Coordinator/Manager of Care / Exam 5 / NUR 112

Types of Goals - *Appropriate*

Ask yourself "Is this goal appropriate for this specific client?" Examples: Can this particular client walk 20 ft. using a walker? - A client on bedrest does not need a goal about ambulating.

Risk factors

Factors that cause a client to be vulnerable developing a health problem.

Risk Diagnostic label

Factors that cause the client to be more vulnerable to the problem.

Priority

Something given or meriting attention before competing alternatives.

Phase 1—Assessment

Systematic & continuous *collection of data*. Includes: History Physical Exam Lab/Diagnostic Critical thinking applied throughout the process allows you to form conclusions or make decisions about a client's health condition and to direct assessment activities in a meaningful and purposeful way.

Problem or Diagnostic Label r/t (related to) Etiology aeb (as evidence by) Defining Characteristics Problem or Diagnostic Label r/t (related to) Etiology Problem or Diagnostic Label: Risk Factors

"Formula" used to construct a Nursing Diagnosis:

Airway

- Highest priority action - Must be open and clear - Client might need: Temporary oral or artificial airway (tracheostomy or endotracheal tude), supplemental oxygen.

Critical Thinking Attitudes- *Intellectual Curiosity*

- Inquisitive - Exhibit an attitude of inquiry - Frequently think or ask, "What if ...?" "How could we do this differently?" "How does this work?" or "Why did that happen?"

Maslow's Hierarchy of Needs- *Safety and Security Needs*

- Living in a safe environment - Adequate income - Shelter from environmental elements

Maslow's Hierarchy of Needs- *Love and Belonging Needs*

- Love - Affection - Relationships - Involvement with community and spiritual groups help to meet this need.

Types of Goals- *Time-limited*

- Must have time frame for client to reach goal - Can be hours, days, weeks, or months - Short-term or long-term Examples: - Client will walk 20 feet down the hall using a walker *within 2 weeks.* - Client will drink 2500 mL of fluids daily *in 48 hours.* - Client will self-administer correct insulin dose using aseptic technique *by discharge.*

Benner's Skill Acquisition Model- *Expert*

- No longer relies on rules, guidelines, or maxims - Intuitive grasp of situations based on deep tacit understanding - Analytic approaches used only in normal situations or when problems occur. - Vision of what is possible - Preceptors - Nurses that often get ask a lot of questions

Types of Goals / Outcomes - *Client Centered*

- Not about nursing activities - Client always the subject Example: Client will...

Planning- *Interventions*

- Nursing actions, delegation of tasks, & documentation. - Help the client achieve his/her goal

Maslow's Hierarchy of Needs- *Physiological Needs*

- Oxygen - Circulation - Nutrition - Elimination - Fluid Balance - Activity and Exercise - Sleep and Rest

Maslow's Hierarchy of Needs- *Self-actualization Needs*

- Personal growth - Fulfilling own potential - Maslow believed very few individuals reach this level.

Implementation Process

- Reassessment of client - Determine nurse's need for assistance - Implementing the nursing interventions - *Supervising/delegating care* - *Coordinating Care* - Documenting

Benner's Skill Acquisition Model- *Novice*

- Rigid adherence to taught rules or plans - Little situational perception - No discretionary judgment - *Generally a student * - Not much clinical experience - Follows steps exactly how taught

Breathing

- Second highest priority - Essential for oxygen exchange: RR within expected reference range & adequate ventilatory rate. - Client may need: Artificial ventilation, negative pressure gradient in the pleural cavity (chest tube may re-establish negative pressure)

Types of Nursing Interventions- *Indirect Care*

Intervention performed away from, but on behalf of the client. Examples: Attending an interdisciplinary meeting or documentation.

Types of Nursing Interventions- *Direct Care*

Intervention performed through interaction with the client. Examples: Inserting a Foley catheter, giving a bed bath.

- Assessments to observe for changes in client status - Preventing complications - Reduction of risk factors - Treating through teaching & physical care - Improvement of health

Interventions focus on:

Continue, Modify, or Terminate the Nursing Plan of Care.

What's next after evaluation?

The client.

Who is the primary source of data?

- Date/Time - Conclusion statement (goal met, partially met, or not met) - Supporting statement with results Examples: 3/7 @1100: Goal met: Pt able to ambulate 20 ft. using walker. 3/7 @1100: Goal partially met: Pt intake increased to 2000 mL/day. 3/7 @1100: Goal not met: Pt not able to self administer insulin.

