2101 - Nursing Process

Instrumental activities of daily living (IADLs)

Instrumental activities of daily living (IADLs) include skills such as shopping, preparing meals, writing checks, and taking medications. Nurses in home care and community nursing frequently help patients find ways to perform IADLs.

Lifesaving measures

Lifesaving measures are those activities you perform when a patient's physiological or psychological state is threatened. They include CPR, administering emergency medications, and falls prevention.

The Nursing Process: Assessment

the gathering and analysis of information about the patient's health status Evaluate the patient's condition

Care Plan Revised (Detailed)

** When there is failure to achieve a goal, no matter what the reason, repeat the entire nursing process sequence for that nursing diagnosis to discover changes the plan needs. **You then will reassess the patient, determine the accuracy of the nursing diagnosis, establish new goals and expected outcomes, and select new interventions. **A complete reassessment of all patient factors relating to the nursing diagnosis and etiology is necessary when modifying a plan. **After reassessment, determine what nursing diagnoses are accurate for the situation. Ask yourself whether you selected the correct diagnosis and whether the diagnosis and the etiological factor are current. **When you modify a care plan, also review the goals and expected outcomes for needed changes. Examine the goals for unchanged nursing diagnoses. Are they still appropriate? A change in one diagnosis may affect others. **Clearly document goals and expected outcomes for new or revised nursing diagnoses so that all team members are aware of the revised care plan. When the goal is still appropriate but has not yet been met, you may change the evaluation date to allow more time. **You may also decide at this time to change interventions. The evaluation of interventions examines two factors: the appropriateness of the interventions selected and the correct application of the intervention. **You may need to increase or decrease the frequency of interventions only when you revise a care plan. During evaluation you may find that some planned interventions are designed for an inappropriate level of nursing care. If you need to change the level of care, substitute a different action verb, such as assist in place of provide, or demonstrate in place of describe. **Make any changes in the plan of care based on the nature of the patient's unfavorable response. Consulting with other health care providers often yields suggestions for improving the approach to care delivery. Practicing nurses are usually excellent resources because of their experience. **Simply changing the care plan is not enough. Implement the new plan, and reevaluate the patient's response to the nursing actions. **Remember, evaluation is continuous.

Second Step: Diagnose (Detailed)

**After you assess a patient, the next step in the process is to form a diagnostic conclusion. Some conclusions can be used to select a nursing diagnosis. If a nurse forms an accurate diagnostic conclusion, nursing therapies will then be appropriate and relevant. **A nurse will make a diagnostic conclusion either in the form of a nursing diagnosis or a collaborative problem. **A nursing diagnosis is a clinical judgment about individual, family, or community responses to actual and potential health problems or life processes that the nurse is licensed and competent to treat. **A medical diagnosis is the identification of a disease condition based on an evaluation of physical signs, symptoms, history, and diagnostic tests and procedures. What makes a nursing diagnostic process unique is having patients involved, when possible, in the process. **A collaborative problem is an actual or potential physiological complication that nurses monitor to detect the onset of changes in a patient's status. When collaborative problems develop, nurses intervene in collaboration with personnel from other health care disciplines, such as social workers and dietitians. **Nurses use scientific and nursing knowledge and previous experience to analyze and interpret assessment data in identifying nursing diagnoses and collaborative problems unique for their patients

Interpreting and Summarizing Finding (Detailed)

**An expert nurse recognizes relevant evidence, even evidence that does not match clinical expectations, and makes judgments about a patient's condition. **When interpreting findings, you compare the patient's behavioral responses and the physiological signs and symptoms you expect to see with those actually seen during evaluation. To objectively evaluate the degree of success in achieving outcomes of care, use the following steps: 1. Examine the outcome criteria to identify the exact desired patient behavior or response. 2. Measure the patient's actual behavior or response. 3. Compare the established outcome criteria with the actual behavior or response. 4. Judge the degree of agreement between outcome criteria and the actual behavior or response. 5. If there is no agreement (or only partial agreement) between outcome criteria and patient response, why did they not agree? Identify any barriers. **Remember to evaluate each expected outcome and its place in the sequence of care. If you do not do this, it will be difficult to determine which outcome in the sequence was not met. This prevents you from revising and redirecting the plan of care at the most appropriate time.

