NURSING PROCESS: 6 STEPS Flashcards
1
Q
• is a scientific process which is a foundation, the essential tool, and the enduring skill that has characterized nursing from the beginning of the profession.
A
Nursing Process
2
Q
• It is a plan of care for the patient which may look different from different institutions but provides both systematic and effective course of intervention to patients.
A
Nursing Process
3
Q
• Data collection to establish DATABASE
A
ASSESSMENT
4
Q
According to _, Assessing is the systematic and continuous collection, organization, validation, and documentation of data.
A
Kozier
5
Q
ASSESSMENT
Purpose:
A
• To gather data, for database, for health, diseases
• Make a judgement about the patient’s health status, ability to manage his/her own health care and need for nursing
• Plan individualized holistic care that draws on a patient’s strength
6
Q
ASSESSMENT
Activities:
A
• Establish a database
• Obtain a nursing health history
• Conduct Physical Assessment
• Review of patient records
• Review of nursing literature
• Consultation of support persons
• Consultation of health professionals.
7
Q
TYPES OF ASSESSMENT
A
Initial Assessment
Problem-Focused Assessment
Emergency Assessment
Time-lapsed Assessment
8
Q
TYPES OF ASSESSMENT
• Performed shortly after being admitted
A
Initial Assessment
9
Q
TYPES OF ASSESSMENT
• Gather data about the problem that has been identified
A
Problem-Focused Assessment
10
Q
TYPES OF ASSESSMENT
• Perform when physiologic/psychologic crisis present to identify life-threatening problem
A
Emergency Assessment
11
Q
COMPONENTS OF ASSESSMENT
A
Data Collection
Data Validation
Data Organization
Communication of Data (Taylor)
Documentation of Data
12
Q
COMPONENTS OF ASSESSMENT
• it includes health history and current problems
A
Data Collection
13
Q
Consideration and Preparing Data Collection:
A
o Establishing assessment priorities
(influenced by: health orientation,
developmental stage, need for nursing)
o Practical considerations
o Structuring data collection
14
Q
TYPES OF DATA
A
Subjective and Objective Data
15
Q
• Information perceived only by the client or by the affected person cannot be perceived or verified by another person.
• Also called __ or __
A
Subjective Data
symptoms or covert data
16
Q
• observable and measurable data that can be seen, heard, smelled or felt by someone other than the person experiencing them
• Also called __ or __
A
Objective Data
signs and overt data
17
Q
SOURCES OF DATA
A
Client/Patient
Support people like family members,
Client or Patient Record
18
Q
CHARACTERISTICS OF DATA
A
Complete
Factual and Accurate
Relevant
19
Q
COMPONENTS OF DATA COLLECTION
A
NURSING HISTORY
composed of:
• PROFILE: name, age, sex, marital status, religion, occupation, education
• Reason for seeking health care
• Normal health habits and patterns and related needs for nursing assistance
• Cultural consideration in relation to diet, decision making and activities
• Current state of health, functioning of body system degree of pain and past medical and surgical history
• Current medication allergies and record of immunizations and exposure to communicable diseases
• Perception of health status and the meaning, the patient attributes to health and illness, and characteristics response or coping patterns
• Developmental history, family history, environmental history and psychosocial history
• Patient’s and family expectations of nursing and health care team
• Patient’s and family’s educational needs and ability and willingness to learn
• Patient’s and family’s ability and willingness to participate in plan of care
• Whether or not an advance directive exists or if the patient wants to help to prepare an advance directive patient’s personal resource (strength) deficit
• Patient’s potential for injury
20
Q
METHODS OF COLLECTION INFORMATION
A
Observation
Interview
Examination
Medical Record Review
21
Q
METHODS OF COLLECTION INFORMATION
• to gather data by using senses (smell, hearing, touch, sight)
A
Observation
22
Q
METHODS OF COLLECTION INFORMATION
• is a planned communication or conservation
A
Interview
23
Q
METHODS OF COLLECTION INFORMATION
• Final activity of data collection
A
Medical Record Review
24
Q
STAGES OF INTERVIEW
A
Preparatory Stage
Introduction Stage
Working Phase/ The Body of Interview
Termination/ Closing Stage
25
STAGES OF INTERVIEW
• read past and current
records and report
when available
• Should provide privacy
for the patient (– room)
• Nurse and patient
distance (3-4 feet apart)
to facilitate easy
exchange
• Length of interview (10-
15 mins)
Preparatory Stage
26
STAGES OF INTERVIEW
• Establish rapport –
understanding
• Orientation – until when,
duty time,
• Crucial because it sets
the tone for nurse-
patient interaction
