module 1 Nursing process

DIAGNOSTIC REASONING AND CLINICAL REASONING

1. Be familiar with nursing diagnoses and other health problems; read professional literature and keep reference guides handy. 2. Trust clinical experience and judgment, but be willing to ask for help when the situation demands more than your qualifications and experience can provide. 3. Respect your clinical intuition, but before writing a diagnosis without evidence, increase the frequency of your observations and continue to search for cues to verify your intuition. 4. Recognize personal biases and keep an open mind.

OUTCOME IDENTIFICATION, PLANNING, AND CLINICAL REASONING

1. Be familiar with standards and agency policies for setting priorities, identifying and recording expected patient outcomes, selecting evidence-based nursing interventions, and recording the plan of care (Box 13-2). 2. Remember that the goal of person-centered care is to keep the patient and the patient's interests and preferences central in every aspect of planning and outcome identification 3. Keep the "big picture" in focus: What are the discharge goals for this patient, and how should this direct each shift's interventions? 4. Trust clinical experience and judgment but be willing to ask for help when the situation demands more than your qualifications and experience can provide; value collaborative practice 5. Respect your clinical intuitions, but before establishing priorities, identifying outcomes, and selecting nursing interventions, be sure that research supports your plan 6. Recognize your personal biases and keep an open mind

Identifying Clinical, Functional, and Quality-of-Life Outcomes

1. Clinical outcomes describe the expected status of health issues at certain points in time, after treatment is complete. They address whether the problems are resolved or to what degree they are improved. 2. Functional outcomes describe the person's ability to function in relation to the desired usual activities. 3. Quality-of-life outcomes focus on key factors that affect someone's ability to enjoy life and achieve personal goals

Skills needed for implementation

1. Cognitive Skills- Critical thinking skills - Remember Alfaro's Rule: "assess, re-assess, revise, record: Assess patients before performing nursing actions. Re-assess them to determine their responses after you perform nursing actions. Revise your approach as indicated. Record patient responses and any changes you made in the plan of care" education is implementation. 2. Interpersonal Skills 3. Technical Skills

Using Cognitive, Psychomotor, and Affective Outcomes

1. Cognitive outcomes describe increases in patient knowledge or intellectual behaviors 2. Psychomotor outcomes describe the patient's achievement of new skills 3. Affective outcomes describe changes in patient values, beliefs, and attitudes.

Clinical Reasoning, Judgments, and Decision Making

1. Critical thinking—a broad term—includes reasoning both outside and inside of the clinical setting. Clinical reasoning and clinical judgment are key pieces of critical thinking in nursing. 2. Clinical reasoning—a specific term—usually refers to ways of thinking about patient care issues (determining, preventing, and managing patient problems). For reasoning about other clinical issues (e.g., teamwork, collaboration, and streamlining work flow), nurses usually use critical thinking. 3. Clinical judgment refers to the result (outcome) of critical thinking or clinical reasoning—the conclusion, decision, or opinion you make.

Avoiding Common Errors in Outcomes(RN)

1. Expressing the patient outcome as a nursing intervention. Incorrect: "Offer Mr. Myer 60 mL fluid every 2 hours while awake." Correct: "Mr. Myer will drink 60 mL fluid every 2 hours while awake, beginning 2/24/15." 2. Using verbs that are not observable and measurable. Incorrect: "Mrs. Gaston will know how to bathe her newborn." Correct: "After attending the infant care class, Mrs. Gaston will correctly demonstrate the procedure for bathing her newborn." *Verbs* to be *avoided* when writing goals include "*know," "understand," "learn," and "become aware*." These verbs are too general and *cannot be measured*. Verbs for writing outcomes should be observable and measurable (as listed previously). 3. Including more than one patient behavior/manifestation in short-term outcomes. Incorrect: "Patient will list dangers of smoking and stop smoking." Correct: "By next meeting, 3/11/15, the patient will (1) identify three dangers of smoking and (2) describe a plan he is willing to try to stop smoking. By 6/20/15, the patient will report that he no longer smokes." 4. Writing outcomes that are so vague that other nurses are unsure of the goal of nursing care. Incorrect: "Patient will cope better." Correct: "After teaching, 10/20/15, the patient will (1) describe two new coping strategies he is willing to try and (2) demonstrate decreased incidence of previously observed ineffective coping behaviors (chain smoking, withdrawal behavior, heavy alcohol consumption)."