Fifth Step: Evaluate (Detailed)

**During the evaluation step, you apply everything you know about a patient and the patient's condition, as well as your experience with previous patients, to evaluate if nursing care was effective. **Nurses conduct evaluation measures to determine whether they have met expected patient outcomes, not whether their nursing interventions were complete. **It is important to remember that expected outcomes are the standards against which the nurse judges whether goals have been met and care was successful. **Think about the sequence used during evaluations and the conclusions that can be drawn. **Positive evaluations occur when desired outcomes occur, leading you to conclude that the nursing interventions effectively met the patient's goals. **Negative evaluations or undesired results indicate that interventions did not minimize or resolve the actual problem or avoid a potential problem. **An unmet outcome reveals that the patient has not responded to interventions as planned. When expected outcomes do not materialize, the nurse needs to change the plan of care by trying different therapies or changing the frequency or approach of existing therapies. **Remember that evaluation is dynamic and ever changing, depending on the patient's nursing diagnoses and condition.

Evaluate

**Each time you evaluate a patient, you determine whether the plan of care continues or if revisions are necessary. **If your patient meets a goal successfully, discuss your evaluation with the patient. If you and the patient agree, discontinue that portion of the care plan. *Why is it important to document a discontinued plan? Discuss: To keep other nurses informed so they don't unnecessarily continue interventions for that part of the plan **Documentation of evaluative findings allows all members of the health care team to know whether or not a patient is progressing.

Data Collection (Detailed)

**You will obtain data from a variety of sources. Each source of data provides information about the patient's level of wellness, risk factors, health practices and goals, and patterns of health and illness. **A patient is usually your best source of information. A patient who is alert and answers questions appropriately provides the most accurate information. Consider the setting for your assessment. A patient experiencing acute pain in an emergency department will not offer the same depth of information as one who comes to an outpatient clinic for a routine checkup. Patients are more likely to share the nature of their health care problems with nurses who are attentive and show a caring presence. **Family members and significant others are primary sources of information for infants, children, critically ill adults, patients with mental handicaps, or patients who are unconscious or have reduced cognitive function. The family and significant others are also good secondary sources of information. They can confirm information a patient provides. Remember, a patient does not always want you to question or involve the family. You must obtain a patient's agreement to include family members or friends. **You will frequently communicate with other health care team members when gathering information about patients. In the acute care setting, the change-of-shift report is the way for nurses on one shift to communicate information to nurses on the oncoming shift. Every member of the health care team is a source of information for identifying and verifying information about the patient. **The medical record is a source for the patient's medical history, laboratory and diagnostic test results, current physical findings, and the health care provider's treatment plan. Data in the records offer a baseline and ongoing information about the patient's response to illness and progress to date. Information in a patient's record is confidential. **Educational, military, and employment records often contain pertinent health care information (e.g., immunizations or prior illnesses). **Reviewing nursing, medical, and pharmacological literature about a patient's illness completes your assessment database. Always be sure to review the most current evidence in the literature as it applies to your patient.

Reviewing and Revising the Care Plan

- 1. Revise data in the assessment section. - 2. Revise the nursing diagnoses. - 3. Revise specific interventions. - 4. Determine the method of evaluation.

Fourth step: Implement

- A nursing intervention is any treatment based on clinical judgment and knowledge that a nurse performs to enhance patient outcomes. - Interventions include direct and indirect care measures aimed at individuals, families, and/or the community. - Evidence based rationales are used for the implementation of all therapeutic interventions. - Caring, professional behaviors from the nurse are the basis of all therapeutic interventions - During implementation, the nurse performs actions, delegates tasks, supervise other health care staff and DOCUMENT **Interventions include direct and indirect care measures aimed at individuals, families, and/or the community. **Direct care interventions are treatments performed through interactions with patients. **Indirect care interventions are treatments performed away from the patient but on behalf of the patient. For example: managing the patient' s environment, such as safety and infection control, documentation and interdisciplinary collaboration..

Nurses provide Direct Care

- Activities of daily living (ADLs) - Instrumental activities of daily living (IADLs) - Physical care techniques - Lifesaving measures - Counseling - Teaching _ Controlling for Adverse reactions - Preventive Measures **To complete any nursing procedure, you need to know the procedure, its frequency, the steps, and the expected outcomes. ** Note that when you delegate aspects of a patient's care, you are responsible for ensuring that each task is assigned appropriately and is completed according to the standard of care.

