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Session #9 SAS - Funda (Lec)

Fundamentals of Nursing (Southwestern University PHINMA)

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Fundamentals of Nursing Practice - Lecture

STUDENT ACTIVITY SHEET BS NURSING / FIRST YEAR
Session # 9

LESSON TITLE: NURSING AS A SCIENCE : NURSING Materials:

PROCESS Pen and notebook
▪ NURSING ASSESSMENT
▪ NURSING DIAGNOSIS
▪ PLANNING

LEARNING OUTCOMES:

Upon completion of this lesson, you can:

1. Describe the types of assessment, types and sources
of data;
2. Explain patient-centered interview and interview
techniques;
3. Describe the components of a nursing history;
4. Describe the steps of the nursing diagnostic process;
5. Describe the differences among health promotion,
problem-focused, and risk nursing diagnosis;
6. Describe sources of diagnostic errors;
7. Explain the relationship of planning to assessment and
nursing diagnosis;
8. Discuss criteria used in priority setting;
9. Discuss the difference between a goal and an
expected outcome;
10. Explain the SMART and correctly write an outcome for
a goal of care; Reference:
11. Develop a plan of care from a nursing assessment; Potter, P. A., Perry, A.G., et al. (2021). Fundamentals
12. Discuss the process of selecting nursing interventions of nursing (10th ed.). Singapore: Elsevier.
during planning; and,
13. Describe the consultation process.

LESSON PREVIEW/REVIEW
Answer the posted questions based on your understanding. You may use the back sheet of this page for your answers.
Here are the tasks:

1. Nursing Process

5. Nursing Implementation
2. Nursing Assessment

6. Nursing Evaluation
3. Nursing Diagnosis

7. Nursing Documentation
4. Nursing Plan

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MAIN LESSON
You will study the contents of this lesson and read your book, if available.

THE NURSING PROCESS

• The nursing process is a critical thinking process that professional nurses use to apply the best available
evidence to caregiving and to promoting human functions and responses to health and illness.
• The nursing process is continuous and dynamic, so you may move back and forth among the steps. Nursing
assessment helps nurses to form a clear definition of the patient's problems, which in turn provides the foundation
for planning and implementing nursing interventions and evaluating the outcomes of care.
• The nursing process is also a standard of practice, which, when followed correctly, protects nurses against legal
problems related to nursing care.
• The nursing process is central to your ability to provide timely and appropriate care to your patients. It begins
with the first step, assessment, the gathering and analysis of information about the patient’s health status.
• You then make clinical judgments from the assessment to identify the patient’s response to health problems in the
form of nursing diagnoses.
• Once you define appropriate nursing diagnoses, you create a plan of care. Planning includes setting goals and
expected outcomes for your care and selecting interventions (nursing and collaborative) individualized to each of
the patient’s nursing diagnoses.
• The next step, implementation, involves performing the planned interventions.
• After performing interventions, you evaluate the patient’s response and determine whether the interventions were
effective.

Five-Step Nursing Process

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NURSING ASSESSMENT

Critical Thinking Approach to Assessment

● Assessment involves collecting information from the patient and from secondary sources (e.g., family members),
along with interpreting and validating the information to form a complete database.
● Two stages of assessment:
Collection and verification of data
Analysis of data

Developing the Nurse-Patient Relationship for Data Collection

● Sources of data
Patient (interview, observation, physical examination)—the best source of information
Family and significant others (obtain patient’s agreement first)
Health care team
Medical records
Scientific literature
● Database

Types of Assessments
● The patient-centered interview during a nursing
health history.
● A physical examination.
● The periodic assessments you make during rounding or administering care.

You learn to differentiate important data from the total data you collect.
▪ A cue is information that you obtain through use of the senses.
▪ An inference is your judgment or interpretation of these cues.