Goals vs. expected outcomes

1. Goals Indicates resolution of an ND More BROAD Summarizes what will be accomplished when patient has met all expected outcomes Ex: Patient remains free from new developing pressure ulcers during hospital stay. 2. Expected Outcomes End result that is: measurable, desirable, observable; and translates into observable patient behaviors Ex: Patient will describe risk factors for impaired/compromised tissue integrity.

Nursing interventions cont'd...

1. Independent Nurse-initiated Do NOT require an order from another healthcare provider Ex: elevating an edematous extremity, assisting a patient with mouth care, turning a patient every 2 hours Governed by each state's Nurse Practice Act 2. Dependent Physician-initiated DO require an order from another healthcare provider Ex: administering ordered meds, inserting a Foley catheter, administering a fluid bolus, preparing the patient for an ordered test/procedure

COMPREHENSIVE PLANNING

1. Initial planning is performed by the nurse with the admission nursing history and the physical assessment. - Standardized care plans are prepared plans of care that identify the nursing diagnoses, outcomes, and related nursing interventions common to a specific population or health problem. 2. Ongoing planning is carried out by any nurse who interacts with the patient. Ongoing planning is problem oriented and has as its purpose keeping the plan up to date as new actual or potential problems are identified. 3. Discharge planning is best carried out by the nurse who has worked most closely with the patient and family, possibly in conjunction with a nurse or social worker with a broad knowledge of existing community resources. 4. Informal planning is a link between identifying a patient's strength or problem and providing an appropriate nursing response. 5. Formal planning involves prioritizing diagnoses, formally planning interventions, and coordinating the home care of a patient being discharged.

Problem Solving

1. Trial-and-error problem solving involves testing any number of solutions until one is found that works for that particular problem. - not good for nursing 2. Scientific problem solving is a systematic, seven-step, problem-solving process that involves (1) problem identification, (2) data collection, (3) hypothesis formulation, (4) plan of action, (5) hypothesis testing, (6) interpretation of results, and (7) evaluation, resulting in conclusion or revision of the hypothesis. 3. Intuitive problem solving is thus a direct understanding of a situation based on a background of experience, knowledge, and skill that makes expert decision making possible. 4. Creative thinking involves imagination, intuition, and spontaneity, factors that underpin(지지하다) the art of nursing.

Determining Patient-Centered Outcomes

1. Patient's health state, overall prognosis 2. Expected length of stay 3. Growth and development 4. Patient values and cultural considerations 5. Other planned therapies for the patient 6. Available human, material, and financial resources 7. Risks, benefits, and current scientific evidence 8. Changes in status that indicate you need to modify usual expected outcomes

ESTABLISHING PRIORITIES

1. Priority is based on Maslow's hierarchy of care Because basic needs must be met before a person can focus on higher ones, patient needs may be prioritized according to the following hierarchy: a. Physiologic needs b. Safety needs c. Love and belonging needs d. Self-esteem needs e. Self-actualization needs 2. Patient Preference - Thoughtful, person-centered nursing directs you to first meet the needs that the patient thinks are most important, as long as this order does not interfere with other vital therapies. 3. Anticipation of Future Problems - Nurses must tap their knowledge base to consider the potential effects of different nursing actions. 4. Clinical Reasoning and Establishing Priorities

Structured Care Methodologies(RN)

1. Procedure: A set of how-to action steps for performing a clinical activity or task 2. Standard of care: A description of an acceptable level of patient care or professional practice 3. Algorithm: A set of steps that approximates the decision process of an expert clinician and is used to make a decision; these clinical rules are typically embedded in a branching flow chart 4. Clinical practice guideline: A statement or series of statements outlining appropriate practice for a clinical condition or procedure

Ensuring Quality Outcomes

1. Safe: avoiding injury 2. Effective: avoiding overuse and underuse 3. Patient-centered: responding to patient preferences, needs, and values 4. Timely: reducing waits and delays 5. Efficient: avoiding waste 6. Equitable: providing care that does not vary in quality to all recipients

Questions to facilitate clinical reasoning during planning and outcome identification include

1. Setting priorities: Which problems require my immediate attention or that of the team? Which problems are my responsibility, and which should I refer to someone else? Which problems are most important to the patient? 2. Identifying outcomes: What must I observe in the patient to demonstrate the resolution of the problems identified by the nursing diagnoses and general problem list? What is the time frame for accomplishing these outcomes? Do the outcomes need to be modified in light of the patient's response (or lack of response) to the planned interventions? 3. Selecting evidence-based nursing interventions: What do nursing science and my clinical experience suggest is the likelihood that this particular nursing intervention will help the patient realize his or her expected outcomes? How can I tailor my interventions to increase the likelihood of patient benefit? What is the worst thing that might happen with this intervention, how likely is it to happen, and what can I do to minimize the possibility of this harm? 4. Communicating the plan of care: Does the plan of care adequately address the patient's priorities today? If the plan of care is computerized or standardized, does it adequately address the specific needs of this particular patient? Can anyone reading the plan of care know how to intervene effectively with this patient?