Types of Nursing Diagnoses (3)

- Actual Nursing Diagnosis - Risk Nursing Diagnosis - Health Promotion Nursing Diagnosis

Expected Outcomes

- Are an objective criterion for goal achievement - Provide a specific, measurable change in a patient's status that you expect in response to nursing care - Direct nursing care - Determine when a specific, patient-centered goal has been met - Are written sequentially, with time frames - Usually, several are developed for each nursing diagnosis and goal.

Critical Thinking in Setting Goals and Expected Outcomes: Goals

- Broad statement describing a desired change in the patient's condition - Realistic and based on patient needs - Require a time frame for resolution

Selection of Interventions SixFactors to Consider:

- Characteristics of nursing diagnoses - Goals and expected outcomes - Evidence base for interventions - Feasibility of the interventions - Acceptability to the patient - Nurse's competency

Fifth step: evaluate

- Crucial to deciding whether a patient's condition or well-being is improving - Ongoing process: every interaction is a time to evaluate - If outcomes are met, patient goals are met: conclusion is that interventions were successful

Formulating the Nursing Diagnosis: Components of a Nursing Diagnosis

- Diagnostic label - Related factor - Definition - The PES format: 3 part diagnosis

Organizing Resources and Care Delivery

- Equipment - Personnel - Environment - Patient

At Risk nursing diagnosis

- For "at risk" nursing diagnoses, no subjective and objective signs are present. Thus, the factors that cause the client to be more vulnerable to the problem form the etiology of a risk nursing diagnosis. - Turn to page 19-20: Risk for Aspiration. - Aspiration is the entry of secretions or materials such as food or liquid into the trachea. - On page 20 note the risk factors for aspiration. - Also note the lack of defining characteristics-because the assessment revealed only risk factors. The at risk nursing diagnosis is written as follows: Risk for aspiration related to treatment related side effects.

The evaluation process includes five elements:

- Identifying evaluative criteria and standards - Collecting data to determine if you met the criteria or standards - Interpreting and summarizing findings - Documenting findings - Terminating, continuing, or revising the care plan

Nursing Process

- It is the fundamental blueprint for how to care for patients. - Practicing the five steps of the nursing process allows you to be organized and to conduct your practice in a systematic way. - A patient-centered approach is essential for all steps of the nursing process. - Allows the identification of a patient's response to a health problem and provides a basis to deliver care to meet those needs. **Clearly defining your patients' problems provides the basis for planning and implementing nursing interventions and evaluating the outcomes of care

Cue Examples

- Lies with arms along sides; tense - states has not turned for some time -Reports pain a 7 on a scale of 0 - 10

Critical Thinking in Setting Goals and Expected Outcomes: Expected Outcomes

- Measurable criteria to evaluate goal achievement. - Provide a focus or direction for nursing care

Second Step: Diagnose

- Medical Diagnosis - Nursing Diagnosis - Collaborative Problem

Objective Data

- Objective data are observations or measurements of a patient's health status. - Also known as signs. - Can be seen, heard, felt, or smelled - Obtained through observation or physical examination of the client ** Inspection of the condition of a wound or observation of a patient's posture and gait are examples of objective data. When you collect objective data, apply critical thinking intellectual standards—be clear, precise, and consistent. Do not include your personal interpretive statements.

Establishing Priorities

- Ordering of nursing diagnoses or patient problems uses determinations of urgency and/or importance to establish a preferential order for nursing actions. - Helps nurses anticipate and sequence nursing interventions - Classification of priorities: ** High—Emergent-life threatening ** Intermediate-health threatening ** Low—Affects patients' future well-being and developmental needs

Reassessing the Patient

- Patient assessment is a continuous process. - Just before implementing a nursing activity, reassess the patient. - Modify the care plan based on your reassessment.

Goals of Care

- Patient-centered goal - Short-term goal - Long-term goal

Additional Data Collection (3)

- Physical Examination - Observation of Patient's Behavior - Diagnostic and Laboratory Data

Sources of Data

- Primary Data - SecondaryData

Concept Mapping

- Provides a visually graphic way to show the relationship between patients' nursing diagnoses and interventions - Groups and categorizes 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 - Helps you learn the interrelationships among nursing diagnoses to create a unique meaning and organization of information

Data Collection: Types of DATA

- Subjective Data - Objective Data

Subjective Data

- Subjective data are your patients' verbal descriptions of their health problems. - Includes sensations, feelings, attitudes, descriptions, and perceptions of personal health status and life situations - Also known as symptoms. Client is the only one who can describe and verify symptoms.