Types of Data
● Subjective
Patient’s verbal descriptions of their health problems.
Often reflect physiological changes, which you further explore through objective review of body systems.
● Objective
Observations or measurements of a patient’s health status
Measured on the basis of an accepted standard such as the Fahrenheit or Celsius measure on a
thermometer, inches or centimeters on a measuring tape, or a rating scale (e.g., pain).
When you collect objective data, apply critical thinking intellectual standards (e.g., clear, precise, and
consistent) so you can correctly interpret your findings/

Sources of Data
● Patient ● Medical records
● Family and significant others ● Other records and the scientific literature
● Health care team ● Nurse’s experience

The Patient-Centered Interview

● Motivational interviewing
● Effective communication
● Interview preparation
● Phases of an interview
Orientation and setting an agenda
Working phase
Termination

Interview Techniques
● Observation ● Leading questions
● Open-ended questions ● Back channeling
● Direct closed-ended questions

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Components of the Nursing Health History

Biographical Information Patient Expectations

Reason for seeking health care Present illness or health concerns
Health history Family history
Psychosocial history Spiritual health
Review of systems

● Diagnostic and laboratory data

Results provide further explanation of alterations or problems identified during the health history and
physical examination
● Interpreting and validating assessment data
Ensures collection of complete database
Leads to second step of nursing process
● Data documentation
Use clear, concise appropriate terminology
Becomes baseline for care
● Concept mapping
Visual representation that allows you to graphically show the connections among a patient’s many health
problems

NURSING DIAGNOSIS
• A nursing diagnosis is a clinical judgment vulnerability for that response by an individual, family, or community
that a nurse is licensed and competent to treat. Patients are actively involved. Nursing diagnoses are ever
changing on the basis of a patient’s needs.
• A collaborative problem is an actual or potential physiological complication that nurses monitor to detect the
onset of changes in a patient’s health status.
• Interprofessional collaboration is a partnership between a team of health care providers (such as nurses,
therapists, dietitians, and physicians) and a patient in a participatory collaborative and coordinated approach for
shared decision making around health issues.

History of Nursing Diagnosis

● First introduced in 1950.
● In 1953, Fry proposed the formulation of a nursing diagnosis.
● In 1973, the first national conference was held.
● In 1980 and 1995, the American Nurses Association (ANA) included diagnosis as a separate activity in its
publication Nursing: A Social Policy Statement.
● In 1982, North American Nursing Diagnosis Association (NANDA) was founded.

Types of Nursing Diagnoses

● NANDA-I (2014) nursing diagnoses include:
Problem-focused
Risk
Health promotion

Data Clustering
● A data cluster is a set of cues, the signs or symptoms gathered during assessment.
● Data clusters are compared with standards to reach a conclusion about a patient’s response to a health problem.
● Each clinical criterion is an objective or subjective sign, symptom, or risk factor that, when analyzed with other
criteria, leads to a diagnostic conclusion.

Data Interpretation
● It is critical to select the correct diagnostic label for a patient’s need.
● When comparing patterns, judge whether the grouped signs and symptoms are expected for a patient (e.g.,
consider current condition, history) and whether they are within the range of healthy responses.
By isolating any defining characteristics not within healthy norms, you can identify a specific problem.

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Formulating a Nursing Diagnosis Statement

● Identify the correct diagnostic label with associated defining characteristics or risk factors and a related factor.
● A related factor allows you to individualize a nursing diagnosis for a specific patient.
● Most settings use a two-part format in labeling health promotion and problem-focused nursing diagnoses.
● Some agencies prefer a three-part nursing diagnostic label:
Problem
Etiology
Symptoms

Concept Mapping Nursing Diagnosis

● A concept map helps you critically think about a patient’s diagnosis and how they relate to one another.
Helps organize and link data about a patient’s multiple diagnoses in a logical way.
Graphically represents the connections among concepts that relate to a central subject.

Sources of Diagnostic Error

● Errors occur during:
Data collection Clustering
Interpretation and analysis of data Diagnostic statement

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1. Identify the patient’s response, not the medical diagnosis.