TYPES OF NURSING ASSESSMENTS

1. The initial assessment is performed shortly after the patient is admitted to a health care agency or service. 2. focused assessment, the nurse gathers data about a specific problem that has already been identified. 1. What are your signs and symptoms? 2. When did they start? 3. Were you doing anything different than usual 4. when they started? 5. What makes your symptoms better? Worse? 6. Are you taking any remedies (medical or natural) for your symptoms? 3. physiologic or psychological crisis presents, the nurse performs an emergency assessment to identify life-threatening problems. 4. The time-lapsed assessment is scheduled to compare a patient's current status to the baseline data obtained earlier.

Writing Patient outcomes

1. measurable outcomes a. Conditions: specifies the particular circumstances in or by which the outcome is to be achieved. Not every outcome specifies conditions. b. Performance criteria: describe in observable, measurable terms the expected patient behavior or other manifestation c. Target time: specifies when the patient is expected to be able to achieve the outcome. The target time or time criterion may be a realistic, actual date or other statement indicating time, such as before discharge, after viewing film, whenever observed. ex)During the next 24-hour period, the patient's fluid intake will total at least 2,000 mL. At the next visit, 12/23/15, the patient will correctly demonstrate relaxation exercises. S - specific M - measurable A - attainable R - realistic T - timebound

Select Nursing Interventions

A Standards of Care Protocols Policies Procedures Standing Orders Indirect care interventions- treatments performed away from the patient but on behalf of the patient B Independent Dependent Collaborative Direct care interventions- treatments performed through interactions w/patients

Components of Assessment

Preparing for data collection 1. Establishing Assessment Priorities 2. Health Orientation 3. Developmental Stage 4. Culture 5. Need for Nursing Collecting data 1. Subjective data are information perceived only by the affected person; these data cannot be perceived or verified by another person. Identifying cues and making inferences. 2. Objective data are observable and measurable data that can be seen, heard, felt, or measured by someone other than the person experiencing them. Validating data Clustering related data and identifying patterns Reporting and recording data 1. Timing 2. Documentation

PES- method of writing nursing dx

Problem Impaired dentition Etiology related to poor oral hygiene Symptoms As evidenced by reluctance to visit the dentist, and frequent c/o mouth pain IMPAIRED DENTITION RELATED TO POOR ORAL HYGIENE AS EVIDENCED BY RELUCTANCE TO VISIT THE DENTIST, AND FREQUENT C/O MOUTH PAIN.

Collaborative Problem

Actual or potential physiological complication that nurse's monitor to detect the onset of changes. Requires working with other disciplines (usually medicine) collaborative problems are the primary responsibility of nurses.

the outcome identification and planning steps of the nursing process

After the nurse collects and interprets patient data, identifying patient strengths and health problems, it is time to plan for nursing actions 1. Establish priorities 2. Identify and write expected patient outcomes 3. Select evidence-based nursing interventions 4. Communicate the plan of nursing care The nurse, patient, and family should work together as much as possible in the outcome identification and planning stage. The primary purpose of the outcome identification and planning step of the nursing process is to design a plan of care with and for the patient that, once implemented, results in the prevention, reduction, or resolution of patient health problems and the attainment of the patient's health expectations, as identified in the patient outcomes

Thoughtful Person-Centered practice

All team members are considered caregivers Care is based on continuous healing relationships Care is customized and reflects patient needs and choices Patient safety is a visible priority Transparency - patients know everything what you do. All caregivers cooperate with the common goals of the patient Patient is the sources of control for their care

Developing Critical Thinking Skills

Reflective Journaling: A tool used to clarify concepts through reflection by thinking back or recalling situations Concept Mapping: A visual representation of patient problems and interventions that illustrates an interrelationship

Why do bad decisions happen?

