Nursing Processes with Pam Newton


I’m Pam Newton and I am a SIM coordinator
actually here at Mohave Community College however the nursing students and I have been
talking for some time and I have been doing a presentation for them on a regular basis
that they keep asking me to do over and over again I did not realize how this might be
something of interest and beneficial to nursing students until I had them asking over and
over again and what I’m talking about is a presentation on nursing process I have recently
become of aware of how much folks that are not medical or in the medical field I should
say or the nursing field that it is of interest to them as well because what it is nursing
processes is a thought process a sort of trouble shooting thought process and it’s how nurses
think we came up with nursing process as a way to put it down on paper and pencil quite
some time ago and well actually let me talk about the history of it just a little it’s
actually been around since as long as nursing has been around, it’s a way we think and
our care of patients so as long as nurses have been caring for patients it’s been
there it has evolved over the years but the basics have never changed if you ever get
a chance to read anything about Florence Nightingale she was not necessarily the founder of nursing
but she was the first to actually put it down where it could be read by others and she attempted
to help other folks understand how nurses thought and she was also communicating to
nursing students this is how we think this is what we need to do and so-fourth OK so
that being said it’s been around for a very long time we labeled it sometime ago as nursing
process and trying to move it to a more solidified kind of thing over the years so that it’s
in textbooks and things for nursing students the problem is, in doing that we took it out
of our heads and tried to put it on paper and it became this I don’t know somewhat more
complicated thing not that it is it really isn’t we are trying to teach a thought process
so students are often when they come in and they have not been exposed to this thought
process prior to being in a nursing program are often very confused and so once it’s presented
in a very basic fashion and somewhat related to things that they already know it becomes
clear and I hope, hopefully after you have seen this you have an understanding as well
I thought of this by the way about 8 years ago it’s a compilation of all the experiences
that I’ve had as a nurse and also the experiences that I have had with students the students
that I have had over the last 8 years are the ones that have taught me how to teach
this that in itself is a long story but it’s a very fruitful process that’s one of the
reason I can do what I do today and I hope very clearly so I’m going to start and nursing
process as nurses know and most nursing students, is assessment, nursing diagnosis, treatment
interventions, goals, evaluations, and then labs/tests and medications the assessment
I have done and I have seen this done in other places this is not unique to me but it made
sense to me and it seems to make sense to students to divide this into the normals and
the abnormals and this morning we are going to be talking about congestive heart failure
to begin with so what would be things that you expect to find abnormal and normal in
a congestive heart failure patient now abnormal would be edema shortness of breath normals
would be skin except in the course of very advanced congestive heart failure patients,
GI you’re not going to find many problems in their GI system or their GU system however
you might find that they have a dry cough and they might have crackles in their lungs
so now we have this information down we can focus on the abnormal and leave the normals
aside because the abnormals are what we are going to address with our nursing process
nurses and supporting body processes need to figure out what’s wrong to begin with to
then be able to figure out what they need to focus on and that’s what a nursing diagnosis
does the heading in this case and by the way nursing diagnosis are four parts heading,
related to, as evidence by, and secondary to now I know that there are many nursing
instructors and nursing schools out there that don’t include the secondary to and the
related to is done in various fashions however the way that I address this with students
and I am trying to address to folks that do not have a medical background need to have
all four pieces and you will see why heading would be let’s say decreased cardiac output
and that certainty happens in a congestive heart failure patient is not the diagnosis
of decreased cardiac output so related to now has to be on a tissue level and the reason
that I say that is because the thinking on a tissue level in other words cells>tissues>organs>systems
focusing on the tissue level for our related to helps clarify what we are trying to do
with this nursing diagnosis so on a tissue level what’s going on with the decreased
cardiac output well of course it is impaired or weakened and lets just put weak cardiac
muscle
so we have decreased cardiac output, weak cardiac muscle, as evidence by, and I know
as evidence by there is other ways of stating that but basically what we are talking about
is the signs and symptoms that are observed by in our case the nursing students so we
would let’s just say dry cough
and then our secondary to is always the medical diagnosis and in this case it is congestive
