patient achieve goals
- Anticipate and prevent complications
- Delegate appropriate actions
- Educate the patient and family Evaluation of Care: Did it Work?
- Evaluate what you did?
- Did the patient get better? Did outcomes improve?
- Was your care effective?
- Requires reassessment and judgment based on your nursing knowledge.
- If it didn’t work- revise plan of care!
- Make changes based on patient’s response Nursing Detective :
- Problem solving
- Clinical decision making
- Based on clues (assessment) – Nursing Knowledge (Diagnosis) – Nursing Interventions (implementation) – Reflection/Evaluation (that worked/or didn’t work)
Genogram :
- Graphic family tree that uses symbols to organize and illustrate the patient’s family history
- Typically, a circle is female, and the square represents male
Chapter 2: Family and Cultural Assessment Cultural Assessment :
- Forming trust with a patient entails of listening to each patient’s individual needs and establishing an awareness of his or her culture
- Culture : the nonphysical attributes of a person o The thoughts, communications, actions, beliefs, values, and institutions of racial, ethnic, religious, or social groups o Universal phenomenon
▪ Subcultures : cultures within cultures that share different beliefs,
values, and attitudes, which may occur because of ethnicity, religion, education, occupation, age, and gender
- Socialization or enculturation: process of being raised within a culture and acquiring the norms, values, and behaviors of that group o Affects many aspects of patient’s lives: ▪ Definitions of health ▪ Health practices ▪ Treatments ▪ Barriers to care Culture has four basic characteristics :
- Learned : from birth through the processes of language acquisition and socialization
- Shared : by all members of the same cultural group
- Adapted : to specific conditions related to environmental and technical factors and to availability of natural resources
- Dynamic : ever changing Definition of Terms:
- Cultural care : professional health care that is culturally sensitive, appropriate, and competent
- Cultural competence : contains five components o Cultural awareness o Cultural skill o Cultural knowledge o Cultural encounters o Cultural desire Ethnicity :
- Describes a group united by: o Common geographic origin o Migratory status o Religion o Race o Language o Shared values, traditions, or symbols
Acculturation :
- Process of adopting the culture and behavior of the majority culture
- Assimilation of cultures o One culture taking on and learning the characteristics of the dominant culture o Acculturative stress : may form when through the losses and changes that occur when adjusting to or integrating a new system of beliefs, routines, and social roles ▪ Has important implications for health and illness **Linguistic Competence: Health Literacy
- Title VI of Civil Rights Act of 1964** o Services cannot be denied to people of limited English proficiency
- In 2012, over 21% of Americans over 5 years of age speak a language other than English in their homes o Most common non-English language is Spanish
- Patients who have limited English proficiency (LEP) are at risk for poor health care outcomes due to the barrier that language presents during health care delivery interactions o Health care facilities may have established interpreters who can assist with therapeutic communication Purpose and Scope of Cultural Assessment :
- To learn about the patient’s beliefs and behaviors associated with health and illness
- Including: disease causes, caregiving, expected treatments (Western medicine and folk practices), daily hygiene, food preferences and rituals, religious beliefs related to health care
- To assess the patient’s health relative to diseases prevalent in the specific cultural group Factors Affecting Approach to Providers :
- Ethnicity (of both patient and the provider)
- Generational status (of both)
- Educational level
- Religion
- Previous health care experiences
- Occupation and income level
- Beliefs about time and space
- Communication needs/preferences Health Related Behaviors Affected by Religion :
- Spirituality : broader term focused on a connection to something larger than oneself and a belief in transcendence
- Religion : refers to an organized system of beliefs concerning the cause, nature, and purpose of the universe, as well as the attendance of regular services o Shared experience of spirituality or the values, beliefs, and practices into which people either are born or that they may adopt to meet their personal spiritual needs through communal actions ▪ Meditating ▪ Exercising/physical fitness ▪ Sleep habits ▪ Vaccinations ▪ Willingness to undergo physical examination
▪ Pilgrimage ▪ Folk healer
events in life have a cause and effect
o Naturalistic or holistic perspective : people believe that human life is the only one aspect of nature and a part of the general order of the cosmos ▪ They believe that the forces of nature must be kept in natural balance or harmony
- Example: yin/yang theory o Yin: represents the female and negative forces such as emptiness, darkness, and cold o Yang: represents the male and positive, emitting warmth and fullness o Magicoreligious perspective : the world is an arena in which supernatural forces dominate ▪ The fate of the world and those in it depends on the action of supernatural forces for good or evil
- Example: witchcraft
mediastinum
- Lies at an angle so right ventricle makes up the most of anterior surface