2. Identify a NANDA-I diagnostic statement rather than the symptom.
3. Identify a treatable cause or risk factor rather than a clinical sign or chronic problem that is not treatable
through nursing intervention.
4. Identify the problem caused by the treatment or diagnostic study rather than the treatment or study itself.
5. Identify the patient response to the equipment rather than the equipment itself.
6. Identify the patient’s problems rather than your problems with nursing care.
7. Identify the patient problem rather than the nursing intervention.
8. Identify the patient problem rather than the goal of care.
9. Make professional rather than prejudicial judgments.
10. Avoid legally inadvisable statements.
11. Identify the problem and its cause to avoid a circular statement.
12. Identify only one patient problem in the diagnostic statement.

Documentation and Informatics

● Once you identify a patient’s nursing diagnoses, enter them either on the written plan of care or in the electronic
health information record (EHR) of the agency.
Computer helps organize data into clusters
Enhances ability to select accurate diagnoses
● When initiating an original care plan, place the highest-priority nursing diagnosis first.

Nursing Diagnosis: Application to Care Planning

● By learning to make accurate nursing diagnoses, your care plan will help communicate the patient’s health care
problems to other professionals.
● A nursing diagnosis will ensure that you select relevant and appropriate nursing interventions.

PLANNING NURSING CARE

• After making a medical diagnosis, a health care provider will choose interventions and communicate the plan to
the health care team.
• The plan of care should be individualized.
• This requires communicating closely with patients, their families, and the health care team, and ongoing
consultation with team members.
• The nursing diagnoses that you identify direct your selection of individualized nursing interventions and the goals
and outcomes you hope to achieve.

Establishing Priorities
● Ordering of nursing diagnoses or patient problems uses determinations of urgency and/or importance to establish
a preferential order for nursing interventions.
● Organization of a vision of desired outcomes.
● Classification of priorities:
High—Emergent
Intermediate—non-life-threatening
Low—Affect patient’s future well-being
● The order of priorities changes as a patient’s condition changes.
● Priority setting begins at a holistic level when you identify and prioritize a patient’s main diagnoses or problems.
● Patient-centered care requires you to know a patient’s preferences, values, and expressed needs.
● Ethical care is a part of the priority setting.

Critical Thinking in Setting Goals and Expected Outcomes

● Goal
A broad statement that describes the desired change in a patient’s condition, perceptions, or behavior
An aim, intent, or end
● Expected outcome
Measurable change that must be achieved to reach a goal
Many times, several must be met to meet a single goal

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Role of the Patient in Goal/Outcome Setting

● Always partner with patients when setting their individualized goals.
● Mutual goal setting includes the patient and family (when appropriate) in prioritizing the goals of care and
developing a plan of action.
● Act as a patient advocate.

Setting Goals and Expected Outcomes

● Patient-centered goal:
A patient’s highest possible level of wellness and independence in function, based on patient needs,
abilities, and resources
● Nursing-sensitive patient outcome
A measurable patient, family, or community state, behavior, or perception largely influenced by and
sensitive to nursing interventions
● Nursing Outcomes Classification (NOC)
Links outcomes to NANDA-I nursing diagnoses

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Writing Goals and Expected Outcomes

● Must be patient-centered
● Use SMART acronym
Specific Attainable
Measurable Realistic
Time-boun
Types of Interventions
● Nurse-initiated
Independent—Actions that a nurse initiates
● Health care provider initiated
Dependent—Require an order from a physician or other health care professional
● Collaborative
Interdependent—Require combined knowledge, skill, and expertise of multiple health care professionals
● When preparing for physician-initiated or collaborative interventions, do not automatically implement the therapy,
but determine whether it is appropriate for the patient.
● The ability to recognize incorrect therapies is particularly important when administering medications or
implementing procedures.