Bias 1. Placing excess emphasis on first data received 2. Avoiding information contrary to one's opinion 3. Selecting alternatives to maintain status quo 4. Being predisposed to a single solution 5. Stating the problem in a way to support one's choices 6. Making decisions to support past choices Failure to consider the situation - listen 1. Using inaccurate data 2. Not clearly identifying the problem 3. Failing to prioritize or rank the problems in order of importance 4. Using unrealistic goals Impatience 1. Failing to identify multiple solutions 2. Incorrectly implementing the decision 3. Failing to use appropriate resources

Choosing Nursing Interventions

Safe & appropriate Achievable Congruent with client's values, beliefs and culture Congruent(적합한) with other treatment Based on evidence based nursing knowledge Within the standards of care

Sources of Data

Client the primary and usually the best source of information. Family, Friends, caregivers especially helpful sources of data when the patient is a child or has limited capacity to share information with the nurse. Healthcare team members Records 1. Records prepared by different members of the health care team provide information essential to comprehensive nursing care. 2. MEDICAL HISTORY, PHYSICAL EXAMINATION, AND PROGRESS NOTES 3. CONSULTATIONS 4. REPORTS OF LABORATORY AND OTHER DIAGNOSTIC STUDIES 5. Other health care professionals who interact with the patient also record their findings and note what progress the patient is making in their specific areas—for example, nutrition, physical therapy, or speech therapy. 6. Assessment Technology- cardiac and respiratory monitors Report Scientific literature To obtain a comprehensive patient database, it may be necessary to consult the nursing and related literature on specific health problems. ex)a nurse who has not cared for a patient with Paget disease before should read about the clinical manifestations(징후) of the disease and its usual progression to know what to look for when assessing the patient. Nurse's experience

Clinical Decision Making in Nursing Practice

Clinical decision making requires critical thinking. Clinical decision-making skills separate professional nurses from technical and ancillary(보조의) staff. Patients often have problems for which no textbook answers exist. Nurses need to seek knowledge, act quickly, and make sound clinical decisions.

Implementation skills

Cognitive skills 1. Applying critical thinking in the nursing process 2. Know rationales for interventions; understand normal vs. abnormal physiological and psychological responses Interpersonal skills Develop a trusting relationship Express a level of caring Communicate Psychomotor skills Integration of cognitive and motor skills...ex: giving an IM injection Competent, consistent psychomotor skills is ESSENTIAL in building patient TRUST

Nursing interventions cont'd...

Collaborative Require combined skill of multiple healthcare providers Can be a combination of BOTH independent and dependent interventions ex) nurses caring for a patient after a motor vehicle accident might eventually implement interventions written by a physical therapist, occupational therapist, or other member of the health care team. NEVER automatically implement an ordered intervention...first determine whether or not it is appropriate for the patient. At some point, you WILL face an incorrect or inappropriate order. The critically thinking nurse recognizes it and knows what to do.

Consulting

Consultation, a process in which two or more people with varying degrees of experience and expertise discuss a problem and its solution, often proves helpful.

Implementing

Do it! Continue data collection Modify plan of care as needed Document

Document data

Document If you do not record an assessment finding, the chance of it being missed, grows. Be specific. Nurse Practice Act in all states requires accurate collection and recording of data...this is viewed as an independent function essential to the role of a professional nurse. Anything heard, seen, felt or smelled, should be reported exactly. Record objective data with accurate terminology. NO→ "Belly hurts when I push on it." YES→ "Abdomen tender to palpation." Record subjective data from a patient in quotation marks. When writing data, do not generalize or form judgments.

CLINICAL DECISION MAKING

Decision making as "purposeful, goal directed effort applied in a systematic way to make a choice among alternatives," and they explain that even choosing not to act in a certain situation is a decision Critical thinking 1. Involves scientific problem solving but it also involves intuition, logic, and creative thinking. A person integrates and adapts the use of all these strategies to address the situation. 2. A continuous process characterized by open-mindedness, continual inquiry, and perseverance, combined with a willingness to look at each unique patient situation and determine which identified assumptions are true and relevant. 3. Recognizing that an issue exists, analyzing information, evaluating information, and making conclusions Problem solving 1. Scientific problem solving is a systematic, seven-step, problem-solving process that involves (1) problem identification, (2) data collection, (3) hypothesis formulation, (4) plan of action, (5) hypothesis testing, (6) interpretation of results, and (7) evaluation, resulting in conclusion or revision of the hypothesis. 2. Intuitive problem solving is thus a direct understanding of a situation based on a background of experience, knowledge, and skill that makes expert decision making possible. Nursing process

Formulate Nursing Diagnosis

Formal statement of the client's health status, containing both the problem and etiology NANDA- North American Nursing Diagnosis Association NANDA-I - North American Nursing Diagnosis Association International Statement of Nursing Judgment Relates to the nurse's independent functions !!!