Introduction Stage
27
STAGES OF INTERVIEW
• Nurse gathers all
information needed to
form the subjective
database
Working Phase/ The body of the interview
28
STAGES OF INTERVIEW
• Patient should be
advised that the
interaction is coming to
an end
Termination/ Closing
29
APPROACHES TO INTERVIEW
Directive Interview
Non-Directive/ Rapport Building Interview
30
APPROACHES TO INTERVIEW
• highly structured interview
Directive Interview
31
APPROACHES TO INTERVIEW
• Allows the client to control the purpose, subject
matter and pacing
• RAPPORT – understanding between 2 or more
people
Non-Directive/ Rapport Building Interview
32
TYPES OF INTERVIEWS
Closed Questions
Open-ended Question
Neutral Question
A Leading Question
33
INTERVIEW CAN BE AFFECTED BY:
Time
Place
Seating Arrangement
Distance/Proxemics
Language
34
EXAMINATION
Purpose:
• Appraisal of health status
• Identification of history problems
35
METHODS OF PHYSICAL EXAMINATION
Inspection
Palpation
Percussion
Auscultation
36
MEDICAL RECORD REVIEW
Purpose:
• Identify what medications the patient is taking
• To understand the interdisciplinary care of planning
• To understand the nursing diagnosis and intervention
• To determine the presence and content of advance directives
37
DATA VALIDATION
Purpose:
To keep the data free from error, bias and possible misinterpretation
38
IMPORTANCE OF VALIDATING DATA
• ensures that assessment information is complete
• ensures objective ones related subjective agree
• obtain additional information that may have been over looked
• differentiate between
39
• are subjective or objective data that can be directly observe by the nurse: that is the client says or what the nurse can see, hear, feel, smells, or measures.
• Baseline data as a result of assessment phase of the nursing process
CUES
40
• Nurse’s interpretation or conclusion made or based on the cues
• Write conclusion/inference as is
Inferences
41
INFERENCES MAY BE VALIDATED IN MULTIPLE WAYS
• Physical examination using proper equipment and process
• Clarifying statement
• Sharing inferences with other respected members of the team
42
DATA ORGANIZATION
• The nurse usses a written format that organized the assessment data systematically. This often referred as:
Nursing health history
Nursing assessment
Nursing database form
43
DATA ORGANIZATION
• Some of the Nursing Conceptual Model
Roy's Adaptation Model
Wellness Model
Henderson's Component of Nursing
44
• Pivotal second phase (Analyzing &
Synthesizing)
• In this phase nurses use critical thinking skills to interpret/analyze assessment data and identify client strength and health problems
• All activities proceeding this is directed towards formulating nursing ____.
DIAGNOSING
45
• refers to the reasoning process, whereas the term DIAGNOSIS is a statement or conclusion regarding the nature of the phenomenon.
DIAGNOSING
46
• The standard NANDA name for the diagnosis are called ____
.
• And the client problem statement consisting the diagnosis, the diagnostic label (+) etiology (causal relationship between a problem and its related or risk factor) is called ____.
DIAGNOSTIC LABELS
NURSING DIAGNOSIS
47
1990 (NANDA)
• clinical judgement about the individual, family or community responses to actual and potential health problems / life processes.
• It provides the bases for selection of nursing interventions to achieve outcomes for which the nurse is accountable. It implies the following:
o Professional nurses (RN) are responsible for making nursing diagnoses even though other health team may contribute to the process and may implement nursing care.
• The domain of nursing diagnosis includes only those health states that nurses are educated and licensed to treat (nurses are not educated to diagnosis and treat diseases)
• A nursing diagnosis is a judgment made only after thorough, systematic data collections.
• Nursing diagnosis describe a continuum of health states:
o deviation from health, presence of risk & factors and areas of enhanced personal growth
o Analysis of patient data to identify patient strength and health problems that independent nursing intervention can prevent or resolve.
48
• are actual or potential health problems that can be prevented or resolved by independent nursing intervention.
NURSING DIAGNOSIS
49
• a specific result of diagnosing and is the problem statement that the nurse makes regarding a patient's condition.
NURSING DIAGNOSIS
50
(ANA) clinical judgment about a patient's response to actual or potential health conditions or needs.
NURSING DIAGNOSIS
51
NURSING DIAGNOSIS
PURPOSE:
• to identify client strength and health problems that can be prevented or resolved by collaborative and independent nursing.
• To develop a list of nursing and collaborative problems.