Writing an Evaluation:

- Client-centered - Specific, single action - Detailed (who, when, how, where, frequency/time) - Realistic - Relevant - (Include Rationale) Examples: RN will monitor VS q 4 hours RN will administer O2 @ 2LPM via NC as ordered by MD

Writing an Intervention:

Comparing the patient's response to nursing actions with goals/outcomes established during planning.

You evaluate by:

Types of Nursing Interventions- *Independent Nursing Interventions*

*Activities that NURSES are licensed to do within the scope of their practice; unique to nursing.* "Nurse-Initiated Intervention" Includes: Physical care, ongoing assessment, emotional support & comfort, teaching. Examples: ↑ HOB for SOB Educating patient about foods high in Na for a low Na diet.

Types of Nursing Interventions- *Dependent Interventions*

*Completed by a nurse under a physician's orders or according to protocols.* "Physician-Initiated Intervention" Direct nurses to administer meds, IV therapy, diet, & activity. Examples: Administer 40 mg Lasix PO daily Insert Foley Catheter

Collecting Data- *Interviewing*

*Planned communication or conversation with a purpose*: - Get information - Identify problems - Evaluate Change - Teach - Provide support, counseling, or therapy

*Clinical decision-making skills*

*Separate professional nurses from technical and supportive staff.*

*Diagnostic Label*

*Standardized NANDA names for the nursing diagnoses.*

- Assessment - (Nursing) Diagnosis - Planning - Implementation - Evaluation "A Delicious Pie"

*The Phases of the Nursing Process:*

evaluation

*You conduct ___________________ to determine if goals/outcomes are met, *NOT* if nursing interventions were completed.*

*Critical Thinking*

- "All or part of the process of questioning, analysis, synthesis, interpretation, inference, inductive & deductive reasoning, intuition, application, and creativity." - Nurses must be able to make meaningful observations, solve problems, & decide on a course of action. - Is NOT memorizing a list of information. - Reflective, purposeful, and self-regulating process. - Involves recognizing that an issue (patient problem) exits, analyzing information related to the issue (clinical data), evaluating information, and drawing conclusions.

Types of Goals- *Single, specific action*

- Clearly stated action for the client to do - Can be observed directly or indirectly Examples: - Client will walk - Client will drink - Client will self-administer

Interpreting Data

- Compare data against standards - Cluster cues - Identify gaps and inconsistencies

Benner's Skill Acquisition Model- *Competent*

- Coping with "crowdedness" - Now sees actions at least partly in terms of long-term goals - Conscious deliberate planning - Standardized & routinized procedures - Nurses for about *2-3 years on the same unit* - Starting to see bigger picture & what's going on with the pts - Starting to do more deliberate planning of day & is more clear of what patients to see first. - Good idea of how work flow goes - Know easily who takes priority & what needs to be done first - Able to look at pt a little more holistically

Phase 3—*Planning*

- Deliberate, systematic - Review client assessment data & nursing diagnoses for *outcome identification*. - *Know standards of practice & agency policies* - Patient-centered care - Keep big picture in mind (discharge goals) - Trust clinical experience & judgement

Critical Thinking Attitudes- *Independent Thinking*

- Do not believe everything told or go with the crowd. - Listen & learn from new ideas - Do not accept or reject info before understanding it

Validating Data

- Ensure assessment data is complete - Ensure subjective & objective data agree - Obtain additional assessment data (if needed) - Differentiate between cues & inferences - *Avoid jumping to conclusions*

Benner's Skill Acquisition Model- *Advanced Beginner*

- Guidelines for action based on attributes or aspects - Situational perception is still limited - All attributes and aspects are treated separately and given equal importance. - Everything treated separately - May can tell in a certain situation that something is not right with your pt, but you may not be able to quite put your finger on what is going on. - May know what to check but not exactly how to fit all the pieces together in every situation.