Data Documentation and Communication

- The last component of a complete assessment - Legal and professional responsibility - Requires accurate and approved terminology and abbreviations **The timely, thorough, and accurate communication of facts is necessary to ensure continuity and appropriateness of patient care. If you do not report or record an assessment finding or problem interpretation, it is lost and unavailable to anyone else caring for the patient. If you do not give specific information, you will leave another health care team member uninformed and often with only general impressions. **Observation, reporting, and recording of a patient's status is a legal and professional responsibility. The patient record is a legal document. It can be used in a court of law. It is reviewed by accreditation agencies. It is used by insurance companies to deny or approve patient charges and payments. **The Nurse Practice Acts in all states and the American Nurses Association policy statement (2010) require accurate data collection and recording as independent functions essential to the role of a professional nurse.

The Nursing Process

- The nursing process is a critical thinking process that professional nurses use to apply the best available evidence to caregiving. - A patient-centered care approach is essential to all steps of the nursing process. - The nursing process is also a standard of practice, which, when followed correctly, protects nurses against legal problems related to nursing care. - As a student, you will learn to integrate elements of critical thinking to form judgments and make safe and effective clinical decisions through the nursing process.

Cultural Considerations

- To conduct an accurate and complete assessment, you need to consider a patient's cultural background. - When cultural differences exist between you and a patient, respect the unfamiliar and be sensitive to a patient's uniqueness. - If you are unsure about what a patient is saying, ask for clarification to prevent making the wrong diagnostic conclusion. **As a professional nurse, it is important to conduct all assessments with cultural competence. This involves not imposing your own attitudes and beliefs. **Avoid making stereotypes; draw on knowledge from your assessment, and ask questions in a constructive and probing way to allow you to truly know who the patient is. **You must be sure that you grasp exactly what a patient means and know exactly what a patient thinks you mean in words and actions. **Do not make assumptions about a patient's cultural beliefs and behaviors without validation from the patient. **Communication and culture are interrelated in the way feelings are expressed verbally and nonverbally. **If you learn the variations in how people of different cultures communicate, you will gather more accurate information from patients. **Using the right approach with eye contact shows respect for your patient and likely results in the patient sharing more information. **It is easier to explore cultural differences if you allow time for thoughtful answers and ask your questions in a comfortable order.

Data Validation

- Validation of assessment data consists of comparison of data with another source to determine accuracy of the data. - Sources for validation include the patient, medical record, other health team members, and family members. - Gather additional data as needed, based on your validation of the patient's information. **Once you have collected your data, validate the data you obtained. This will help you more accurately analyze and interpret the patient's clinical picture. **Validation of assessment data is the comparison of data with another source to confirm accuracy. **Ask your patient to validate the information you gather during the interview and health history. **Validate findings from physical examination and observation of patient behavior by comparing data in the medical record and by consulting with other health team members or even family members. **Validation often will lead you to gather more assessment data because it clarifies vague or ambiguous data. **Occasionally you will need to reassess previously covered areas of the nursing history or gather further physical examination data. **A nurse continually analyzes and thinks about a patient's database, enabling one to fully understand the problems, judge the extent of the problems, and discover possible relationships between the problems.

Cues and Inferences

- Whatever approach you use for assessment, you will begin to cluster cues, make inferences, and identify emerging patterns and potential problems. - A cue is information that you obtain through use of the senses. - An inference is your judgment or interpretation of those cues. - This patient's grimace, a cue, is indicating his discomfort

Documenting Findings

- When documenting the patient's response to interventions, always describe the same evaluative measures. - Communicate a patient's progress toward meeting outcomes and goals on assessment flow sheets and summary progress notes and by sharing information between nurses during change-of-shift reports. **Documentation and reporting are a part of evaluation. **Accurate information needs to be present in a patient's medical record for nurses and other health care providers to make ongoing clinical decisions. **Your aim is to present a clear argument from the evaluative data as to whether a patient is progressing or not

Inferences Examples

- pain is severe - pain limits patient's ability to mov and reposition self

Critical Thinking in Setting Goals and Expected Outcomes

-Goals - Expected Outcomes

Short-term goal:

An objective behavior or response expected within hours to a week

Implementation Process

1) Reassess the Patient 2) Review and revise the existing nursing care plan 3) Organize resources and care delivery 4) Anticipate and prevent complications

Critical Thinking in Implementation

1) Review the set of all possible nursing interventions. 2) Review all possible consequences associated with each possible nursing action. 3) Determine the probability of all possible consequences. 4) Make a judgment of the value of that consequence for the patient.