• To identify how an individual, groups or community responds to actual or potential health and life processes,
• Identify factors that contribute to a cause of health problems (etiology)
• Identify resources or strengths the individual, group or community can draw on, to prevent or resolve problems,
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• It is a condition that necessitates intervention to prevent/resolve disease or illness or to promote coping wellness.
HEALTH PROBLEM
o Memorize: hemoglobin, blood pressure, vital signs, standards, of certain age groups
53
NURSING DIAGNOSIS
ACTIVITIES:
1. Interpret and analyze patient data.
o Compare data against standards/
o Cluster or group data (generate tentative hypotheses)
o Identify gaps and inconsistencies
2. Determine client's strengths, health problems, risk and diagnosis (problem identification).
3. Formulate and validate nursing diagnoses and collaborative problem statements.
4. Develop prioritized list of nursing diagnoses.
5. Document nursing diagnosis in the care plan.
54
TYPES OF NURSING DIAGNOSIS
Actual Nursing Diagnosis
Risk Nursing Diagnosis
Wellness Nursing Diagnosis
Possible/Tentative Nursing Diagnosis
Syndrome Nursing Diagnosis
55
TYPES OF NURSING DIAGNOSIS
• A client problem that is present at the time of the nursing assessment
Actual Nursing Diagnosis
o Example: ineffective breathing pattern, anxiety
o P + E + S = actual nursing diagnosis
56
TYPES OF NURSING DIAGNOSIS
• a clinical judgment that problem does not exist, but the presence of risk factors indicate that a problem is likely to develop unless nurses intervene.
Risk Nursing Diagnosis
• All people admitted to a hospital have possibility of acquiring infection but a patient with DM or compromised immune system are risk or acquiring infection.
o Example: Risk for infection
o P + E (eliminate signs and symptoms) = risk nursing diagnosis
57
TYPES OF NURSING DIAGNOSIS
• Describe human responses to levels of wellness in an individual, family or community that have a readiness for enhancement.
Wellness Nursing Diagnosis
58
WELLNESS NURSING DIAGNOSIS
• 2 cues must be present for valid wellness diagnosis:
o a desire for a high level of wellness
o an effective, present status or function
o Example: Readiness for enhanced family coping
59
TYPES OF NURSING DIAGNOSIS
• While not an official type of nursing diagnosis, ___ applies to problems suspected to arise.
• This occurs when risk factors are present and require additional information to diagnose a potential problem.
Possible/Tentative Nursing Diagnosis
Example:
o Possible sensory-perceptual alteration
o Possible nutritional deficit
o Possible social isolation R/T unknown etiology.
60
TYPES OF NURSING DIAGNOSIS
• A clinical judgment describing a specific cluster of nursing diagnoses that occur together, and are best addressed together and through similar interventions.
Syndrome Diagnosis
Example:
Risk for disuse syndrome (cluster of diagnosis associated with this syndrome includes):
o Impaired physical mobility
o Risk for impaired tissue integrity
o Risk for activity intolerance
o Risk for constipation.
o Risk for injury risk for powerlessness
o Impaired gas exchange
61
COMPONENTS OF A NANDA NURSING DIAGNOSIS:
P + E + S
1. The problem and its definition (P)
2. The Etiology (E)
3. The defining characteristics (S–signs and symptoms)
62
• Describes the client's health problem, state or response for which nursing therapy is given.
• It describes the client's health status clearly or concisely in a few words.
Problem(Diagnostic Label)
63
PROBLEM (DIAGNOSTIC LABEL)
Purpose:
• To direct the formation of client's goals and desired outcomes.
• It may also suggest some nursing interventions.
(It must be specific and should follow a NANDA label).
Example:
o Deficient knowledge (Medication – emphasize the kulang) or
o Deficient knowledge (Dietary Adjustment)
64
• words that have been added to some NANDA labels to give additional meaning to the diagnostic statement.
Qualifiers
65
Example of QUALIFIERS:
• DEFICIENT - inadequate in amount, quantity, or degree not sufficient: incomplete
• IMPAIRED - made worse, weakened, damaged, reduced, deteriorated
• DECREASED - lesser in size, amount or degree
• INEFFECTIVE - not producing the desired effect
• COMPROMISED - to make vulnerable to threat
66
• related factors and risk factors
• identifies one or more probable causes of the health problem, give direction to the required nursing therapy and enables the nurse to individualize the client's care,
Etiology
o Activity intolerance R/T generalized
weakness (P+ E)
67
• the clusters of signs and symptoms that indicated the Object & Subject data the signal the existence of actual and potential presence of a particular diagnostic label.