heart failure or CHF so that is all of the pieces and parts of the nursing diagnosis
and why we approach which one the way we do now interventions or treatments for folks
that aren’t sure of the word intervention interventions is what we do what does the
nurse do the nurse has figured out this is what the abnormals are this is what the nursing
diagnosis is so the focus is going to be on decreased cardiac output so then what interventions
are we going to take so we are going to educate this patient and it is going to be about diet
exercise if they are in the hospital they may be on an IV so we will administer the
IV administer the medications we may do an inspirameter with them
that’s some basic stuff that’s the interventions
that we would do with this patient and of course there are many more now with goals,
we are going to do this with them where do we want them to go where do we want them to
end up because it is no good if we have no idea where we are going we cannot take the
patient there so we are going to do two long-term and short-term and I know nursing students
out there I know that your instructors ask for many more than two but I am just going
to demonstrate two or illustrate two for you long-term would be could easily be a goal
that would be accomplished long after the patient has left the hospital for instance
it could be something that they are going to accomplish in home care or in cardiac rehab
or whatever that is fine and short-term can be as short as in the next half-hour so long-term
let’s say they’re going to patient will oh and that’s the other thing before I go
any farther you must make them measurable and have to be specific there is no other
way to do it you cannot do it any other way and I will tell you why in two seconds patient
will walk 50 ft. on 05/01/14 of 8 am okay that is a very specific goal extremely specific
and the reason you want it so specific is so that you can easily say met or unmet or
unable if you ever have a problem in writing your evaluation the problem is in the goal
do not write the evaluation over and over and struggle and struggle if you have a problem
you immediately go back to goal, if the goal is not specific enough that’s why you’re
having a problem with the evaluation it’s not a problem of the evaluation there is only
three evaluations met, unmet or unable don’t worry about those partially unmet or partially
whatevers those are too gray for beginning students beginning students must have three
choices met unmet or unable to make it clear and concrete what am I doing with this patient
so that is a good long term goal and the reason I say long term by the way is because today
is the 18th of April so this is May 1st I’m anticipating this patient would be discharged
when they are walking this 50 ft. so this would for me be an unable short term goal
since this patient is in the hospital with me today would be patient will and by the
way I do not like the words demonstrate and all those very non-specific verbs it needs
to be will walk lift whatever it is but make it an action verb there are tons of action
verbs on the internet look it up there is tons of them so patient will do inspirameter
once and reach 1500 on 04/18/14 at 8 am that is something that you can easily say met unmet
and forget the unable I am going to walk into this patients room in an hour at 8 o’clock
hand them their inspirameter and ask them to do the best they can and if they reach
1500 it’s a met now this is where it gets confusing for nursing students because if
that patient were to do 1600 or 1800 they are actually doing better but it is still
unmet my goal was 1500 the fact that they are doing better is great don’t get me wrong
but it did not meet your goal your goal was not specific enough to that particular patient
and they did better than you anticipated that’s fabulous we want the patient to do better
but your goal is that they reach 1500 so that’s how you write goals specifically and measurable
numbers are best 800 ml of urine if you’re going to try and describe the color of the
urine you’re going to have a problem it is not as measurable it is easy to say urine
was yellow to you was amber to someone else and what is amber to somebody else is actually
orange and it is not measurable a patient walking from the bed to the bathroom sounds
like measurable but think about a hospital room that is semi-private is this patient
in the bed closest to the bathroom or is this patient in the bed farthest from the bathroom
and yet you have that goal walking from the bathroom to the bed we don’t know how far
that patient is actually walking you need to make it measurable how many feet is it
to the bathroom in older hospitals was great they used to have the floor tiles on the floor
that were 12×12 and all you had to do was count the number of tiles but I know this
is not the case in newer hospitals now however it is easy enough to estimate and that’s okay
you can do that but it still gives a better idea than saying the patient will walk from
the bed to the bathroom okay so now for CHF patient the congestive heart failure patient
what labs and tests would we anticipate now this where the nursing students get all I’m
not going to order these tests I’m not going to be necessarily involved I’m not even
necessarily going to draw the blood for these tests why do I have to have this in my nursing
process my thought process well the thing is, is that you have to anticipate what needs
to be done and you also have to know how to read those results because very often you’re