Selection of Interventions
● Six factors to consider:

Desired patient outcomes

Characteristics of the nursing diagnosis
Research-based knowledge for the intervention
Feasibility of the interventions
Acceptability to the patient
Nurse’s competency

Nursing Interventions Classification (NIC)

● The Iowa Intervention Project developed a set of nursing interventions that provides a level of standardization to
enhance communication of nursing care across health care settings and to compare outcomes.
● The NIC model includes three levels—domains, classes, and interventions—for ease of use.
● NIC interventions are linked with NANDA International nursing diagnoses.

Systems for Planning Nursing Care

● Nursing care plan = Nursing diagnoses, goals and expected outcomes, and nursing interventions, and a section
for evaluation findings so any nurse is able to quickly identify a patient’s clinical needs and situation
Reduces the risk for incomplete, incorrect, or inaccurate care
Changes as the patient’s problems and status change
● Interdisciplinary care plans = Contributions from all disciplines involved in patient care

Hand-Off Reporting
● A critical time, when nurses collaborate and share important information that ensures the continuity of care for a
patient and prevents errors or delays in providing nursing interventions
● Transferring essential information from one nurse to the next during transitions in care
● Ask questions, clarify, and confirm important details about a patient’s progress and continuing care needs

Student Care Plans

● A student care plan
Helps you apply knowledge gained from the nursing and medical literature and the classroom to a
practice situation
Is more elaborate than a care plan used in a hospital or community agency because its purpose is to
teach the process of planning care
● Planning care for patients in community-based settings involves
Educating the patient/family about care
Guiding them to assume more of the care over time

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Consulting Other Health Care Professionals

● Planning involves consultation with members of the health care team.
● Consultation is a process by which you seek the expertise of a specialist such as your nursing instructor, a
physician, or a clinical nurse educator to identify ways to handle problems in patient management or in planning
and implementation of therapies.
● Consultation occurs at any step in the nursing process, most often during planning and implementation

Concept Maps
● Visual representation of all of a patient’s nursing diagnoses that allows you to diagram interventions for each
● Group and categorize nursing concepts to give you a holistic view of your patient’s health care needs and help
you make better clinical decisions in planning care
● Help you learn the interrelationships among nursing diagnoses to create a unique meaning and organization of
information

CHECK FOR UNDERSTANDING

You will answer and rationalize this by yourself. This will be recorded as your quiz. One (1) point will be given to the
correct answer and another one (1) point for the correct ratio. Superimpositions or erasures in your answer/ratio is not
allowed.

1. A patient is admitted to the hospital with shortness of breath. As the nurse assesses this patient, the nurse is using
the process of:
a. evaluation.
b. data collection.
c. problem identification.
d. testing a hypothesis.
ANSWER: ________
RATIO:___________________________________________________________________________________________
_________________________________________________________________________________________________

2. The nursing process organizes your approach to delivering nursing care. To provide care to your patients, you will
need to incorporate nursing process and:
a. decision making.
b. problem solving.
c. interview process.
d. intellectual standards.
ANSWER: ________
RATIO:___________________________________________________________________________________________
_________________________________________________________________________________________________

3. A patient is suffering from shortness of breath. The correct goal statement would be written as:
a. the patient will be comfortable by the morning.
b. the patient will breath unlabored at 14 to 18 breaths per minute by the end of the shift.
c. the patient will not complain of breathing problems within the next 8 hours.
d. the patient will have a respiratory rate of 14 to 18 breaths per minute.
ANSWER: ________
RATIO:___________________________________________________________________________________________
_________________________________________________________________________________________________

4. When caring for a patient who has multiple health problems and related medical diagnoses, nurses can best perform
nursing diagnoses and nursing interventions by developing a:
a. critical pathway.
b. nursing care plan.
c. concept map.
d. diagnostic label.
ANSWER: ________
RATIO:___________________________________________________________________________________________
_________________________________________________________________________________________________