Three Part Nursing Diagnosis

1) the Problem 2) Etiology (related cofactors or risk factors) 3) Defining Characteristics Gulanick and Myers Pg 8

Interpreting and Summarizing Findings

1. Examine the outcome criteria. 2. Evaluate the patient's actual response. 3. Compare the established outcome criteria with the actual response. 4. Judge the degree of agreement between the outcome criteria and the response. 5. If no or only partial agreement, what are the barriers?

Health Promotion Nursing Diagnosis

A clinical judgment of motivation, desire, and readiness to enhance well-being and actualize human health potential

Patient-centered goal:

A specific and measurable behavior or response that reflects a patient's highest possible level of wellness and independence in function

First Step:

ASSESS **Assessment is the deliberate and systematic collection of information about a patient. The data will reveal a patient's current and past health status, functional status, and present and past coping patterns. **Assessment requires you to apply critical thinking so that, in the end, you have a clear picture of a patient's condition. **There are two steps in nursing assessment: 1) Collection and verification of data from a primary source (the patient) and secondary sources (e.g., family, friends, health professionals, medical record). 2) Analysis of all data as a basis for the second step of the nursing process, developing nursing diagnoses and identifying collaborative problems. **The purpose of the assessment is to establish a thorough database about the patient's perceived needs, health problems, and responses to these problems. In addition, the data reveal related experiences, health practices, goals, values, and expectations about the health care delivery system. To establish this database, you first apply knowledge that helps to identify what to assess. **An assessment database includes a patient's comprehensive health history, which includes information about a patient's physical and developmental status, emotional health, social practices and resources, goals, values, lifestyle, and expectations about the health care system. The database also includes physical examination findings and a summary of results from laboratory and diagnostic testing. **Prior clinical experience contributes to your assessment skills. **You become competent in assessment through validation of abnormal assessment findings and personal observation of assessments performed by skilled nurses. You also learn to apply standards of practice and accepted standards of "normal" physical assessment data when assessing a patient. These standards help you to collect the right kind of information and ensure that you have a standard against which to compare your findings.

Activities of daily living (ADLs)

Activities of daily living (ADLs) are activities usually performed in the course of a normal day, including ambulation, eating, dressing, bathing, and grooming. You will perform these activities of direct care as you carry out the nursing interventions you have selected for your patients. When an assessment reveals a patient is experiencing fatigue, a limitation in mobility, confusion, and/or pain, that patient will likely need assistance with ADLs.

Here's an ACTUAL example of the nursing diagnosis written in it's three parts:

Activity intolerance related to prolonged bed rest as evidenced by abnormal heart rate (110) and verbal report of weakness and fatigue.

Collaborative Problem

Actual or potential physiological complication that nurses monitor to detect a change in patient status

Goals of Care Continued

Always partner with patients when setting their individualized goals. - For patients to participate in goal setting, they need to be alert and must have some degree of independence in completing activities of daily living, problem solving, and decision making. - Patients need to understand and see the value of nursing therapies, even though they are often totally dependent on you as the nurse.

Controlling for Adverse Reactions

An adverse reaction is a harmful or unintended effect of a medication, diagnostic test, or therapeutic intervention. Before performing any skill or task, you need to know the possible adverse effects or reactions that can occur. It is important that you recognize the signs and symptoms of an adverse reaction and intervene in a timely manner.

Long-term goal:

An objective behavior or response expected within days, weeks, or months

Patient

Before you deliver interventions, be sure the patient is as physically and psychologically comfortable as possible. Start any intervention by controlling environmental factors, positioning, and taking care of other physical needs (e.g., elimination). Plan only the amount of activity the patient can comfortably tolerate. Also consider the patient's psychosocial needs.

Personnel

As a nurse, you are responsible for determining whether to perform an intervention or to delegate it to another member of the nursing team. Nursing staff work together as patients' needs demand it. When interventions are complex or physically difficult, you may need assistance from colleagues.