Defining Characteristics
68
DEFINING CHARACTERISTICS
PHRASES:
o Sign/symptom + Related to (R/T) + specific probable cause
o Secondary to + Medical diagnosis
o As manifested by + “verbalization of the patient” “observation”
69
DEFINING CHARACTERISTICS
FOR ACTUAL NURSING DIAGNOSIS
• defining characteristics are the client's signs and symptoms.
70
DEFINING CHARACTERISTICS
FOR RISK NURSING DIAGNOSIS
• no subjective and objective signs are present.
• Thus the factor that causes the client to be more than "normally" vulnerable to the problem form the etiology of a risk nursing diagnosis.
71
REMEMBER THE FOLLOWING GUIDELINES
• to ensure that your Diagnostic statement are correctly written:
1. Phrase the nursing diagnosis as a patient problem or alteration in health statement rather than the patient need.
2. Check to make sure that the patient problem proceeds the etiology and that the two are limited by the phrase "Related to."
3. Defining characteristics, when included in the nursing diagnosis, should follow. the etiology and be linked by the phrase as manifested by or evidenced by.
4. Write in legally advisable term.
5. Use non-judgmental language. validation
6. Be sure the problem statement indicates what is unhealthy about the patient or what the patient wants to change (enhance).
7. Avoid using defining characteristic, medical diagnoses, or something that cannot be changed in the problem statement.
8. Reread the diagnosis to make sure the problem statement suggests patient outcomes and that etiology will direct the selection of nursing measures.
9. Disease process
72
DIFFERENCE BETWEEN NURSING DIAGNOSIS AND MEDICAL DIAGNOSIS
NURSING DIAGNOSIS:
• Is a statement of nursing judgment referred to a condition that nurses are licensed to treat
• Describe a client's physical, socio-cultural, psychological, and spiritual responses to an illness or health problems.
• Nursing diagnosis changes as the client's response change.
• Focus on unhealthy responses to health and illness
• Describe problems treated by nurses within the scope of independent nursing practice.
73
DIFFERENCE BETWEEN NURSING DIAGNOSIS AND MEDICAL DIAGNOSIS
MEDICAL DIAGNOSIS:
• Is made by a physician and refers to a condition that only a physician can treat.
• It refers to the disease processes
o specific pathophysiologic responses that are fairly uniform from one client to another.
• Remains the same for as long as the disease process in present.
• Identify diseases
• Describe problems for which the physician directs the primary treatment.
74
THE DIAGNOSTIC PROCESS
1. Analyzing Data
2. Identifying Health Problems and Risks and Strength (Focus Area)
3. Formulating Diagnostic Statements
75
THE DIAGNOSTIC PROCESS
• a process of determining the relatedness of facts and determining whether any patterns are present, whether and patterns represent isolated incident, whether the data are significant.
• Compare data against standard/norm
o is generally accepted measure, rule, model or pattern (identify significant cues)
• Cluster cues (generate tentative hypothesis)
• Identify gaps and inconsistencies.
1. ANALYZING DATA
76
THE DIAGNOSTIC PROCESS
2. IDENTIFYING HEALTH PROBLEMS AND RISKS AND STRENGTH (FOCUS AREA)
• Determine problems and risks
• Determine strengths
77
THE DIAGNOSTIC PROCESS
3. FORMULATING DIAGNOSTIC STATEMENTS
Basic Two-Part Statement
Basic Three-Part Statement
One-Part Statement
78
VALIDATE NURSING DIAGNOSIS
• With the patient, family and other health care providers when possible and appropriate
79
PROMPTS FOR CRITICAL THINKING DURING DIAGNOSIS
• What do the data mean? How do you know?
• Are your assessment date accurate?
• Complete? Are you sure?
• How are these similar/different? How are you clustering them
• What assumption or biases do you have in this situation?
• Is your diagnosis/etiology supported by enough data?
• Does the patient see this as a problem? The family? Other health care providers?
• Is this a nursing problem or collaborative problem? Should you talk to other nurses about this problem or speak with the doctor?
• Have you missed any other problem because you focused only on the obvious one?
• Did you include patient and family strengths, resources, and deficits in your thinking?
• HOLISTIC
80
VARIATIONS AND FORMATS:
• Writing unknown etiology when the defining characteristics are present but the nurse does not know the cause or contributing factors.
• Using the phrase complex there are too many etiologic factors or when there are too many complex states in brief phrases.
• Using the word possible to describe either the problem or the etiology.
• When the nurse believes more data are needed about the client's problem or the etiology, the word possible is inserted.