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5. Consultation occurs most often during which phase of the nursing process?
a. Assessment
b. Diagnosis
c. Planning
d. Evaluation
ANSWER: ________
RATIO:___________________________________________________________________________________________
_________________________________________________________________________________________________

6. Concept mapping is one way to:

a. connect concepts to a central subject.
b. relate ideas to patient health problems.
c. challenge a nurse’s thinking about patient needs and problems.
d. graphically display ideas by organizing data.
e. all of the above.
ANSWER: ________
RATIO:___________________________________________________________________________________________
_________________________________________________________________________________________________

7. For a student to avoid a data collection error, the student should:

a. assess the patient and, if unsure of the finding, ask a faculty member to assess the patient.
b. review his or her own comfort level and competency with assessment skills.
c. ask another student to perform the assessment.
d. consider whether the diagnosis should be actual, potential, or risk.
ANSWER: ________
RATIO:___________________________________________________________________________________________
_________________________________________________________________________________________________

8. The nurse in charge identifies a patient’s responses to actual or potential health problems during which step of the
nursing process?
a. Assessment
b. Diagnosis
c. Planning
d. Evaluating
ANSWER: ________
RATIO:___________________________________________________________________________________________
_________________________________________________________________________________________________

9. The nurse performs an assessment of a newly admitted patient. The nurse understands that this admission
assessment is conducted primarily to:
a. Diagnose if the patient is at risk for falls.
b. Ensure that the patient's skin is intact
c. Establish a therapeutic relationship
d. Identify important data
ANSWER: ________
RATIO:___________________________________________________________________________________________
_________________________________________________________________________________________________

10. The guidelines for writing an appropriate nursing diagnosis include all of the following except:
a. State the diagnosis in terms of a problem, not a need
b. Use nursing terminology to describe the patient's response
c. Use statements that assist in planning independent nursing interventions
d. Use medical terminology to describe the probable cause of the patient's response
ANSWER: ________
RATIO:___________________________________________________________________________________________
_________________________________________________________________________________________________

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RATIONALIZATION ACTIVITY
The instructor will now provide you the rationalization to these questions. You can now ask questions and debate among
yourselves. Write the correct answer and correct/additional ratio in the space provided.

1. ANSWER: ________
RATIO:________________________________________________________________________________________
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2. ANSWER: ________
RATIO:________________________________________________________________________________________
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3. ANSWER: ________
RATIO:________________________________________________________________________________________
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4. ANSWER: ________
RATIO:________________________________________________________________________________________
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5. ANSWER: ________
RATIO:________________________________________________________________________________________
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6. ANSWER: ________
RATIO:________________________________________________________________________________________
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7. ANSWER: ________
RATIO:________________________________________________________________________________________
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8. ANSWER: ________
RATIO:________________________________________________________________________________________
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9. ANSWER: ________
RATIO:________________________________________________________________________________________
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10. ANSWER: ________
RATIO:________________________________________________________________________________________
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LESSON WRAP-UP

You will now mark (encircle) the session you have finished today in the tracker below. This is simply a visual to help you
track how much work you have accomplished and how much work there is left to do.

You are done with the session! Let’s track your progress.

AL ACTIVITY: THE OUTCOME SENTENCES STRATEGY

This strategy is an excellent way to show your grasp of learning and to give you time to reflect about what you have
learned. Complete each phrase with what you have deemed to express.

1. I was surprised that __________________________________________________________________________

__________________________________________________________________________________________
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2. I have a question about _______________________________________________________________________

__________________________________________________________________________________________
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3. I would still like to know more about _____________________________________________________________

__________________________________________________________________________________________
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4. I learned a great deal about ___________________________________________________________________

__________________________________________________________________________________________
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5. Today, I understood __________________________________________________________________________

__________________________________________________________________________________________
__________________________________________________________________________________________

6. I am still confused about ______________________________________________________________________

__________________________________________________________________________________________
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