Nursing Diagnosis

Clinical judgment about the patient in response to an actual or potential health problem

Collecting data to determine if you met the criteria or standards

Collecting data to determine if you met the criteria or standards: Evaluating a patient's response to nursing care requires the use of evaluative measures, which are simply assessment skills and techniques (e.g., auscultation of lung sounds, observation of a patient's skill performance, or discussion of the patient's feelings). In fact, evaluative measures are the same as assessment measures, but you perform them at the point of care when you make decisions about the patient's status and progress. The intent of evaluation is to determine if the known problems have remained the same, improved, worsened, or otherwise changed. In many clinical situations it is important to collect evaluative measures over a period of time to determine if a pattern of improvement or change exists. The primary source of data for evaluation is the patient. However, you will also use input from the family and other caregivers.

Cultural Relevance of Nursing Diagnoses

Consider patients' cultural diversity when selecting a nursing diagnosis. Ask questions such as: - How has this health problem affected you and your family? - What do you believe will help or fix the problem? - What worries you most about the problem? - Which practices within your culture are important to you? Cultural awareness and sensitivity improve your accuracy in making nursing diagnoses.

Counseling

Counseling involves providing emotional, intellectual, spiritual, and psychological support to your patients.

Writing a nursing Diagnosis 3. Defining characteristics

Defining characteristics are the client's signs and symptoms and support the diagnosis. This is the data that you have found in your assessment. Using a sticky note, label defining characteristics as "signs and symptoms" and "AS EVIDENCED BY". In this case, an example is a verbal report of fatigue.

Actual Nursing Diagnosis

Describes human responses to health conditions or life processes

Risk Nursing Diagnosis

Describes human responses to health conditions/life processes that may develop

Care Plan Revision

Discontinuing a care plan: - Has the goal been met? - Does the patient agree? - Document the discontinued plan. Modifying a care plan: - Reassess - Determine accuracy of nursing diagnoses - Establish new goals and expected outcomes - Select new interventions Implement the new plan, and reevaluate the patient's response to the nursing actions

Writing a nursing Diagnosis 2. Etiology

Etiology: (related factors and risk factors) is the component of a nursing diagnosis that identifies one or more probable causes of the health problem, gives direction to the required nursing therapy, and enables the nurse to individualize the client's care. See common related factors box to activity intolerance: pain, side effects of medications, prolonged bed rest, etc. Use a sticky note and label the section "common related factors" as "etiology and "related to"

Student Care Plans

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 **Student care plans are useful for learning the problem-solving technique, the nursing process, skills of written communication, and organizational skills needed for nursing care. **The plan also helps you to apply theory you learned. Most commonly, a column format is used. **Show students our format

Medical Diagnosis

Identification of a disease condition based on specific evaluation of signs and symptoms

Diagnostic and Laboratory Data

Identify or verify alterations * The results of diagnostic and laboratory tests identify or verify alterations questioned or identified during the nursing health history and physical examination.

Identifying evaluative criteria and standards

Identifying evaluative criteria and standards: Your evaluative criteria include the goals and expected outcomes established during planning. Evaluation is most effective when you know what to observe or measure. During evaluation you compare your findings with the goals and expected outcomes set for your patient

Physical Examination

Includes a patient's height, weight, vital signs, general appearance and behavior, and a head-to-toe examination of all body systems *A physical examination allows a nurse to examine the patient's body to determine his or her state of health. A physical examination involves use of the techniques of inspection, palpation, percussion, auscultation, and smell. A complete examination includes a patient's height, weight, vital signs, general appearance and behavior, and a head-to-toe examination of all body systems.

Observation of Patient's Behavior

Includes a patient's level of function *During an interview and physical examination it is important for you to closely observe a patient's verbal and nonverbal behaviors. Observations lead you to gather the additional objective information to form accurate conclusions about a patient's condition. The level of function involves a person's ability to perform during everyday activities. The hands-on physical examination measures the extent of function through measures such as range of motion and muscle strength

Medical Diagnoses versus nursing diagnoses

Medical diagnoses: - Describe disease and pathology - Does not consider human responses - Oriented to pathology - Physician is responsible for medical diagnosis and treatment orders

Formulating the Nursing Diagnosis

NANDA International nursing diagnoses - Provide a precise definition that gives all members of the health care team a common language for understanding patient needs - Allow nurses to communicate what they do among themselves, with other health care professionals, and with the public - Distinguish the nurse's role from that of physicians and other health care providers - Help nurses to focus on the scope of nursing practice - Foster the development of nursing knowledge

Seven Guidelines for Writing Goals

Patient centered - Singular goal or outcome - Measurable - Mutual factors - Observable - Time Limited - Realistic

Preventive Measures

Preventive nursing actions promote health and prevent illness to avoid the need for acute or rehabilitative health care. Prevention includes assessment and promotion of the patient's health potential, application of prescribed measures, health teaching, and identification of risk factors for illness and/or trauma.