Collect Data

History -Relevant past and current PATIENT INTERVIEW Assessment 1. Physical assessment is the examination of the patient for objective data that may better define the patient's condition and help the nurse plan care. *The nursing physical assessment involves the examination of all body systems, called the review of systems (ROS), in a systematic manner, commonly using a head-to-toe format. Four methods are used to collect data during the physical assessment: inspection, palpation, percussion, and auscultation.(RN) Documents - Client Chart Laboratory/Diagnostic tests

Documenting the Nursing Process

If it wasn't documented, it wasn't done! Keep accurate, timely assessment information Document all diagnoses and plans in appropriate charting area what Interventions did you do. How's patients Response.

Differentiate data

Important data vs. the whole package Cues- Information obtained through use of the senses Inferences- Judgment or interpretation of cues

Five Components of Critical Thinking

Knowledge base Experience Nursing process competencies Attitudes Standards

Nursing outcomes classification (NOC)

Measuring patient outcomes that are influenced by nursing care. Examples: Patient reports pain at level <2 within 72 hrs post-op. Goal: Patient will report pain level of 0 by discharge. Patient denies increased fatigue during exercise. Goal: Patient ambulates independently in hall 4x daily by discharge. Patient describes need for home in/out catheterizations. Goal: Patient correctly demonstrates self-catheterization within 24 hrs before discharge.

TYPES OF diagnoses

Medical diagnosis Identification of a disease condition based on physical signs, symptoms, PMH, and results of diagnostic (dx) tests and procedures. Physicians, PAs, and NPs can write medical diagnoses, and treat diseases described therein Nursing diagnosis Classifies health problems within the domain of nursing. Clinical judgment about patient's responses to actual and potential health problems, that the nurse is licensed and competent to treat. **Different from medical dx by individualizing dx to each patient and involving the patient in the process as much as possible.** A medical diagnosis remains the same for as long as the disease is present, whereas a nursing diagnosis may change from day to day as the patient's responses change.

Concepts for a Critical Thinker

Truth seeking Open-mindedness Analytic approach Systematic approach Self-confidence Inquisitiveness(몹시 알고 싶어함) Maturity

Components of a Nursing Diagnosis (ND)

Nursing Diagnostic Label (Problem) Name of diagnosis...ex: Impaired physical mobility Descriptors→ impaired, compromised, decreased, deficient, delated, effective, imbalanced, increased Related Factors (Etiology) Reason the patient is displaying the ND Use critical thinking to individualize the dx and interventions Ex: r/t change in cognitive status, r/t decreased mobility, r/t sleep deprivation(결핍) ALWAYS within the realm of nursing practice...NOT medical. Condition that responds to nursing interventions. Incorrect ex: "Impaired comfort r/t appendectomy". Corrected ex: "Acute pain r/t impaired skin integrity at incision site" Defining Characteristics (Symptoms) Ex: pain rating of 8 on scale of 1-10, wincing when turning, guarding, blood glucose levels >500, forgetting names of immediate family members

Organize, & Validate Data

Organize Assessment Sheets- computerized or paper Validate 1. The purpose of validating is to keep data as free from error, bias, and misinterpretation as possible. 2. Back your assessment up with objective data 3. Make sure you chart it!! *Whenever there is any data discrepancy or conflict, the nurse must investigate further, gathering focused information to support, confirm, or negate the suspicions. *the goal of reflective practice is to look at an experience, understand it, and learn from it.

Components of Assessment

Preparing for data collection Collecting data Identifying cues and making inferences Validating data Clustering related data and identifying patterns Reporting and recording data *The nursing history identifies the patient's health status, strengths, health problems, health risks, and need for nursing care.

Writing Nursing Interventions

Use action word (verb) to guide nursing care Teach - Evaluate Perform Assess Apply Encourage Measure Obtain Administer Identify Describe Avoid Remove Demonstrate Review Initiate Maintain Assist

Characteristics of the Nursing process

Systematic Dynamic Interpersonal - ask patient what they want. Outcome oriented Universally applicable

Assessment

Systematic and continuous collection Accurate Relevant Client focused EX) (1) Purposeful: The nurse identifies the purpose of the nursing assessment (comprehensive) and gathers the appropriate data. (2) Prioritized: The nurse gets the most important information first. (3) Complete: The nurse gathers as much data as possible to understand the patient health problem and develop a plan of care. (4) Systematic: The nurse gathers the information in an organized manner. (5) Factual and accurate: The nurse verifies that the information is reliable. (6) Recorded in a standard manner: The nurse records the data according to agency policy so that all caregivers can easily access what is learned.