• Using Secondary to, to divide etiology, into past, thereby making the statement more descriptive and useful.
• The part following secondary to is often pathophysiologic or disease process.
• Adding a second part to the general response to NANDA label to make it more precise.
• It is allowed to write “unknown etiology”
• Using COMPLEX when too many
• Use POSSIBLE if not sure
• SECONDARY TO
81
IMPORTANCE OF WRITING ETIOLOGY
• It clarifies the problem
• It can be concisely stated
• It helps suggest nursing action
82
AVOIDING ERROR IN DIAGNOSTIC REASONING
• Verify
• Have a working knowledge on what is normal
• Build a good knowledge on what is normal
• Consult resources
• Base diagnosis on patterns
• Improve critical thinking in skill
83
o The nurse develops, outcomes for the patient to achieve showing an optimum or improved level of functioning in the problem areas identified in the nursing diagnoses.
OUTCOME IDENTIFICATION
84
• The nurse analyzes the strength and
weaknesses of the patient. The patient’s family the nursing personnel, the healthcare facility and available resources (including other health care professional)
• The nurse also examines her own strength, beliefs, and values that might affect outcome identification
OUTCOME IDENTIFICATION
85
OUTCOME IDENTIFICATION
• The resulting outcomes and plan of nursing care are designed to help the patients and their family:
o make informed decisions about their health and functioning
o maintain their current level of health and functioning if they are identified as being at risk for developing problems
o Avoid injury or disease
o Regain a previous level of health and functioning
o Reached an improved level of health and functioning
o Adjust to a reduced level of health and functioning when improvement is not possible
o Adapt to a progressive level of functioning
o Experience a peaceful death
86
OUTCOME IDENTIFICATION =
SETTING PRIORITES + ESTABLISHING OUTCOMES
87
• Ordering the delivery of nursing care so that more important or life threatening problems are treated before the less critical
Setting Priorities
o High – deserves immediate nursing
attention for plan of treatment
o Middle
o Low
88
GUIDELINES FOR SETTING PRIORITIES
• Maslow’s hierarchy of needs
• Focus on the problems the patient feels most important
• Consider the patient’s culture, values, beliefs when setting priorities
• Consider the effect of potential problems when setting priorities (prevention of high problem, rather than treatment of the problems when it is developed).
• Consider cost resources available, personnel and time needed to plan
• Consider state laws, hospital policy statement and outcome criteria establishing for the particular setting
89
ESTABLISHING OUTCOMES
AN OUTCOME
PATIENT OUTCOME
AN OUTCOME
• is a measurable, expected client goal (ANA 1988)
• To be achieved at some specific time in the future
PATIENT OUTCOME
• The desired result of nursing care
• That which you hope to achieve with your patient and which is designed to prevent, remedy, lessen the problem identified in the nursing diagnosis
90
WHY IS OUTCOME IDENTIFICATION NEEDED?
• It gives guidance in the selection of nursing interventions
• They are constant future targets to remind all caregivers and the patient why certain action or interventions are done
• Gives sense of where this particular patient started from and where the individual and the nurse hope to end up
• Outcome will be the criteria and to evaluate the success of nursing interventions
• It helps motivate the nurse, the patient and the family to continue their efforts.
91
COMPONENTS OF A STATEMENT
Outcome statement = patient behavior (verb) + criteria of performance + condition (if needed) /modifier + time frame
92
COMPONENTS OF STATEMENT
• Observable (it can be seen, heard, felt or measured by the nurse or reported by the patient).
Patient Behavior/Verb
93
A. PATIENT BEHAVIOR/VERB
FOR RISK NURSING DIAGNOSIS:
• The activity selected which reflect maintenance of current status or level of functioning.
• The outcome should not deal w/ etiology but should address a lessening or elimination of the problem
94
COMPONENTS OF STATEMENT
• A stated level or standard for the
patient behavior stated in the outcome
B. Criterion of Performance
95
Criterion of Performance
• The level at which the pt will perform the behavior
• How will? How Far? How much?