- Left ventricle lies left and posteriorly - Pulmonary arteries and aorta are termed “the great vessels” - Aorta curves upward and outward of left ventricle and bends posteriorly and downward just above the sternal angle - Pulmonary arteries emerge from superior aspect of right ventricle near third intercostal space Heart Wall : has numerous layers - Pericardium : tough, fibrous, double- walled sacs that surround and protects heart - Myocardium : muscular wall of heart (does the pumping) - Endocardium : thin layer of endothelial tissues that lines inner surface of heart chambers and valves Heart Chambers : - Four chambers o Right and left atrium (RA and LA) o Right and left ventricle (RV and LV) o Separated by an impermeable wall ( septum ): two pumps ▪ Atria: thin-walled reservoir for holding blood ▪ Ventricles: thick-walled ventricle responsible for pumping the blood out Valves : (AV) entrance - One way “doors” at the entrance and exit of each ventricle that prevent backflow (four in the heart) - Two atrioventricular (AV) valves : located at the entrance of the ventricles o Tricuspid : between the right atrium and the right ventricle o Mitral/bicuspid : between the left atrium and left ventricle o Allows blood from the atria to ventricles, then snaps shut when the ventricles begin to contract ▪ The valves are anchored by collagenous fibers ( chordae tendineae ) ▪ Opens during the heart’s filling phase, diastole , to allow ventricles to fill with blood ▪ AV valves close during the systole phase Valves : (semilunar) exit - Two semilunar (SL) Valves : located at the exit of each ventricle at the great vessel o Pulmonic : exits right ventricle and entrance to the pulmonary artery o Aortic : exits left ventricle and entrance to the aorta o Opening during ventricular contraction, and closes when the ventricles relax ▪ SL valves pens during systole , which is when blood is ejected from the heart
ventricles is accomplished when pressure of blood in atria becomes higher than pressure in ventricles o Higher atrial pressures passively open AV valves, allowing blood to fill ventricles o About 80% of blood from atria flows into relaxed ventricles
Systole: contraction Ventricles contract, creating pressure that closes AV valves, preventing backflow of blood into atria. Ventricular pressure also forces semilunar valves to open, resulting in ejection of blood into aorta from left ventricle and pulmonary arteries from right ventricle As blood is ejected, ventricular pressure decreases, causing semilunar valves to close Ventricles relax to begin diastole Characteristics of Sound : All heart sounds are described by: Frequency (pitch): high or low Intensity (loudness): loud or soft Duration : very short for heart sounds; silent periods are longer Timing : systole or diastole o Contraction of atria forces remaining 20% of blood into ventricles o This added atrial thrust is termed the atrial kick o At end of diastole, ventricles are filled with blood Pumping Ability :
- Cardiac output : in resting adult, heart normally pumps between 4 and 6 L of blood per minute throughout body CO= HR x SV - Heart can alter its cardiac output to adapt to metabolic needs of body. - Preload and afterload affect heart’s ability to increase cardiac output. - Preload: venous return that builds during diastole - According to Frank-Starling law, greater the stretch, the stronger the heart’s contraction. - This increased contractility results in an increased volume of blood ejected, increased stroke volume. - Afterload: opposing pressure ventricle must generate to open aortic valve against higher aortic pressure - Resistance against which ventricle must pump its blood Heart Sounds: - First heart sound (S 1 ) – LUB SOUND o Closure of AV valve: signals beginning of systole o S1 Loudest at apex of the heart o Correlates with pulse, with carotid - Second heart sound (S 2 ) – DUB SOUND o Closure of semilunar valve—signals end of systole, beginning of Diastole
- Third heart sound (S 3 ): Volume Overload o Heard immediately after S o S3: Ventricular Gallop o ( fluid causes extra sound) - use BELL over APEX ▪ Physiologic : Children, Young adults (<40 men and < women), athletes, pregnancy (3rd^ trimester) - Disappears when patient sits up ▪ Pathologic : Fluid overload. CHF, hyperthyroidism, anemia, pregnancy (1st^ & 2 nd^ Trimester) - Fourth heart sound (S 4 ): hearing this sound is bad o S4: atrial gallop o ( hardening of ventricle(pressure) causes sound) - use BELL over APEX ▪ Heard just before S - Physiologic : (hardly ever) 40-50 y/o after exercise. - Pathologic : hypertension, coronary artery disease, cardiomyopathy, obstruction of blood (aortic stenosis and ventricular hypertrophy) - Extra heart sounds : murmurs o Gentle blowing, swooshing sound that can be heard on chest wall o Conditions that create turbulent blood flow and collision currents o Conditions that can result in murmurs: ▪ Velocity of blood increases (in exercises, thyrotoxicosis) ▪ Viscosity of blood decreases (in anemia) ▪ Structural defects in valves (stenotic or narrowed valve, or a septal defect)
o Systolic murmur : may occur with healthy heart or with heart disease ( usually
heard with S1 )
o Diastolic murmur : always heart disease
o Innocent- no pathological cause o Functional- increased blood flow through the heart (pregnancy, anemia, fever, and in children) Developmental Considerations :
- Pregnant woman o Blood volume increases by 30% to 50% ▪ Increases stroke volume. Cardiac output, and increased pulse rate to 10- beats/min o Despite increased cardiac output, arterial blood pressure decreases in pregnancy as a result of peripheral vasodilation - Infants and children o Fetal heart begins to beat after 3 weeks’ gestation. o Inflation and aeration of lungs at birth produces circulatory changes - Aging adult o Closely interrelated with lifestyle, habits, and diseases o Lifestyle, smoking, diet, alcohol use, exercise patterns, and stress have an influence on coronary artery disease Neck Vessels
Hemodynamic Changes with Aging :
- EKG changes and dysrhythmias - Pressure/pulse changes o Isolated systolic hypertension : Increase in systolic blood pressure due to thickening and stiffening of the arteries ▪ Increases the systolic blood pressure o Left ventricular wall becomes thicker but the overall size of the heart does not change o Ability of heart to augment cardiac output with exercise is decreased Cardiac Disease and Aging Adult : - Incidence of coronary artery disease increases sharply with advancing age and accounts for about half of deaths of older people. o Hypertension and heart failure also increase with age o Lifestyle habits play a significant role in the acquisition of heart disease - Increasing the physical activity of older adults associated with a reduced risk for death from cardiovascular diseases and respiratory illnesses Culture and Genetics : - Cardiovascular disease: most common underlying cause of death globally - Risk increased with race, ethnicity, gender, socioeconomic status, and educational - Risk factors - Identification, early treatment, and health promotion: o Hypertension o Smoking o Serum cholesterol o Physical activity