the person that’s standing there calling the Physician and you need to speak knowledgeably
one and you need to anticipate what they or recommend to them what needs to be done so
on a CHF patient we would probably do a, a Physician would probably order a CBC, a CMP,
a BNP, and an echo now those folks that are not in the medical field or in the nursing
field I know these acronyms are just drive people crazy, but a CBC is a Complete Blood
Count and all that is, is your red blood cells, your white blood cells, all that kind of stuff
it just tells the Physician and the nurse the number of cells that you have that’s it
just counting them that’s why it’s called the complete blood count and a CMP is a comprehensive
metabolic panel sounds fancy all that does is tell the Physician and the nurse where
you’re at for salts and things like calcium and all that, that’s all your salts and your
electrolytes you have heard that word before all that means is we count, we know where
your blood level is at, at that particular moment because all of those salts work together
to keep you alive and then BNP is specific, well relatively specific to Congestive heart
failure folks, it is a I’m not going to get complicated but it’s a chemical that
is produced its actually specifically by blood vessel in our bodies that comes off our heart
that in congestive heart failure folks tends to stretch and when it stretches it throws
off this chemical the higher the level the greater the stretch that’s all there is to
it so we need to know where that stretch level is in congestive heart failure folks the more
that blood vessel is being stretched then the more fluid they have in their body the
more their heart is tiring to work and it’s not capable and so on and so on then we know
where they fall as far as being a mild CHF or a mild congestive heart failure patient
or a moderate or a sever severe of course is treated all together differently than a
mild so we need to know where that stretch is and then an echo this sounds awful you
know whatever all it is, is an ultrasound of your heart that’s all it is they are taking
a look at the structures and most importantly they want to know where and this is another
one EF or ejection refract is how efficiently your heart is working how much blood is it
actually pushing out now the problem with an echo is that it is just it’s more of
an estimate than it is an exact and so sometimes the doctor may say depending on the results
here that a MUGA is needed following an ECHO and a MUGA is a more exact measurement of
the Ejection Fracture and they use a radio isotope and they measure it with x-ray that’s
all it is specialized x-ray basically alright so there are some other tests they may or
may not order but those are kind of the basics and then medications what do we commonly give
congestive heart failure patients well we give them diuretics now diuretics are those
medications that help the body get rid of fluid the heart when it’s not working well
tends to well the body tends to accumulate fluid because the heart is not working as
well the pumps not working so the body is going park that fluid until it’s because
its accumulating and it cannot function with all of that so it parks it I always talk about
it being parked in a garage if you don’t need something you put it in your garage because
you might need it later you never know so if you can’t get rid of it right now well
you put it in your garage well the problem is your garage only has so much room and after
a while it keeps accumulating and accumulating and there is no room to put it in the garage
then you’re in trouble because there is no place to put it and that’s exactly what
happens to congestive heart failure patients at any case we give them diuretics now there’s
problems with a side effect of these diuretics and that is another whole different lecture
but it does have to do with the electrolytes and so that’s why the CMP is so important
also we tend to give them ACE inhibitors and beta blockers which are two medications that
lower your blood pressure and basically help your heart work and then especially beta blockers
help your heart work more efficiently but in any case and then aspirin and that’s kind
of the basics there are some others and they are generally depending on the physician depending
on the patient and where the patient is at in this Disease process mild congestive failure
folks of course are in one regimen and severe can be on another and the amounts of these
drugs are tied directly into that as well but I don’t want to get that specific because
what I’m tiring to do is give you an overview of how nurses think so let’s start at this
end and let’s talk about COPD or Congestive not congestive I did it didn’t I Chronic Pulmonary
nope chronic obstructive pulmonary Disease I am so used to saying COPD I’ve been saying
it for so many years but what it is and that makes it sound like this terrible whatever
all it is, is an umbrella term for three Disease processes that you have all probably heard
of one time or another these processes are Asthma Chronic bronchitis and emphysema all
pretty commonly known and who hasn’t had been in elementary one time or another and had
a fellow classmate that has asthma we all know what asthma looks like right we saw when
we went out on the playground with that kid and they were running around and they might
have gotten a little blue or short of breath and what did they do reach in their pocket