Writing a nursing Diagnosis 1. The problem

Problem: describes the client's health problem or response for which nursing therapy is given. It describes the client's health status clearly and concisely. Open your Gulanick & Myers (2014) book to page 8 - Activity intolerance is an example of a nursing diagnosis-write nursing diagnosis on a sticky note beside "activity intolerance" - Note the definition: "insufficient physiological or psychological energy to endure or complete required or desired daily activities"

First Step: Assess

Purpose: Establish a database of patient information 2 Steps: 1) Collect & Verify Data Deliberate and Systematic collection of information about a patient

Third step: Plan

Requires you to think critically. - A plan of care will change as your patient's needs change. Planning involves: - setting priorities - identifying patient-centered goals and expected outcomes - prescribing individualized nursing interventions.

Data Collection

Source 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 - Other records and the literature

Secondary data

Subjective: "My husband's shoulder is sore every day". Objective: - Physical therapy note in the chart states that the left shoulder has decreased range of motion and strength

Primary Data

Subjective: "My shoulder is really sore". Objective: - Nurse obtains data through observation and examination. - Client observed to grimace when raising arm.

Teaching

Teaching is a constant part of nursing. As a nurse, you teach correct principles, procedures, and techniques of health care to inform patients about their health status and to prepare them for self-care (see Chapter 12). Teaching occurs formally and informally and involves patients and their family members.

Direct Care Versus Indirect Care Indirect Care

Treatments performed away from the patient but on behalf of the patient or group of patients Examples: Managing the patient's environment Documentation Interdisciplinary collaboration **Nurses spend much time in indirect and unit management activities. Communication of information about patients (e.g., change-of-shift report, consultation) is critical, ensuring that direct care activities are planned, coordinated, and performed with the proper resources

Direct Care Versus Indirect Care Direct Care

Treatments performed through interactions with patients Examples: Medication administration Insertion of an intravenous (IV) infusion Counseling during a time of grief **Nurses provide a wide variety of direct care measures. All direct care measures require competent and therefore safe practice. Adopt a caring approach each time you provide direct care.

Physical care techniques

You will routinely use a variety of physical care techniques when caring for patients. Physical care techniques involve the safe and competent administration of nursing procedures (e.g., inserting a urinary catheter, performing range-of-motion exercises). When you apply physical care during a procedure, know the clinical practice guidelines and how to perform the procedure, the standard frequency, and the expected outcomes.

Critical Pathways

are patient care management plans that provide the interdisciplinary health care team with activities and tasks to be put into practice sequentially. - The main purpose of critical pathways is to deliver timely care at each phase of the care process for a specific type of patient. ** A critical pathway clearly defines transition points in patient progress and draws a coordinated map of activities by which the health care team can help to make these transitions as efficiently as possible. **Critical pathways improve continuity of care because they clearly define the responsibility of each health care discipline. Well-developed pathways include evidence-based interventions and therapies. **A critical pathway is a standardized care plan that outlines care for clients with common, predictable conditions such as a hip replacement. Critical pathways are patient care management plans that provide the interdisciplinary health team with the activities and tasks to be put into practice sequentially over time

The Nursing Process: Implement

implementation, involves performing the planned interventions Preform the nursing actions identified in planning

The Nursing Process: Planning

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 Set goals of care and desired outcomes and identify appropriate nursing actions

The Nursing Process: Evaluate

you evaluate the patient's response and determine whether the interventions were effective Determine if goals met and outcomes achieved

The Nursing Process: Diagnosis

you make clinical judgments from the assessment to identify the patient's response to health problems in the form of nursing diagnoses Identify the patient's problems

Environment

​A patient's care environment needs to be safe and conducive for implementing therapies. Patients benefit most from nursing interventions when surroundings are compatible with care activities. When you need to expose a patient's body parts, do so privately because the patient will be more relaxed. Reduce distractions to enhance learning opportunities. Make sure the lighting is adequate to perform procedures correctly.

Equipment

​Most nursing procedures require some equipment or supplies. Decide what supplies are necessary and determine their availability before you start implementation. Have extra supplies available in case of errors or accidents, but do not open extra supplies unless they are needed. This controls health care costs. After a procedure, return any unopened supplies.