Criterion of Acceptable Performance
96
COMPONENTS OF STATEMENT
• Can be thought as specific aids that will help the patient perform a behavior at the time specified in the criteria performance of the outcome statement
Conditions
* Not all outcome will have conditions
97
COMPONENTS OF STATEMENT
• The outcome statement includes a time/date to clarify how long it would realistically take for the patient to reach the level of functioning stated in the criteria part of the outcome
• Stated in minutes, hours, weeks, or months
D. Time Frame
98
Types of Outcome
Intermediate Outcome
Long Term/Final Outcome
Discharge Outcome
Health Promotion/Wellness Outcome
99
TYPES OF OUTCOME
• Identify behavior a patient can achieve easily or quickly
Intermediate Outcome
Ex:
o Reestablishment of urinary elimination within 6 hours of surgery
o Respiration below 30 breath per minute within 1 hour
• Return bowel round within 12 hours post OP
100
INTERMEDIATE OUTCOME
Ex.
o Weight of 210 lbs. by Feb 7
o Weight of 210 lbs. by Feb 14
o Weight of 210 lbs. by Feb 21
OR
o Week of 10/10: feed self by the end of the week
o Week 10/17: brushes teeth at the end of the week (personal hygiene)
Progressive Intermediate Outcome
101
TYPES OF OUTCOME
• Gives the direction for nursing care over time
• This can be thought of an eventual destination
• Is a series of stops on the way to final destination
• Like a cross country trip
Long Term/Final Outcome
EX:
• Reestablishment of patient usual bowel elimination pattern within 2 months
• Reestablishment of normal voiding patterns by 5 days post-OP (catheter, bladder training)
• Self-care of colostomy 1 month after surgery
• Patient state no longer afraid of sever pain during terminal illness from cancer after 1 week on IV morphine.
102
LONG TERM/FINAL OUTCOME
Considerations:
• Prognosis of the patient health problem
• Resources available
• Strength and weaknesses of the patient (pt/fx)
• Nursing care abilities of the personnel who will be working with the patient
103
TYPES OF OUTCOME
• Often appear at the end in critical pathways used with the hospitalized patient
• These outcomes identify the behavior the patient is expected to achieve to be safely discharge from institution.
Discharge Outcomes
EX:
• After a total knee replacement, states that pain management is acceptable on oral analgesic not IV
• Low impact exercise
• Walk for 50 feet demonstrating correct technique for crutch care or walking
• No signs (sn/sx) or symptoms of wound infection/delayed healing at infection size.
• Some outcomes are designed to maintain level of functioning during the time the patient is receiving care
EX:
• Pt to report that pain is controlled at an acceptable level during hospitalization
• Even within the hospital, _ such as post anesthesia and _ often time discharge outcome for acute-care areas
EX:
• Spontaneous respiration in the normal adult range (normal RR: 12-16)
104
TYPES OF OUTCOME
Example:
• Physical well-being: freedom from injury, illness and disease
• Active movement in life, physically, mentally, and emotionally from birth to death
• Psychosocial well-being: strong, self-esteem and social support system
• Balance of life roles: personal, family, career
• Reports feeling healthy, useful and happy in all growth and developmental stages (neonatal, infancy, etc.)
• Stress should be low with life satisfaction rating high
Health Promotion/Wellness Outcome
105
GUIDELINES FOR WRITING OUTCOME IDENTIFICATION
FOR ACTUAL NURSING DIAGNOSIS
1. the outcome is a patient behavior that demonstrate reduction or alleviation at the problem
FOR RISK NURSING DIAGNOSIS
2. The outcome is a patient behavior that demonstrate maintenance of the current status of health or function
3. The outcome is realistic for the patients _ in the time space you designate in your outcome
4. The outcome is realistic for the nurse’s level of skills, experience and time/_
5. The outcome is congruent with and supportive
of other therapies
6. Whenever _ of the outcome is important and
valued
7. The outcome is observable or measurable pt behavior (hear, smell, feel, measured the patient’s response and avoid words such as good, normal, adequate and improved –
general objectives)
8. Write outcomes in terms of patient behavior not nursing actions
9. Keep the outcome short
10. Make the outcome specific
11. Device level outcomes from only one nursing dx
12. Designate a specific time for the achievement of
each outcome
106
• The nurse develops a plan of care that prescribes interventions to attain expected outcomes.
Planning
107
_____ are specific activities that
the nurse plans and implement to help a patient achieve identified outcome - the patient will reduce to eliminate the diagnosed problems.