Benner's Skill Acquisition Model- *Proficient*

- Sees situations holistically rather than in terms of aspects - Sees what is most important in a situation - Perceives deviations from the normal pattern - Decision-making less labored - Uses maxims for guidance, whose meaning varies according to the situation. - Mentors - People who orient you - Person you go to for questions - Know how to do their job and know how to do it well - They can see the big picture and organize

Maslow's Hierarchy of Needs- *Self Esteem Needs*

- Self Respect - Personal worth - Social recognition

Maslow's Hierarchy of Needs

- Start at the base of the pyramid

Circulation

- Third highest priority - HR and BP within expected reference range necessary for adequate cardiac, cerebral, and peripheral perfusion. - Pt may need: Chemical or physical cardiac support, resuscitation, or supplemental fluids to re-establish intravascular fluid volume and blood pressure)

Critical Thinking Attitudes- *Intellectual courage*

- Willing to rethink and reject previous beliefs - Willing to change

Critical Thinking Attitudes- *Intellectual humility*

- You do not know everything - When unsure, ASK - Admit when wrong

Stage 2: *Advanced beginner*

A *new graduate* usually functions at this level. Begins to focus on more aspects of a clinical situation, uses more facts, and recognizes abnormalities in situations. However, the nurse functioning at this level cannot readily attach meaning to the findings.

The Nursing Process

A systematic, rational method of planning and providing nursing care. It is: - Cyclical - Dynamic - Client Centered - Interpersonal & Collaborative

*Actual*: Patient problem exists at time of nursing assessment. Diagnosis is based on identification of defining characteristics. Nursing care focuses on *relief or resolution of the problem*. *Risk:* Presence of risk factors indicates likelihood of problem developing. Diagnosis is based on presence of risk factors rather than defining characteristics. Nursing care focuses on *reduction of risk factors* to prevent the problem from occurring.

Actual Diagnosis vs. Risk Diagnosis

Diagnostic Label: Acute Pain Etiology: Inflammatory process Defining Characteristic: Dysuria

Acute pain r/t inflammatory process in the bladder AEB dysuria. Diagnostic Label? Etiology? Defining Characteristic?

- Independent thinking - Intellectual curiosity - Intellectual humility - Intellectual empathy - Intellectual courage - Fairmindedness

Critical Thinking Attitudes:

Etiology

Causal relationship between a problem & its related (r/t)

*A*irway

Client needs a patent airway so O2 will have a pathway into the lungs...

*B*reathing

Client needs effective breathing pattern & effort to take in enough O2...

*C*irculation

Client needs effective circulatory system to deliver O2 throughout body & remove CO2.

Actual Nursing Diagnosis

Client's present validated signs and/or symptoms.

- *Clinical decision-making skills separate professional nurses from technical and supportive staff.* - No two patients have the identical health problems, which challenges nurses. - *Nurses need to utilize knowledge, act quickly, and make sound clinical decisions.* - Examples of decisions nurses make daily: "Which client should I see first?"

Clinical Decision-Making:

Types of Nursing Diagnoses- *Syndrome Diagnosis*

Cluster of nursing diagnoses that occur together (ie. have the same etiology); may result in best client outcomes if *addressed at the same time*. Example: Risk for Disuse Syndrome May occur in a bedridden client with cluster diagnoses of Impaired Physical Mobility, Activity Intolerance, Risk for Constipation, Impaired Gas Exchange.

- Observing - Interviewing - Examining

Collecting Data:

Goals/Outcomes

Comes from the problem statement, client response; what the nurse hopes to achieve through nursing actions. Ex.: Acute Pain r/t injury Goal/Outcome: Client will report no pain within 8 hours.

Diagnosis—Statement or conclusion regarding the nature of a phenomenon. Nursing Diagnosis—Client's problem statement (includes diagnostic label & etiology or risk factors)

Common Terms:

Diagnostic Label: Constipation Etiology: Obstruction Defining Characteristic: Presence of tumor

Constipation r/t obstruction secondary to presence of tumor. Diagnostic Label? Etiology? Defining Characteristic?

- Primary nursing roles - Liaison among members of healthcare team - To effectively coordinate care, nurses must be able to collaborate with multidisciplinary team. - Multidisciplinary rounding, etc.

Coordinating/Managing Care:

- Objectively gathering information on a problem or issue. - Recognizing the need for more information. - Evaluating the credibility and usefulness of sources of information. - Recognizing gaps in one's own knowledge - Listening carefully; reading thoughtfully - Separating relevant from irrelevant data and important from unimportant data. - Organizing or grouping information in meaningful ways - Making inferences (tentative conclusions) about the meaning of the information. - Visualizing potential solutions to a problem - Exploring the advantages, disadvantages, and consequences of each potential action. - Evaluating the credibility and usefulness of sources of information. - Recognizing differences and similarities among things or situations. - Prioritizing or ranking data as needed.

Critical Thinking Skills:

Diagnostic Label: Death anxiety Etiology: Anticipated suffering

Death anxiety r/t anticipated suffering. Diagnostic Label? Etiology?