pull out their inhaler do a couple puffs and the next thing you know they are running around
again there is no problem we know what asthma looks like and isn’t it on the television
being the medications being advertised on a constant basis so we know medications as
well don’t we because their bronchodilators and they are if they are in the hospital they
might be corticosteroid and they may be on that type of inhaler not so much those kids
in elementary as elderly folks are a lot of times on the low level inhaler corticosteroids
inhalers they also and of course if they are in the hospital they may be on IV corticosteroids
but these are two of the common some of the others have to do with an allergy process
like leukotriene inhibitor and
some other things that might ease their breathing but these are kind of the basic ones and then
labs and tests so you know they are going to have the good old CBC and the reason for
the CBC remember is the complete blood count you want to know where their white blood cells
are as well as their red blood cells but the white blood cells let us know whether or not
there is an infection process going on these folks as you can well imagine if they have
compromised breathing or compromised lungs then they may be prone to things like Pneumonia
or whatever and of course infections so if we do a CBC then we know where the white blood
cells are and if they are high there very likely might be an infection the other possibility
too is the red blood cells if they are not where they need to be, let’s say they are
low, there may be something else going on and that could be a trigger for the shortness
of breath because if you don’t have enough red blood cells to carry the oxygen you’re
going to be short of breath okay so CBC that’s important and more than likely going to do
a CMP just to make sure that everything is where it needs to be and then something like
a pulmonary function test would be very commonly ordered and then as you can imagine I don’t
need to explain its a test to see where the actuate function of the lungs is if it’s
not where it needs to be then something needs to be corrected there also allergy testing
things like that and from here on out its more specific to the patient but as you can
imagine the allergy testing may help the patient and the medical personnel figure out what
the triggers may be particularly for those asthmatic folks okay so we got that, and then
we are going to skip evaluation for now and we are going to go over to goals and as you
can imagine some of the goals that would be specific to the patient with let’s say asthma
would be again it could be the patient walking if they are not moving around patient will
walk then of course the specific time and date and then the same thing with the inspramotoer
the patient will use the inspramoter and specific time and date okay so again all you have to
do is remember here it must be specific to the patient and it must be measurable specific
and measurable so remember those numbers dates and times and then you won’t go around treatments
and interventions for someone with asthma actually I hate to say similar to a congestive
heart failure patient is of course diet exercise and educating them in diet and exercise administering
the IV and meds and so forth as ordered and use of the inspramotoer but we could also
include here education them on those possibly allergy triggers that we identified with the
allergy testing very often for the little folks its pets or pet dander and it could
be an environmental thing there is a lot it can be food too so those are things there
is a ton of education to be done there especially since asthmatic folks you can’t see your
lungs working so we as nurses we can think this through and we have an understanding
of what the disease process is but they don’t so that’s where that education comes in for
them to help them understand their body processes and why it’s going wrong they can’t see
it so they don’t understand it so we can help them understand and then understand how we
are thinking this through nursing diagnosis for someone with asthma our heading would
be ineffective airway for one that would actually be very specific so ineffective airway the
related to would be inflammation in the brochonicals again I am saying asthma that’s not going
to work for esphmsa folks inflammation in the bronchioles certainly that is tissue and
that is a tissue level than as evidence by certainly they have a dry cough but you could
also say shortness of breath and that kind of thing that’s our as evidence by and then
of course our secondary too is asthma does that sound like that little kid on the playground
it does doesn’t it so what would we find in these folks remember that little kid on the
playground with the dry cough you know they started coughing and they stopped running
and they sat down because they were not able to get that breath in because they were short
of breath and then let’s say they might have gotten a little blue which is called
cyanosis might have gotten just a little blue around the lips so some cyanosis and some
anxiety anybody that cant breath is going to be anxious it’s a given okay so dry cough
short of breath cyanosis and anxious now the normals for these folks very often again is
like the congestive heart failure they don’t tend to have too many problems with their
skin now I of course if they are the allergic folks they may and I realize that but very
often they don’t they don’t probably unless they are having some sort of food allergy