Nursing Interventions
108
PLANNING/ Nursing Interventions
Also called:
o Nursing Actions, Nursing Strategies, Nursing Treatment Plans, and Nursing Orders
109
PLANNING
Interventions should be identified:
• What to be done
• When the activity is to be done and how often
• The derivation of each intervention when appropriate
• Any preceding or follow-up activities
• The date of interventions were(?) selected
• The sequence in which nursing action are to be performed when one action is dependent on or facilitated by a previous action
• Signed/ _
110
TYPES OF NURSING INTERVENTIONS
1. Environmental Management
2. Physician - Initiated and Ordered Interventions
3. Nurse - Initiated and Physician Ordered Interventions
4. Nurse - Initiated and Ordered Interventions
111
TYPES OF NURSING INTERVENTIONS
• Establishing and maintaining safe environment
Environmental Management
112
TYPES OF NURSING INTERVENTIONS
• Ex: IV Fluid or antibiotics
PHYSICIAN-INITIATED AND ORDERED
INTERVENTION
113
TYPES OF NURSING INTERVENTIONS
Ex: prn (paracetamol) orders, analgesic
NURSE-INITIATED AND PHYSICAN ORDERED INTERVENTIONS
114
TYPES OF NURSING INTERVENTIONS
• Interventions solely in the range of professional nursing
NURSE-INITIATED AND ORDERED
115
NURSE-INITIATED AND ORDERED
• Within this category are several forms of individual nursing interventions
1. Health teaching and promotion
2. Consistency to help _
3. Referrals to other nurses or health care professionals;
4. Specific nursing treatments to prevent problems or lessen amount(?) difference such as repositioning, functioning, dressing wound, ROM exercise, etc.
5. Provide supports, comfort and
encouragement
6. Assessment of patient status or _ treatments ordered by nurses, physicians, other health professionals
7. Discharge (?) planning, related to lifestyle changes, coping with health changes and medical treatments, setting priorities. (EX: DM through exercise and diet)
8. Assistance with meeting basic needs/ADL and ensuring safety
116
• Nursing actions are based on principles and knowledge integrated from previous nursing education and experienced
RATIONALE FOR NURSING INTERVENTIONS
117
SUGGESTION IN SELECTING NURSING INTERVENTIONS
1. Review nursing dx so that the problem and etiology are clear
o For risk nursing dx, select interventions to minimize or eliminate risk factors
o Ex: insulin dependent diabetics are at risk for tissue damage in the legs and feet
o Hence, teaching good foot care and maintenance of blood glucose level as close to normal
2. Examine the intermediate and final outcomes so that you know where you are going and know the step to get there
3. Consider all possible nursing actions that might help the patient achieve the outcome:
o Changes in the environment
o Activity for the patient and the family to perform independently
o Activities to perform with the patient
o Activities to perform for the patient
o Ass. Of other healthcare professionals
o Involvement of the patient’s friends and family
o Change in the nurse (increase knowledge and skills)
4. Use standard care plan and critical clinical pathways as guideline for developing and planning a patient’s nursing care
5. Use the patient and the family as source of possible nursing intervention
6. Use resources such as nursing books
7. Consider dis/advantages of possible nursing interventions and select those that meet the following criteria:
o Nursing action must be safe for the patient
o Nursing action must be congruent
o Nursing actions selected are most likely to develop the behavior described in the outcome
o Nursing actions are realistic
o Nursing actions consider meeting lower-level
survival needs before high level needs
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NURSING INTERVENTION IS DIVIDED INTO 6 DOMAINS
Physiological: Basic
Physiological: Complex
Behavior
Safety
Family
Health Care System
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6 Domains
Physical functioning
PHYSIOLOGICAL:
BASIC
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6 DOMAINS
Balance or homeostatic
Physiological: Complex
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6 DOMAINS
Care that supports psychological
functioning and lifestyle changes
Behavior
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6 Domains
Care that supports protection against harm
Safety
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6 Domains
Care that promotes the family unit
Family
124
6 Domains
Care that supports the efficient use of available health care system
Healthcare System
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CRITERIA OF CHOOSING NURSING INTERVENTIONS
• Safe and appropriate for the individual’s age, health and condition
• Congruent with the client’s values, beliefs, and culture
• Congruent with other therapies
• Based on knowledge and experience on knowledge from relevant sciences
• Within established nursing standards of care as determined by state laws, professionally associated and the policies of institution.
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Writing Nursing Orders
Date
Action Verb
Content Area
Time
Signature
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• It is the fifth phase in the nursing process and is consists of validating the care plan, documenting the care plan, giving and documenting the nursing care, and continuing data collection.
Implementation
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• It is primarily focused on working with the patient and the family to carry out the plan of care.