Types of Nursing Diagnoses- *Wellness Diagnosis*

Describes health status, no problem present; can be used to describe individual, family, group, community; client is well and wants to move to higher level of wellness. Example: Readiness for enhanced Family Processes. Key Assessment: Activities support the growth of family members, boundaries of family members are maintained, energy level of family members supports activities of daily living.

Types of Nursing Diagnoses- *Actual Diagnosis*

Describes human responses to health conditions that exist in an individual, family, or community. Sufficient assessment data available to establish existence of the nursing diagnosis. Example: Fatigue r/t the disease process of cancer. Key Assessment: Inability to maintain usual level of physical activity; lethargic; increased rest requirements.

Types of Nursing Diagnoses- *Risk Nursing Diagnosis*

Describes human responses to health conditions that have a chance of developing in a vulnerable individual, family, or community. It is supported by risk factors that contribute to increased vulnerability. The key assessment is the data that support the client's vulnerability or risk. Example: Risk for falls: risk factors: history of falls, advanced age. Key Assessment: History for falls, age 65 and over, lives alone, visual limitations, urinary urgency, symptoms of fatigue and weakness.

Phase 5—Evaluation

Determines: - Client's progress toward achievement of goals/outcomes - The effectiveness of the nursing plan of care

Nursing Diagnosis

Formal statement of an actual or potential health problem that *nurses can legally and independently treat*. Describes the *human response* to an illness or health condition.

Prioritizing care

Helps nurses manage time; establishes order for completing responsibilities & care interventions for client(s) - By order of importance (pertinent health issue) - Appropriate timing (med due at certain time)

Types of Nursing Interventions- *Collaborative Interventions*

Includes both dependent interventions as well as actions the nurse carries out in *collaboration with other healthcare workers (physical therapists, social workers, dietitians, & physicians)*, may need physician's order. Reflect overlapping responsibilities & cooperative relationships among healthcare personnel. Example: MD orders PT to evaluate & treat pt→ RN coordinates with PT.

*A*irway *B*reathing *C*irculation

Mnemonic for prioritizing:

Were my goals: *S*PECIFIC *M*EASURABLE *A*TTAINABLE *R*EALISTIC *T*IME

Mnemonic for unmet goals:

1.) Begin with assessment & determine WHY they were not met Use SMART: Were the outcomes SPECIFIC? Were the outcomes MEASURABLE? Were the outcomes ATTAINABLE & REALISTIC? Did you allow adequate TIME for a positive outcome?

My outcomes weren't met (or were partially met)!!! Now what?

Collecting Data- *Observing*

Noticing the data & selecting, organizing, and interpreting the data. Example: Client's face is flushed...

Stage 3: *Competence*

Nurses achieve this after *2 to 3 years of nursing practice in the same area*. These performers have gained additional experience and are able to handle their patient load, deal with complexity, and prioritize situations. They are also more involved in their caregiving role and may be emotionally involved in the clinical choices made. Although these nurses manage clinical care with mastery, they often do not fully grasp the overall scope and most important aspects.

Phase 2—Diagnosis

Nursing Diagnosis—"A clinical judgment about individual, family, or community responses to actual and potential health problems/life processes. A nursing diagnosis provides the basis for the selection of nursing interventions to achieve outcomes for which the nurse is accountable" (NANDA International, 2011)

Documentation of Assessment—Digital or written format. Organize Assessment Data Example: Head-to-toe, by body system

Organizing Data:

Phase 4—Implementation

Performance of nursing interventions necessary for achieving the goals and expected outcomes of nursing care.

Diagnostic Label: Risk for Infection Etiology: None Risk Factor: Invasive Procedure

Risk for Infection: risk factor: invasive procedure Diagnostic Label? Etiology? Risk Factor?

- Assessment (history, physical exam, diagnostics /labs) (data collection) - Data collection includes observing, interviewing, and examining. - Then organize the data, validate the data, and interpret the data.

Phase 1-Assessment Steps:

Collecting Data- *Examining*

Physical Assessment

Delegation

Process of assigning part of one's responsibility to another qualified person in a specific situation. Ex: Delegating a blood sugar check to NAP when another patient needs pain medication. *RN'S CAN NOT DELEGATE TEACHING.*

Concept Map

Provides a visual representation of a nursing plan of care. Shows your patient's medical problems, nursing assessment data, nursing diagnoses, and their relationship to one another. As you apply the nursing process, it will have more detailed planned interventions.