their GI track is fine and you wouldn’t anticipate anything with their GU either now this is
crucial because you can see what we just did we went backwards we started down here and
went this way with this nursing process and that is the way nurses think we teach it going
this way going from assessment all the way down to medications but we think it this way
we start at medications and we go this way the interesting thing about that’s thinking
defectively that is the most common way for all of us to think we start thinking deductively
at age two and either life or our parents reinforced that deductive thinking you know
it’s the old if I touch this hot thing I will get burned that’s deductive thinking
inductive is teaching it this way and it’s the more familiar way for folks to think so
when they come in and generally it starts at the college level we try to teach them
inductively and there is nothing wrong with that its presenting the information and they
do need to put it together the problem is it’s just not as easy for folks so thinking
deductively until you can get the information down then you can think inductively there
is nothing wrong with that and that’s how you think defectively with this process you
start with the medications go to labs and tests then you write out your goals then you
do your treatments then you think nursing diagnosis and thinking deductively you go
up from the bottom so you go asmaha dry cough inflammation ineffective air way and I just
realized I forgot to do that when I was doing this lecture but I know it backwards and forwards
now as a student you want to do it backwards you want to think medical diagnosis first
remember when you know that kid on the playground you know what they look like you know what
their symptoms were you know that to be asthma okay so if that is asthma then you can write
that down easily and then you can think of those symptoms associated with that comes
easily you saw that kid on the playground and then your now learning as you’re in
the nursing program and hopefully before because its pathopsyhology what’s happening on a
tissue level what is happening on that tissue level and at inflammation and then and believe
me there are many other answers here that are absolutely correct but what’s happening
on a tissue level and there-for you can come up with the nursing diagnosis the least known
to you, the least familiar it is the most unfamiliar for a nursing student to be able
to come up with a nursing diagnosis they have not heard nursing diagnosis prior to being
in the nursing program so you’re going from the known to the unknown you are using your
deductive reasoning because you know that best and it comes easiest so then moving this
way you can then come up with your abnormals you probably came up with one or two here
anyway so now you can list these and then think about the normals that you would find
in that patient now one of the problems with this and students ask me to do this presentation
all the time but then when I end it I always tell them one of the problems with this is
now you know how to do this it’s not that hard it’s just not that hard and the thing
is, is you can do this with very minimal information so the next time you go to clinical and your
clinical instructor was there before you and figured out your patient assignment and then
when you got there they gave you the name of the patient that you were to care for that
day and you went to the chart or the nurse in charge of that patient and you collected
the list of medications and you got the diagnosis and then won’t you know here comes the clinical
instructor and says listen there’s a really cool surgery going on, and your one of the
few students that I can find real quick here I am going to send you down there and you
may be a beginning student and that’s okay I am going to show you how to gown and do
everything and you’re just going to stand in the corner and watch the surgery because
I think you will get a lot out of it and so you do you go down there and you do get a
lot out of it you stand in the corner and you watch this procedure or do get involved
in whatever this is and it’s so cool and then you realize what time it is and you go
running back up to the floor and you say to your clinical instructor I was there the whole
time, and now clinical is over and I never went in and even introduced myself to my patient
do I really have to do that care plan and you know that instructor is going to say yes
you have to do the care plan because she is trying to teach you nursing process she is
trying to teach you how nurses think so she wants you to do that care plan and all you
have is the medications and the diagnosis the medical diagnosis but now that you know
this you can do it because all you have to do is put down the medications and then think
it out and look it up what labs and tests do they need to have done or most likely to
have done what goals would you have for that patient what treatments and interventions
would you do most commonly do with a patient with that diagnosis you can do the nursing
diagnosis by starting with the medical diagnosis and using your powers of deduction to go backwards
and make up your nursing diagnosis and then what are the symptoms you would most likely
find with that patient and what would you most likely find normal you now have your
care plan and that’s the problem you now know how to do it, so you can’t say I can’t
do it.

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