Implementation
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IMPLEMENTATION
PURPOSE:
To assist the pt in achieving valued health outcomes: promote health, prevent illness and disease restore health and facilitate coping with altered functioning
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UNIQUE FOCUS OF IMPLEMENTATION
In all nurse-pt interaction, the nurse is concerned with the pt response to health and illness and their ability to meet basic human needs
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IMPLEMENTATION
ACTIVITIES: (KOZIER)
• Reassess the client to update the database and review the plan of care (validating NCP)
• Determine need for nursing assistance
• Reformed planned nursing intervention
• Communicate what nursing actions were implemented
• Document care and client responses to care
• Give verbal reports as necessary (Taylor)
• Continue data collection, and modify the plan of care as needed
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VALIDATING CARE PLAN
GUIDELINES IN VALIDATING CARE PLAN:
• Does the plan assure the patient’s safety?
• Is the plan based on _ scientific principle?
• Is the plan supported by acceptable nursing knowledge
• Are the nsg dx. Supported by the data
• Are the major defining characteristics present?
• Priorities consider patient preference and physiological and psychological area
• Outcome _ to the problem identified in the nsg dx.
• Do the outcome _ & patient behavior for evaluation
• Can the planned nursing action realistically help the patient achieve
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4 Areas in Reviewing the Care Plan
Safety
Appropriateness
Effectiveness
Individualized Nursing Care
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IMPLEMENTATION SKILLS
Cognitive Skills (Intellectual Skills)
Interpersonal Skills
Technical Skills
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IMPLEMENTATION SKILLS
COGNITIVE SKILLS (INTERPERSONAL SKILLS)
• Problem solving
• Decision making
• Critical thinking
• Creativity
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IMPLEMENTATION SKILLS
INTERPERSONAL SKILLS
• All actions, verbal and nonverbal, people use when interacting directly with one another
• Effectiveness of a nursing action depends largely on the nurse’s ability to communicate with other
• Necessary in all act, caring, comforting, advocating, referring
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IMPLEMENTATION SKILLS
TECHNICAL SKILLS
• Are hand-on skills such as manipulating equipment
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PROCESS OF IMPLEMENTING
• Reassessing client
• Determining nurse need for assistance
• Implementing nurse intervention (primary component)
• Supervising delegated care
• Documenting nursing activities (if it was not done, it was not documented.)
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DELEGATING IMPLEMENTATION
DELEGATION:
ASSIGNMENT:
DELEGATION
• Transfer of responsibility from one person to another while retaining accountability for the outcomes
ASSIGNMENT
• Downward/_ transfer of both the responsibility and accountability of _ from one individual to another
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RESPONSIBILITY OF THE NURSE IN DELEGATION AND ASSIGNMENT
• Appropriate delegation of duties
• Adequate supervision or assigned in _
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GUIDELINES IN IMPORTANT NURSING INTERVENTIONS
• Base nursing intervention on scientific knowledge nursing research or professional
standard cae (evidence-based practice) whenever possible
• Clearly understand the orders to be
implemented and _ that are not understood
• Adapt actions to the individual client
• Implement safe care
• Provide _ support comfort
• Holistic
• Respect the dignity of the client and enhance self-esteem
• Encourage client in participating actions in implementing nursing intervention
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____ is composed of documenting responses to interventions, evaluating the effectivenes of interventions, evaluating outcome achievement, and reviewing the nursing care plan.
Evaluating
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EVALUATION
PURPOSE:
• Determine whether to continue, modify, or terminate the plant of care
• Allow patient achievement of expected outcomes in directed future nurse-patient interaction
• Based on the pt responses of the plan of care the nurse decide to _
1. Terminate the plan of care when expected outcome is achieved
2. Modify the plan of care if different _
3. _
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UNIQUE FOCUS OF NURSING EVALUATION
• Involved in many types of evaluation
• Measure patient outcome achievement
• Help targeted groups of patient achieve specific outcomes
• Competence of individual nurses
• Degree of external factors”
o Different types of healthcare services
o Specific equipment, procedure, socio-economic factors influenced health and wellness
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EVALUATION
ACTIVITIES: (KOZIER)
• Collaboration with client and collect the data related to desired outcomes
• Judge whether goals/outcomes have been achieved
• Relate nursing actions to client outcome
• Make decisions about problem status
• Review and modify plan of care
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EVALUATION
ACTIVITIES: (TAYLOR)
• Identify factors that contribute to the patient’s success/failure
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OUTCOME EVALUATION STATEMENT:
Outcome met
Outcome partially met
Outcome not met
+
Actual patient behavior as evidence
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OUTCOME EVALUATION STATEMENT
• Was able to demonstrate the
behavior by the specific time/date
in outcome statement
Outcome met
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OUTCOME EVALUATION STATEMENT
• Was able to but not as well
Partially met
150
OUTCOME EVALUATION STATEMENT
• Was not able to
Not met