The Nursing Process

The fundamental blueprint for how to care for patients !!!!!!!!! A standard of practice, which, when followed correctly, protects nurses from legal problems related to nursing care. A systematic problem-solving process that guides all nursing actions. Originated in 1955. Included in ANA standards of practice in 1973. ADPIE

Delegating Implementation

The nurse is responsible for determining the correct caregiver to whom care should be implemented The nurse is responsible and accountable for all care that is delegated. The nurse must be aware of the scope of practice of all members of the health care team. Know and learn the differences between CNA I and CNA II scopes of practice NEVER delegate education!! it is nursing role.

Diagnosis

The reasoning process used in interpreting assessment data Analyze data Identify health problems, risks, and strengths Determine risk factors to be managed Formulate diagnostic statements

Nurse-Initiated Interventions

an autonomous action based on scientific rationale that a nurse executes to benefit the patient in a predictable way related to the nursing diagnosis and projected outcomes. 1. Monitor patient health status and response to treatment 2. Reduce risks 3. Resolve, prevent, or manage a problem 4. Promote independence with activities of daily living 5. Promote optimum sense of physical, psychological, and spiritual well-being 6. Give patients the information they need to make informed decisions and be independent

IDENTIFYING NURSING INTERVENTIONS

as "any treatment based upon clinical judgment and knowledge that a nurse performs to enhance patient/client outcomes"

TYPES OF NURSING INTERVENTIONS

as "any treatment based upon clinical judgment and knowledge that a nurse performs to enhance patient/client outcomes" A direct care intervention is a treatment performed through interaction with the patient(s). - include both physiological and psychosocial nursing actions and include both the 'laying of hands' actions and those that are more supportive and counseling in nature. An indirect care intervention is a treatment performed away from the patient but on behalf of a patient or group of patients. - include nursing actions aimed at management of the patient care environment and interdisciplinary collaboration. A community (or public health) intervention is targeted to promote and preserve the health of populations. - emphasize the health promotion, health maintenance, and disease prevention of populations and include strategies to address the social and political climate in which the population resides.

Nursing Outcomes Classification (NOC)

developed by the Iowa Outcomes Project presents the first comprehensive standardized language used to describe the patient outcomes that are responsive to nursing intervention Current classification list includes 490 outcomes Linked with NANDA-I diagnoses Short-term vs. long-term(usually more than a week)

Well-written nursing interventions(RN)

include 1. Date 2. Verb: Action to be performed 3. Subject: Who is to do it 4. Descriptive phrase: How, when, where, how often, how long, or how much 1. Assist the patient to meet specific outcomes that are related directly to one outcome 2. Clearly and concisely describe the nursing action to be performed (answer the questions who, what, where, when, and how) 3. Are dated when written and when the plan of care is reviewed 4. Are signed by the nurse prescribing the order or intervention 5. Use only those abbreviations accepted in the institution (these are usually found in the agency's policy manual; a list of commonly accepted abbreviations appears in Chapter 16) 6. Refer the nurse to the agency's procedure manual or other literature for the steps of routine, lengthy procedures ex) 1. Offer patient 60 mL water or juice (prefers orange or cranberry juice) every 2 hours while awake for a total minimum PO intake of 500 mL. 2. Teach patient the necessity of carefully monitoring fluid intake and output; remind patient each shift to mark off fluid intake on record at bedside. 3. Walk with patient to bathroom for toileting every 2 hours (on even hours) while patient is awake.

WHEN A PATIENT DOES NOT COOPERATE WITH THE PLAN OF CARE

it is time to reassess strategy. Common reasons for noncompliance 1. Lack of family support 2. Lack of understanding about the benefits of compliance 3. Low value attached to outcomes or related interventions 4. Adverse physical or emotional effects of treatment (such as pain and fatigue) 5. Inability to afford treatment 6. Limited access to treatment

Evaluating

the nurse and patient together measure how well the patient has achieved the outcomes specified in the plan of care. 1. Terminate the plan of care when each expected outcome is achieved 2. Modify the plan of care if there are difficulties achieving the outcomes 3. Identify factors contributing to the patient's success or failure 4. Continue the plan of care if more time is needed to achieve the outcomes