- Get information - Identify problems - Evaluate Change - Teach - Provide support, counseling, or therapy

Purpose of an interview:

Types of Goals- *Measurable Goals*

Quantifiable or determining how often. Examples: - Client will walk *20 ft.* down the fall using a walker - Client will drink *2500 mL* of fluid daily - Client will self-administer correct dose of insulin

"Were the desired patient outcomes met?" If outcomes are met, the overall goals for the patient are met. "Were the nursing interventions appropriate & effective?" Compare patient behavior and responses assessed before implementing nursing interventions with behavior and responses that occur after administering nursing care. "Do the outcomes and/or interventions need to be modified?"

Questions the nurse should ask during evaluation:

Defining characteristics

Refer to the cluster of signs & symptoms (subjective and objective data or both) Patients actual signs and symptoms.

Types of Goals - *Realistic & attainable*

Review client's physical, emotional, & psychological capabilities. Examples: - Walking a mile would not be achievable for a client with end-stage COPD, but walking 20 ft. might - A very small child might not be capable of self-administering insulin.

- Task - Circumstance - Person - Direction/Communication (time to do the task, what to report, etc..) - Supervision

Rights of Delegation:

Medical Diagnosis

The identification of a *disease process* based on an evaluation of physical signs, symptoms, history, diagnostic tests, and procedures.

- Identify a client's health status & actual or potential healthcare needs. - Deliver specific nursing interventions to meet those needs. - To evaluate the success of the interventions.

The nursing process is used to:

Stage 5: *Expert*

These nurses are able to see what needs to be achieved and how to do it. They trust in and use their intuition while operating with a deep understanding of a situation, often recognizing a problem in the absence of its classic signs and symptoms. They are often consulted when others need advice or assistance.

Stage 4: *Proficient*

This nurse is able to quickly take in all aspects of a situation and immediately give meaning to the cluster of assessment data. Such nurses are a resource for less experienced nurses. *They are able to see the "big picture"* and can coordinate services and forecast needs. They are much more flexible and able to adapt to the nuances of various patient situations.

Stage 1: *Novice*

This phase begins with the *onset of education*. Has little clinical experience and is task oriented and narrowly focused on "learning the rules."

- Know the scientific rationale or reason for the intervention; Why did you choose this intervention? - Possess the technical, cognitive, and interpersonal skills to perform the interventions. - Include client's input The nurse selects interventions that are most likely to achieve desired outcomes. Example: Recording intake and output for a pt. who needs increased fluid intake.

To select interventions you need to:

Critical Thinking Attitudes- *Fairmindedness*

Treat all viewpoints fairly.

Critical Thinking Attitudes- *Intellectual empathy*

Try to see a situation as another person sees it.

*Subjective* (obtained from the client) Example: Anxiety or pain *Objective* (obtained through assessment & physical examination of the client) Example: PERRLA (pupils equal, round, and reactive to light and accommodation)

Types of Data:

- Client centered - Single, specific action - Measurable - Appropriate for client - Realistic & Attainable - Time-limited

Types of Goals/Outcomes:

Types of Goals- *Long-term goals*

Used for clients who have chronic health problems; nursing homes, rehab centers; can be achieved *in a week to several months.* Examples: - Client will eat at least 60% of all meals within 3 weeks. - Client will regain full use of her right arm within 6 weeks.

Types of Goals- *Short-term goals*

Useful for clients who require health care for a short time; *acute care* setting; can be achieved in a few hours to a few days. Examples: - Client will raise her right arm to shoulder height within 4 days. - Client will demonstrate how to change his leg dressing before discharge.

Support people, client records, healthcare professionals, & literature.

What are some examples of *secondary* sources of data?

Maslow's hierarchy of needs

What do you move on to use when prioritizing if all of your pts ABC's are okay?

Ineffective breathing pattern

What is the priority? - Acute pain - Ineffective Breathing Pattern - Risk for Infection

Impaired Skin Integrity

What is the priority? Anxiety Impaired Skin Integrity Risk for Deficient Fluid Volume

Nausea

What is the priority? Fatigue Ineffective Health Maintenance Nausea

Ineffective Airway Clearance

What is the priority? Ineffective Airway Clearance Risk for Aspiration Imbalanced Nutrition

Impaired Gas Exchange

What is the priority? Spiritual Distress Impaired Gas Exchange Social Isolation

Patient outcomes that are stated in specific, measurable terms are easier to evaluate.

What makes evaluation easier?